Many of our patients with refractory migraine do not respond to first-line acute or preventive treatments, and, almost by definition, first- and second-line treatments have failed in the majority of patients on calcitonin gene-related peptide (CGRP) antagonist medications. Three studies this month highlight the efficacy of CGRP monoclonal antibody (mAb) and small-molecule medications in this population specifically.

Most headache specialists are familiar with the "standard" or PREEMPT onabotulinumtoxinA (Botox) paradigm used preventively for migraine. This protocol uses 155 units of onabotulinumtoxinA over 31 sites in seven muscle groups. OnabotulinumtoxinA vials typically come in 100 or 200 units, and when preparing onabotulinumtoxinA for patients who are being injected most providers are forced to discard most or all of the remaining 45 units. Anecdotally, some providers do inject the entire 200-unit vial, and the additional injection sites are either given in another standard protocol or in a follow-the-pain manner.

The study by Zandieh and colleagues followed 175 patients with chronic migraine who first received three injections of 150 units of onabotulinumtoxinA, then three injections of 200 units of this agent. The additional 50 units were injected into the temporalis and occipitalis muscles — the standard sites were used, but additional units were injected into each of the sites. The majority of patients experienced primarily frontal pain; the injections were not given in specific areas where more pain was manifesting.

The average number of headache days per month decreased significantly when the onabotulinumtoxinA dose was increased; patients tolerated the medication over the 3-month period as well. In practice, many providers use the additional units of onabotulinumtoxinA. This study argues that there is a minimal risk, and probably a potential significant benefit, when using up to 200 units every 3 months. Providers should, however, be aware that in rare instances, some insurances will only cover a 155-unit injection, and the use of additional units may jeopardize reimbursement for those plans.

Many patients anecdotally will use cold or heat as a treatment for acute migraine pain; however, the topical use of temperature has not been well studied for this purpose. Cold stimulus has, importantly, been known to be a trigger of migraine as well as other headache disorders classified in the International Classification of Headache Disorders, third edition (ICHD-3), including external cold stimulus headache and "brain freeze" or internal cold stimulus headache. Hsu and colleagues produced a meta-analysis and systematic review on the use of cold for acute treatment of migraine.

Six studies were found to be eligible for this review. The cold stimulus could be placed anywhere on the head, and the studies could have considered its use for any migraine-associated symptom. This includes headache, eye pain, nausea, or vomiting. The interventions used cold somewhat differently, including as ice packing, cooling compression, soaking, and as a rinse. Both randomized and nonrandomized trials were included in the systematic review; however, only randomized controlled trials were used for the meta-analysis.

The primary outcome evaluated by the authors was pain intensity; secondary outcomes were duration of migraine pain as well as associated symptoms (eg, nausea, vomiting). The meta-analysis revealed that cold interventions reduce migraine pain by 3.21 points on an analog scale, and this was found to be effective within 30 minutes. At 1-2 hours after the intervention, the effect was not seen to be significant. At 24 hours, the effect of cold intervention was marginal. Cold was not seen to significantly reduce nausea or vomiting at 2 hours after intervention.

Although cold treatments are commonly used by patients, there appears to be benefit only early in the onset of a migraine attack. Headache specialists typically recommend early treatment with a migraine-specific acute medication; however, the medication may take minutes to hours before taking effect. Cold can be recommended to patients during that intervening period, and it may help until the time that their acute medications take effect.

Chronic refractory migraine remains one of the most debilitating neurologic disorders and is a challenge even for the best trained neurologist or headache specialist. There are few headache centers with inpatient headache units around the United States, and those that remain use treatments that most neurologists are not familiar with. Schwenk and colleagues retrospectively reviewed the data of a major academic headache center and revealed impressive outcomes in this very difficult-to-treat population.

This study reviewed the outcomes of 609 consecutive patients admitted to the Thomas Jefferson University inpatient headache unit from 2017 to 2021. These patients all received continuous lidocaine infusions that were titrated according to an internal protocol that balanced daily plasma lidocaine levels, tolerability, and pain relief. Hospital discharge occurred when patients were pain-free for 12-24 hours or had a minimal response after 5 days of treatment. All patients had at least eight severe headaches per month for at least 6 consecutive months and had tried one to seven preventive medications, with the result of either intolerance or ineffectiveness.

The primary outcome was change from baseline to discharge pain level. Patients were admitted with an average score of 7.0 of 10 on admission and were discharged at a score of 1.0 of 10. Secondary outcomes were average pain at post-discharge appointment vs baseline (5.5 vs 7.0), number of monthly headache days at post-discharge appointment (22.5 vs 26.8), and current and average pain levels at the post-discharge appointment, which were both significantly lower as well. The most common adverse effect was nausea; others noted were cardiovascular changes, hallucinations or nightmares, sedation, anxiety, and chest pain.

This is an important retrospective on the effectiveness of an inpatient lidocaine protocol for refractory chronic migraine. When considering this population, especially if multiple lines of preventive and acute medications are not effective, referral to an academic inpatient headache center should definitely be considered. This patient population does not respond effectively to most treatment modalities, and this is cause to give them hope.

Many of our patients with refractory migraine do not respond to first-line acute or preventive treatments, and, almost by definition, first- and second-line treatments have failed in the majority of patients on calcitonin gene-related peptide (CGRP) antagonist medications. Three studies this month highlight the efficacy of CGRP monoclonal antibody (mAb) and small-molecule medications in this population specifically.

Most headache specialists are familiar with the "standard" or PREEMPT onabotulinumtoxinA (Botox) paradigm used preventively for migraine. This protocol uses 155 units of onabotulinumtoxinA over 31 sites in seven muscle groups. OnabotulinumtoxinA vials typically come in 100 or 200 units, and when preparing onabotulinumtoxinA for patients who are being injected most providers are forced to discard most or all of the remaining 45 units. Anecdotally, some providers do inject the entire 200-unit vial, and the additional injection sites are either given in another standard protocol or in a follow-the-pain manner.

The study by Zandieh and colleagues followed 175 patients with chronic migraine who first received three injections of 150 units of onabotulinumtoxinA, then three injections of 200 units of this agent. The additional 50 units were injected into the temporalis and occipitalis muscles — the standard sites were used, but additional units were injected into each of the sites. The majority of patients experienced primarily frontal pain; the injections were not given in specific areas where more pain was manifesting.

The average number of headache days per month decreased significantly when the onabotulinumtoxinA dose was increased; patients tolerated the medication over the 3-month period as well. In practice, many providers use the additional units of onabotulinumtoxinA. This study argues that there is a minimal risk, and probably a potential significant benefit, when using up to 200 units every 3 months. Providers should, however, be aware that in rare instances, some insurances will only cover a 155-unit injection, and the use of additional units may jeopardize reimbursement for those plans.

Many patients anecdotally will use cold or heat as a treatment for acute migraine pain; however, the topical use of temperature has not been well studied for this purpose. Cold stimulus has, importantly, been known to be a trigger of migraine as well as other headache disorders classified in the International Classification of Headache Disorders, third edition (ICHD-3), including external cold stimulus headache and "brain freeze" or internal cold stimulus headache. Hsu and colleagues produced a meta-analysis and systematic review on the use of cold for acute treatment of migraine.

Six studies were found to be eligible for this review. The cold stimulus could be placed anywhere on the head, and the studies could have considered its use for any migraine-associated symptom. This includes headache, eye pain, nausea, or vomiting. The interventions used cold somewhat differently, including as ice packing, cooling compression, soaking, and as a rinse. Both randomized and nonrandomized trials were included in the systematic review; however, only randomized controlled trials were used for the meta-analysis.

The primary outcome evaluated by the authors was pain intensity; secondary outcomes were duration of migraine pain as well as associated symptoms (eg, nausea, vomiting). The meta-analysis revealed that cold interventions reduce migraine pain by 3.21 points on an analog scale, and this was found to be effective within 30 minutes. At 1-2 hours after the intervention, the effect was not seen to be significant. At 24 hours, the effect of cold intervention was marginal. Cold was not seen to significantly reduce nausea or vomiting at 2 hours after intervention.

Although cold treatments are commonly used by patients, there appears to be benefit only early in the onset of a migraine attack. Headache specialists typically recommend early treatment with a migraine-specific acute medication; however, the medication may take minutes to hours before taking effect. Cold can be recommended to patients during that intervening period, and it may help until the time that their acute medications take effect.

Chronic refractory migraine remains one of the most debilitating neurologic disorders and is a challenge even for the best trained neurologist or headache specialist. There are few headache centers with inpatient headache units around the United States, and those that remain use treatments that most neurologists are not familiar with. Schwenk and colleagues retrospectively reviewed the data of a major academic headache center and revealed impressive outcomes in this very difficult-to-treat population.

This study reviewed the outcomes of 609 consecutive patients admitted to the Thomas Jefferson University inpatient headache unit from 2017 to 2021. These patients all received continuous lidocaine infusions that were titrated according to an internal protocol that balanced daily plasma lidocaine levels, tolerability, and pain relief. Hospital discharge occurred when patients were pain-free for 12-24 hours or had a minimal response after 5 days of treatment. All patients had at least eight severe headaches per month for at least 6 consecutive months and had tried one to seven preventive medications, with the result of either intolerance or ineffectiveness.

The primary outcome was change from baseline to discharge pain level. Patients were admitted with an average score of 7.0 of 10 on admission and were discharged at a score of 1.0 of 10. Secondary outcomes were average pain at post-discharge appointment vs baseline (5.5 vs 7.0), number of monthly headache days at post-discharge appointment (22.5 vs 26.8), and current and average pain levels at the post-discharge appointment, which were both significantly lower as well. The most common adverse effect was nausea; others noted were cardiovascular changes, hallucinations or nightmares, sedation, anxiety, and chest pain.

This is an important retrospective on the effectiveness of an inpatient lidocaine protocol for refractory chronic migraine. When considering this population, especially if multiple lines of preventive and acute medications are not effective, referral to an academic inpatient headache center should definitely be considered. This patient population does not respond effectively to most treatment modalities, and this is cause to give them hope.

Many of our patients with refractory migraine do not respond to first-line acute or preventive treatments, and, almost by definition, first- and second-line treatments have failed in the majority of patients on calcitonin gene-related peptide (CGRP) antagonist medications. Three studies this month highlight the efficacy of CGRP monoclonal antibody (mAb) and small-molecule medications in this population specifically.

Most headache specialists are familiar with the "standard" or PREEMPT onabotulinumtoxinA (Botox) paradigm used preventively for migraine. This protocol uses 155 units of onabotulinumtoxinA over 31 sites in seven muscle groups. OnabotulinumtoxinA vials typically come in 100 or 200 units, and when preparing onabotulinumtoxinA for patients who are being injected most providers are forced to discard most or all of the remaining 45 units. Anecdotally, some providers do inject the entire 200-unit vial, and the additional injection sites are either given in another standard protocol or in a follow-the-pain manner.

The study by Zandieh and colleagues followed 175 patients with chronic migraine who first received three injections of 150 units of onabotulinumtoxinA, then three injections of 200 units of this agent. The additional 50 units were injected into the temporalis and occipitalis muscles — the standard sites were used, but additional units were injected into each of the sites. The majority of patients experienced primarily frontal pain; the injections were not given in specific areas where more pain was manifesting.

The average number of headache days per month decreased significantly when the onabotulinumtoxinA dose was increased; patients tolerated the medication over the 3-month period as well. In practice, many providers use the additional units of onabotulinumtoxinA. This study argues that there is a minimal risk, and probably a potential significant benefit, when using up to 200 units every 3 months. Providers should, however, be aware that in rare instances, some insurances will only cover a 155-unit injection, and the use of additional units may jeopardize reimbursement for those plans.

Many patients anecdotally will use cold or heat as a treatment for acute migraine pain; however, the topical use of temperature has not been well studied for this purpose. Cold stimulus has, importantly, been known to be a trigger of migraine as well as other headache disorders classified in the International Classification of Headache Disorders, third edition (ICHD-3), including external cold stimulus headache and "brain freeze" or internal cold stimulus headache. Hsu and colleagues produced a meta-analysis and systematic review on the use of cold for acute treatment of migraine.

Six studies were found to be eligible for this review. The cold stimulus could be placed anywhere on the head, and the studies could have considered its use for any migraine-associated symptom. This includes headache, eye pain, nausea, or vomiting. The interventions used cold somewhat differently, including as ice packing, cooling compression, soaking, and as a rinse. Both randomized and nonrandomized trials were included in the systematic review; however, only randomized controlled trials were used for the meta-analysis.

The primary outcome evaluated by the authors was pain intensity; secondary outcomes were duration of migraine pain as well as associated symptoms (eg, nausea, vomiting). The meta-analysis revealed that cold interventions reduce migraine pain by 3.21 points on an analog scale, and this was found to be effective within 30 minutes. At 1-2 hours after the intervention, the effect was not seen to be significant. At 24 hours, the effect of cold intervention was marginal. Cold was not seen to significantly reduce nausea or vomiting at 2 hours after intervention.

Although cold treatments are commonly used by patients, there appears to be benefit only early in the onset of a migraine attack. Headache specialists typically recommend early treatment with a migraine-specific acute medication; however, the medication may take minutes to hours before taking effect. Cold can be recommended to patients during that intervening period, and it may help until the time that their acute medications take effect.

Chronic refractory migraine remains one of the most debilitating neurologic disorders and is a challenge even for the best trained neurologist or headache specialist. There are few headache centers with inpatient headache units around the United States, and those that remain use treatments that most neurologists are not familiar with. Schwenk and colleagues retrospectively reviewed the data of a major academic headache center and revealed impressive outcomes in this very difficult-to-treat population.

This study reviewed the outcomes of 609 consecutive patients admitted to the Thomas Jefferson University inpatient headache unit from 2017 to 2021. These patients all received continuous lidocaine infusions that were titrated according to an internal protocol that balanced daily plasma lidocaine levels, tolerability, and pain relief. Hospital discharge occurred when patients were pain-free for 12-24 hours or had a minimal response after 5 days of treatment. All patients had at least eight severe headaches per month for at least 6 consecutive months and had tried one to seven preventive medications, with the result of either intolerance or ineffectiveness.

The primary outcome was change from baseline to discharge pain level. Patients were admitted with an average score of 7.0 of 10 on admission and were discharged at a score of 1.0 of 10. Secondary outcomes were average pain at post-discharge appointment vs baseline (5.5 vs 7.0), number of monthly headache days at post-discharge appointment (22.5 vs 26.8), and current and average pain levels at the post-discharge appointment, which were both significantly lower as well. The most common adverse effect was nausea; others noted were cardiovascular changes, hallucinations or nightmares, sedation, anxiety, and chest pain.

This is an important retrospective on the effectiveness of an inpatient lidocaine protocol for refractory chronic migraine. When considering this population, especially if multiple lines of preventive and acute medications are not effective, referral to an academic inpatient headache center should definitely be considered. This patient population does not respond effectively to most treatment modalities, and this is cause to give them hope.

How long should mothers breastfeed their babies?

The controversial question has cropped up again after the nation’s leading pediatrics group has issued new recommendations calling for women to breastfeed until their children turn 2, and possibly even longer.

The policy statement, Breastfeeding and the Use of Human Milk, was released on June 27 by the American Academy of Pediatrics. It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers.

But the new policy statement isn’t going down smoothly with the Fed Is Best Foundation, a nonprofit group hoping to “debunk and sort out for the public” many of the proclamations in the AAP’s policies, said Christie del Castillo-Hegyi, MD, cofounder of the group and emergency physician at CHI St. Vincent, Little Rock, Ark.

The goal of Fed Is Best is to assist families and health care professionals with current research on the safe feeding of infants – whether with breast milk, formula, or a combination.

The AAP’s previous guidelines, issued in 2012, called for infants to be fed breast milk exclusively for their first 6 months. Continued breastfeeding was recommended while introducing complementary foods for a period of 1 year or longer, the policy stated. The updated policy extends the optimum time line for breastfeeding to up to 2 years, citing the health benefits for babies.
 

‘Tone deaf and one-sided’

The AAP policy is “tone deaf and one-sided to the 75% of the U.S. mothers who use formula either by necessity or choice,” Dr. del Castillo-Hegyi told this news organization.

She pointed to a long list of factors that could affect the health outcomes of infants with regard to breastfeeding versus formula-feeding. These include socioeconomic status, baseline maternal health and education, maternal genetics, and the effects of developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. These issues can contribute to negative health outcomes and brain development in infants who go on to be formula fed, she said.

She also objected to the fact that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months – and even before that – to meet her infant’s nutritional requirements.

Mothers need to hear “that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation,” Dr. del Castillo-Hegyi said. She noted that the AAP’s rigid guidelines may be impossible for many mothers to follow.

“The pressure to meet [the AAP’s] exceedingly high expectations is causing harm to mothers and babies,” she said, referring to earlier guidelines that contained similar suggestions.

If a mother’s milk is insufficient, babies are at risk for low growth rates, jaundice, and dehydration. Mothers also can be affected if they’re made to feel shame because they cannot provide adequate amounts of breast milk and must supplement their supply with formula.

The blanket nature of the AAPs recommendations is “irresponsible,” given the fact that only about one in four nursing people can produce sufficient breast milk to feed their baby, Dr. del Castillo-Hegyi said.

“Not only is there harm to the infant, who may suffer from developmental problems as a result of the malnutrition they experience, but it harms the mother who believes in the AAP to provide responsible guidelines that help them ensure the best nutrition to their infants,” she said.

Lori Feldman-Winter, MD, chair of the AAP Section on Breastfeeding, defended the updated guidance.

The policy aims “to clarify the evidence that breastfeeding matters and to use the best evidence to equip pediatricians with the ways they can support the mother’s choice,” Dr. Feldman-Winter said in an interview. “The bottom line is that most women can exclusively breastfeed according to our recommendation, but a growing number of women have conditions that make it difficult, such as obesity. Pediatricians are essential in recognizing suboptimal intake in the breastfed infant, and the policy delineates how to do this.”

Dr. Feldman-Winter added that the criticism of the policy “is not unexpected, given the many barriers in our society for women doing the work of mothering and trying to reach their personal breastfeeding goals. We know over 60% of mothers do not reach their intended goals. These barriers are even more apparent for the populations that are underserved and least likely to breastfeed.”

But Dr. del Castillo-Hegyi pushed back on the AAP’s claim that exclusive breastfeeding of infants up to 6 months of age confers significant benefits beyond combination breastfeeding and formula feeding. The policy “fails to address the fact that many mothers do not have the biological capacity to meet the recommendation and are simply unable to exclusively breastfeed their infants” for that length of time, she said.

While the differences of opinion might leave lactating mothers in limbo, another expert pointed out that “support” of mothers is critical.

Jessica Madden, MD, a pediatrician and lactation consultant in Cleveland, Ohio, said advocates should work to normalize extended breastfeeding in the general public.

“I think everyone should work to advocate together,” Dr. Madden said. “From the professional society standpoint, advocacy for extended breastfeeding should come from the Academy of Breastfeeding Medicine and the AAP’s Section on Breastfeeding Medicine.”

She said more emphasis should be focused on the roles that pediatricians and health care providers play, along with insurers and employers, to ensure that moms are confident and comfortable with whatever breastfeeding journey they take.

The AAP will be revisiting the recommendations again soon, Dr. Feldman-Winter said. The U.S. Preventive Services Task Force has completed a systematic review but has not set a date to release findings, she said.

Among the issues the USPSTF will address are whether interventions that support breastfeeding improve outcomes for children and mothers; how to improve the initiation, duration, intensity, and exclusivity of breastfeeding; and the identification of any potential harms of interventions that support breastfeeding.

“The research plan illustrates that breastfeeding is now an active area for research, and we will continue to update our recommendations according to the best evidence,” Dr. Feldman-Winter said.

Dr. del Castillo-Hegyi, Dr. Feldman-Winter, and Dr. Madden have disclosed no relevant financial relationships.

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

How long should mothers breastfeed their babies?

The controversial question has cropped up again after the nation’s leading pediatrics group has issued new recommendations calling for women to breastfeed until their children turn 2, and possibly even longer.

The policy statement, Breastfeeding and the Use of Human Milk, was released on June 27 by the American Academy of Pediatrics. It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers.

But the new policy statement isn’t going down smoothly with the Fed Is Best Foundation, a nonprofit group hoping to “debunk and sort out for the public” many of the proclamations in the AAP’s policies, said Christie del Castillo-Hegyi, MD, cofounder of the group and emergency physician at CHI St. Vincent, Little Rock, Ark.

The goal of Fed Is Best is to assist families and health care professionals with current research on the safe feeding of infants – whether with breast milk, formula, or a combination.

The AAP’s previous guidelines, issued in 2012, called for infants to be fed breast milk exclusively for their first 6 months. Continued breastfeeding was recommended while introducing complementary foods for a period of 1 year or longer, the policy stated. The updated policy extends the optimum time line for breastfeeding to up to 2 years, citing the health benefits for babies.
 

‘Tone deaf and one-sided’

The AAP policy is “tone deaf and one-sided to the 75% of the U.S. mothers who use formula either by necessity or choice,” Dr. del Castillo-Hegyi told this news organization.

She pointed to a long list of factors that could affect the health outcomes of infants with regard to breastfeeding versus formula-feeding. These include socioeconomic status, baseline maternal health and education, maternal genetics, and the effects of developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. These issues can contribute to negative health outcomes and brain development in infants who go on to be formula fed, she said.

She also objected to the fact that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months – and even before that – to meet her infant’s nutritional requirements.

Mothers need to hear “that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation,” Dr. del Castillo-Hegyi said. She noted that the AAP’s rigid guidelines may be impossible for many mothers to follow.

“The pressure to meet [the AAP’s] exceedingly high expectations is causing harm to mothers and babies,” she said, referring to earlier guidelines that contained similar suggestions.

If a mother’s milk is insufficient, babies are at risk for low growth rates, jaundice, and dehydration. Mothers also can be affected if they’re made to feel shame because they cannot provide adequate amounts of breast milk and must supplement their supply with formula.

The blanket nature of the AAPs recommendations is “irresponsible,” given the fact that only about one in four nursing people can produce sufficient breast milk to feed their baby, Dr. del Castillo-Hegyi said.

“Not only is there harm to the infant, who may suffer from developmental problems as a result of the malnutrition they experience, but it harms the mother who believes in the AAP to provide responsible guidelines that help them ensure the best nutrition to their infants,” she said.

Lori Feldman-Winter, MD, chair of the AAP Section on Breastfeeding, defended the updated guidance.

The policy aims “to clarify the evidence that breastfeeding matters and to use the best evidence to equip pediatricians with the ways they can support the mother’s choice,” Dr. Feldman-Winter said in an interview. “The bottom line is that most women can exclusively breastfeed according to our recommendation, but a growing number of women have conditions that make it difficult, such as obesity. Pediatricians are essential in recognizing suboptimal intake in the breastfed infant, and the policy delineates how to do this.”

Dr. Feldman-Winter added that the criticism of the policy “is not unexpected, given the many barriers in our society for women doing the work of mothering and trying to reach their personal breastfeeding goals. We know over 60% of mothers do not reach their intended goals. These barriers are even more apparent for the populations that are underserved and least likely to breastfeed.”

But Dr. del Castillo-Hegyi pushed back on the AAP’s claim that exclusive breastfeeding of infants up to 6 months of age confers significant benefits beyond combination breastfeeding and formula feeding. The policy “fails to address the fact that many mothers do not have the biological capacity to meet the recommendation and are simply unable to exclusively breastfeed their infants” for that length of time, she said.

While the differences of opinion might leave lactating mothers in limbo, another expert pointed out that “support” of mothers is critical.

Jessica Madden, MD, a pediatrician and lactation consultant in Cleveland, Ohio, said advocates should work to normalize extended breastfeeding in the general public.

“I think everyone should work to advocate together,” Dr. Madden said. “From the professional society standpoint, advocacy for extended breastfeeding should come from the Academy of Breastfeeding Medicine and the AAP’s Section on Breastfeeding Medicine.”

She said more emphasis should be focused on the roles that pediatricians and health care providers play, along with insurers and employers, to ensure that moms are confident and comfortable with whatever breastfeeding journey they take.

The AAP will be revisiting the recommendations again soon, Dr. Feldman-Winter said. The U.S. Preventive Services Task Force has completed a systematic review but has not set a date to release findings, she said.

Among the issues the USPSTF will address are whether interventions that support breastfeeding improve outcomes for children and mothers; how to improve the initiation, duration, intensity, and exclusivity of breastfeeding; and the identification of any potential harms of interventions that support breastfeeding.

“The research plan illustrates that breastfeeding is now an active area for research, and we will continue to update our recommendations according to the best evidence,” Dr. Feldman-Winter said.

Dr. del Castillo-Hegyi, Dr. Feldman-Winter, and Dr. Madden have disclosed no relevant financial relationships.

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

How long should mothers breastfeed their babies?

The controversial question has cropped up again after the nation’s leading pediatrics group has issued new recommendations calling for women to breastfeed until their children turn 2, and possibly even longer.

The policy statement, Breastfeeding and the Use of Human Milk, was released on June 27 by the American Academy of Pediatrics. It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers.

But the new policy statement isn’t going down smoothly with the Fed Is Best Foundation, a nonprofit group hoping to “debunk and sort out for the public” many of the proclamations in the AAP’s policies, said Christie del Castillo-Hegyi, MD, cofounder of the group and emergency physician at CHI St. Vincent, Little Rock, Ark.

The goal of Fed Is Best is to assist families and health care professionals with current research on the safe feeding of infants – whether with breast milk, formula, or a combination.

The AAP’s previous guidelines, issued in 2012, called for infants to be fed breast milk exclusively for their first 6 months. Continued breastfeeding was recommended while introducing complementary foods for a period of 1 year or longer, the policy stated. The updated policy extends the optimum time line for breastfeeding to up to 2 years, citing the health benefits for babies.
 

‘Tone deaf and one-sided’

The AAP policy is “tone deaf and one-sided to the 75% of the U.S. mothers who use formula either by necessity or choice,” Dr. del Castillo-Hegyi told this news organization.

She pointed to a long list of factors that could affect the health outcomes of infants with regard to breastfeeding versus formula-feeding. These include socioeconomic status, baseline maternal health and education, maternal genetics, and the effects of developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. These issues can contribute to negative health outcomes and brain development in infants who go on to be formula fed, she said.

She also objected to the fact that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months – and even before that – to meet her infant’s nutritional requirements.

Mothers need to hear “that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation,” Dr. del Castillo-Hegyi said. She noted that the AAP’s rigid guidelines may be impossible for many mothers to follow.

“The pressure to meet [the AAP’s] exceedingly high expectations is causing harm to mothers and babies,” she said, referring to earlier guidelines that contained similar suggestions.

If a mother’s milk is insufficient, babies are at risk for low growth rates, jaundice, and dehydration. Mothers also can be affected if they’re made to feel shame because they cannot provide adequate amounts of breast milk and must supplement their supply with formula.

The blanket nature of the AAPs recommendations is “irresponsible,” given the fact that only about one in four nursing people can produce sufficient breast milk to feed their baby, Dr. del Castillo-Hegyi said.

“Not only is there harm to the infant, who may suffer from developmental problems as a result of the malnutrition they experience, but it harms the mother who believes in the AAP to provide responsible guidelines that help them ensure the best nutrition to their infants,” she said.

Lori Feldman-Winter, MD, chair of the AAP Section on Breastfeeding, defended the updated guidance.

The policy aims “to clarify the evidence that breastfeeding matters and to use the best evidence to equip pediatricians with the ways they can support the mother’s choice,” Dr. Feldman-Winter said in an interview. “The bottom line is that most women can exclusively breastfeed according to our recommendation, but a growing number of women have conditions that make it difficult, such as obesity. Pediatricians are essential in recognizing suboptimal intake in the breastfed infant, and the policy delineates how to do this.”

Dr. Feldman-Winter added that the criticism of the policy “is not unexpected, given the many barriers in our society for women doing the work of mothering and trying to reach their personal breastfeeding goals. We know over 60% of mothers do not reach their intended goals. These barriers are even more apparent for the populations that are underserved and least likely to breastfeed.”

But Dr. del Castillo-Hegyi pushed back on the AAP’s claim that exclusive breastfeeding of infants up to 6 months of age confers significant benefits beyond combination breastfeeding and formula feeding. The policy “fails to address the fact that many mothers do not have the biological capacity to meet the recommendation and are simply unable to exclusively breastfeed their infants” for that length of time, she said.

While the differences of opinion might leave lactating mothers in limbo, another expert pointed out that “support” of mothers is critical.

Jessica Madden, MD, a pediatrician and lactation consultant in Cleveland, Ohio, said advocates should work to normalize extended breastfeeding in the general public.

“I think everyone should work to advocate together,” Dr. Madden said. “From the professional society standpoint, advocacy for extended breastfeeding should come from the Academy of Breastfeeding Medicine and the AAP’s Section on Breastfeeding Medicine.”

She said more emphasis should be focused on the roles that pediatricians and health care providers play, along with insurers and employers, to ensure that moms are confident and comfortable with whatever breastfeeding journey they take.

The AAP will be revisiting the recommendations again soon, Dr. Feldman-Winter said. The U.S. Preventive Services Task Force has completed a systematic review but has not set a date to release findings, she said.

Among the issues the USPSTF will address are whether interventions that support breastfeeding improve outcomes for children and mothers; how to improve the initiation, duration, intensity, and exclusivity of breastfeeding; and the identification of any potential harms of interventions that support breastfeeding.

“The research plan illustrates that breastfeeding is now an active area for research, and we will continue to update our recommendations according to the best evidence,” Dr. Feldman-Winter said.

Dr. del Castillo-Hegyi, Dr. Feldman-Winter, and Dr. Madden have disclosed no relevant financial relationships.

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

Four years ago, Atrium Health, in Charlotte, N.C., embarked on a dramatic change in how it cares for newborns exposed to opioids in the womb.

Until then, most of the 700 or so babies who underwent opioid withdrawal each year in the hospital system spent their first weeks in a neonatal intensive care unit (NICU), isolated from their parents and treated with regular doses of morphine to ease their symptoms.

Now, most babies stay in the hospital for just a few days under a new approach called Eat, Sleep, Console. These young patients stay in private rooms where they can bond with their parents and volunteer caregivers. The usual course of treatment is no longer extended therapy with opioid replacements. Instead, mothers are encouraged to stay overnight and are taught how to sooth their babies with swaddling, rocking, and cooing.

As a result, the average length of stay for newborns with neonatal abstinence syndrome (NAS) has dropped from 12 days to 6. Use of morphine has fallen by 79%, from 2.25 to 0.45 mg/kg per stay, according to results of a quality improvement pilot project at one of Atrium’s community hospitals.

Similar outcomes from other hospitals around the country have led to widespread uptake of Eat, Sleep, Console since its advent in 2017. That year, according to federal data, seven newborns were diagnosed with NAS for every 1,000 births.

Advocates say the family-centric model helps parents feel less stigmatized and more confident in their ability to care for their babies, who can have symptoms such as irritability and difficulty feeding for months.

The approach “really empowers families to do what they do best, which is take care of each other,” Douglas Dodds, MD, a pediatrician who led the effort at Atrium, told this news organization.
 

Questioning the old protocols

Numerous state perinatal collaboratives, hospital associations, and health systems say the program is the new standard of care for infants with NAS and neonatal opioid withdrawal syndrome (NOWS).

Twenty-six hospitals have adopted Eat, Sleep, Console as part of a clinical trial sponsored by the National Institutes of Health and a program called Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). Researchers are comparing the approach to previous care protocols in regard to 12 outcomes, including time to medical readiness for discharge, frequency of opioid replacement therapy, and safety problems, such as seizures during treatment.

The transition has been swift. Less than a decade ago, most hospitals used the Finnegan Neonatal Abstinence Scoring System, which was developed in the 1970s to assess babies whose mothers had used heroin during pregnancy.

The Finnegan score entails monitoring babies every 3 hours for 21 symptoms, including high-pitched crying, sneezing, gastrointestinal problems, and yawning. If a baby scores an 8 or more three times in a row, most protocols using the traditional Finnegan approach recommend that providers move infants to an NICU, where they receive morphine or methadone. Once opioid replacement therapy is started, the protocols require a gradual weaning that lasts 3-4 weeks.

As the opioid epidemic grew and NICUs around the country began to fill with babies experiencing NAS or NOW, some clinicians began to question the Finnegan-driven approach.

“You have these miserable babies who are going through this really tough experience, and our first move is to separate them from their moms,” said Matthew Grossman, MD, a pediatric hospitalist at Yale New Haven Children’s Hospital, New Haven, Conn., who created Eat, Sleep, Console.

Dr. Grossman, associate professor and vice chair for quality in the department of pediatrics at Yale University, said he noticed that when mothers stayed overnight with their babies, the infants tended to have fewer withdrawal symptoms. Indeed, previous studies had demonstrated the benefits of breastfeeding and allowing mothers and babies to share a room.

“If you think of mom as a medicine, then you can’t put the baby in a unit where the mom can’t be there,” Dr. Grossman told this news organization. “It would be like taking a kid with pneumonia and putting him in a unit that doesn’t have antibiotics.”

Despite its prominence, the Finnegan score has never been validated for guiding the treatment of NAS. In addition, Finnegan scores can be inconsistent, and the assessment requires disturbing an infant to check signs such as its startle reflex, which, as Dr. Grossman and his fellow researchers pointed out, flies in the face of American Academy of Pediatrics’ recommendations to prioritize swaddling and minimize stimulation for infants with NAS.

By contrast, Eat, Sleep, Console offers a simplified assessment. Interventions are called for if a baby eats less than an ounce of food at a time/does not breastfeed, sleeps less than an hour at a stretch, or takes more than 10 minutes to be consoled. After nonpharmacologic interventions have been tried, doses of medication are used as needed. Babies who are doing well can be discharged in as few as 4 days.
 

Quashing bias against parents with substance abuse disorder

Even with the promise of shorter stays and better care, switching to nonpharmacologic care presents hurdles for hospitals. Among these is a lack of physical space for mothers to room with their babies in a quiet environment.

“In many community hospitals, the only place for infants to go is a neonatal intensive care unit, outside of the newborn nursery,” said Stephen Patrick, MD, MPH, associate professor and director of the Center for Child Health Policy at Vanderbilt University, Nashville, Tenn., who researches stigma associated with opioid use during pregnancy.

Administrators at SSM St. Mary’s Hospital in St. Louis initially balked at providing private rooms for mothers and their babies with NAS and NOWS, according to Kimberly Spence, MD, a neonatologist at SSM Health. She said the initial plan was to put the babies in a busy, brightly lit nursery.

But resistance waned as the hospital convinced health plans to pay for private rooms for the 5-7 days it typically takes a baby to go through withdrawal, said Dr. Spence, associate professor of pediatrics at Saint Louis University.

“We were able to provide enough data that this is evidence-based medicine and babies do better with their moms, and that ethically, this is the right thing to do, to reduce transfers to an NICU,” she said.

In addition, news stories about the family-centric approach and shorter stays for infants, along with SSM’s launch of an outpatient clinic to treat pregnant women with opioid use disorder, helped the system to attract more patients and increase its market share, said Dr. Spence.

Another challenge was getting physicians and nurses to set aside any judgments of parents with substance abuse disorder, according to Dr. Grossman and others.

“A lot of faculty and staff on the medical team didn’t feel like we should trust moms with their babies’ medical care” at SSM, Dr. Spence said.

Some hospitals conduct anti-bias training to teach providers that substance abuse is a disease that deserves proper medical treatment and not the moral failing of a patient. Such education may involve explaining that babies’ outcomes are improved when women undergo treatment with methadone or buprenorphine during pregnancy, even though use of those medications does pose a risk of NAS.

Creating a system that supports parents with substance abuse disorders may help to change perceptions. At Atrium Health, some staff members now enjoy working with these families because they can make a profound impact, Dr. Dodds said. He said they’ve learned that families suffering from substance abuse disorder “are not that different than any other family.”

Dr. Dodds, Dr. Patrick, Dr. Spence, and Dr. Grossman reported no relevant financial relationships.

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

Four years ago, Atrium Health, in Charlotte, N.C., embarked on a dramatic change in how it cares for newborns exposed to opioids in the womb.

Until then, most of the 700 or so babies who underwent opioid withdrawal each year in the hospital system spent their first weeks in a neonatal intensive care unit (NICU), isolated from their parents and treated with regular doses of morphine to ease their symptoms.

Now, most babies stay in the hospital for just a few days under a new approach called Eat, Sleep, Console. These young patients stay in private rooms where they can bond with their parents and volunteer caregivers. The usual course of treatment is no longer extended therapy with opioid replacements. Instead, mothers are encouraged to stay overnight and are taught how to sooth their babies with swaddling, rocking, and cooing.

As a result, the average length of stay for newborns with neonatal abstinence syndrome (NAS) has dropped from 12 days to 6. Use of morphine has fallen by 79%, from 2.25 to 0.45 mg/kg per stay, according to results of a quality improvement pilot project at one of Atrium’s community hospitals.

Similar outcomes from other hospitals around the country have led to widespread uptake of Eat, Sleep, Console since its advent in 2017. That year, according to federal data, seven newborns were diagnosed with NAS for every 1,000 births.

Advocates say the family-centric model helps parents feel less stigmatized and more confident in their ability to care for their babies, who can have symptoms such as irritability and difficulty feeding for months.

The approach “really empowers families to do what they do best, which is take care of each other,” Douglas Dodds, MD, a pediatrician who led the effort at Atrium, told this news organization.
 

Questioning the old protocols

Numerous state perinatal collaboratives, hospital associations, and health systems say the program is the new standard of care for infants with NAS and neonatal opioid withdrawal syndrome (NOWS).

Twenty-six hospitals have adopted Eat, Sleep, Console as part of a clinical trial sponsored by the National Institutes of Health and a program called Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). Researchers are comparing the approach to previous care protocols in regard to 12 outcomes, including time to medical readiness for discharge, frequency of opioid replacement therapy, and safety problems, such as seizures during treatment.

The transition has been swift. Less than a decade ago, most hospitals used the Finnegan Neonatal Abstinence Scoring System, which was developed in the 1970s to assess babies whose mothers had used heroin during pregnancy.

The Finnegan score entails monitoring babies every 3 hours for 21 symptoms, including high-pitched crying, sneezing, gastrointestinal problems, and yawning. If a baby scores an 8 or more three times in a row, most protocols using the traditional Finnegan approach recommend that providers move infants to an NICU, where they receive morphine or methadone. Once opioid replacement therapy is started, the protocols require a gradual weaning that lasts 3-4 weeks.

As the opioid epidemic grew and NICUs around the country began to fill with babies experiencing NAS or NOW, some clinicians began to question the Finnegan-driven approach.

“You have these miserable babies who are going through this really tough experience, and our first move is to separate them from their moms,” said Matthew Grossman, MD, a pediatric hospitalist at Yale New Haven Children’s Hospital, New Haven, Conn., who created Eat, Sleep, Console.

Dr. Grossman, associate professor and vice chair for quality in the department of pediatrics at Yale University, said he noticed that when mothers stayed overnight with their babies, the infants tended to have fewer withdrawal symptoms. Indeed, previous studies had demonstrated the benefits of breastfeeding and allowing mothers and babies to share a room.

“If you think of mom as a medicine, then you can’t put the baby in a unit where the mom can’t be there,” Dr. Grossman told this news organization. “It would be like taking a kid with pneumonia and putting him in a unit that doesn’t have antibiotics.”

Despite its prominence, the Finnegan score has never been validated for guiding the treatment of NAS. In addition, Finnegan scores can be inconsistent, and the assessment requires disturbing an infant to check signs such as its startle reflex, which, as Dr. Grossman and his fellow researchers pointed out, flies in the face of American Academy of Pediatrics’ recommendations to prioritize swaddling and minimize stimulation for infants with NAS.

By contrast, Eat, Sleep, Console offers a simplified assessment. Interventions are called for if a baby eats less than an ounce of food at a time/does not breastfeed, sleeps less than an hour at a stretch, or takes more than 10 minutes to be consoled. After nonpharmacologic interventions have been tried, doses of medication are used as needed. Babies who are doing well can be discharged in as few as 4 days.
 

Quashing bias against parents with substance abuse disorder

Even with the promise of shorter stays and better care, switching to nonpharmacologic care presents hurdles for hospitals. Among these is a lack of physical space for mothers to room with their babies in a quiet environment.

“In many community hospitals, the only place for infants to go is a neonatal intensive care unit, outside of the newborn nursery,” said Stephen Patrick, MD, MPH, associate professor and director of the Center for Child Health Policy at Vanderbilt University, Nashville, Tenn., who researches stigma associated with opioid use during pregnancy.

Administrators at SSM St. Mary’s Hospital in St. Louis initially balked at providing private rooms for mothers and their babies with NAS and NOWS, according to Kimberly Spence, MD, a neonatologist at SSM Health. She said the initial plan was to put the babies in a busy, brightly lit nursery.

But resistance waned as the hospital convinced health plans to pay for private rooms for the 5-7 days it typically takes a baby to go through withdrawal, said Dr. Spence, associate professor of pediatrics at Saint Louis University.

“We were able to provide enough data that this is evidence-based medicine and babies do better with their moms, and that ethically, this is the right thing to do, to reduce transfers to an NICU,” she said.

In addition, news stories about the family-centric approach and shorter stays for infants, along with SSM’s launch of an outpatient clinic to treat pregnant women with opioid use disorder, helped the system to attract more patients and increase its market share, said Dr. Spence.

Another challenge was getting physicians and nurses to set aside any judgments of parents with substance abuse disorder, according to Dr. Grossman and others.

“A lot of faculty and staff on the medical team didn’t feel like we should trust moms with their babies’ medical care” at SSM, Dr. Spence said.

Some hospitals conduct anti-bias training to teach providers that substance abuse is a disease that deserves proper medical treatment and not the moral failing of a patient. Such education may involve explaining that babies’ outcomes are improved when women undergo treatment with methadone or buprenorphine during pregnancy, even though use of those medications does pose a risk of NAS.

Creating a system that supports parents with substance abuse disorders may help to change perceptions. At Atrium Health, some staff members now enjoy working with these families because they can make a profound impact, Dr. Dodds said. He said they’ve learned that families suffering from substance abuse disorder “are not that different than any other family.”

Dr. Dodds, Dr. Patrick, Dr. Spence, and Dr. Grossman reported no relevant financial relationships.

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

Four years ago, Atrium Health, in Charlotte, N.C., embarked on a dramatic change in how it cares for newborns exposed to opioids in the womb.

Until then, most of the 700 or so babies who underwent opioid withdrawal each year in the hospital system spent their first weeks in a neonatal intensive care unit (NICU), isolated from their parents and treated with regular doses of morphine to ease their symptoms.

Now, most babies stay in the hospital for just a few days under a new approach called Eat, Sleep, Console. These young patients stay in private rooms where they can bond with their parents and volunteer caregivers. The usual course of treatment is no longer extended therapy with opioid replacements. Instead, mothers are encouraged to stay overnight and are taught how to sooth their babies with swaddling, rocking, and cooing.

As a result, the average length of stay for newborns with neonatal abstinence syndrome (NAS) has dropped from 12 days to 6. Use of morphine has fallen by 79%, from 2.25 to 0.45 mg/kg per stay, according to results of a quality improvement pilot project at one of Atrium’s community hospitals.

Similar outcomes from other hospitals around the country have led to widespread uptake of Eat, Sleep, Console since its advent in 2017. That year, according to federal data, seven newborns were diagnosed with NAS for every 1,000 births.

Advocates say the family-centric model helps parents feel less stigmatized and more confident in their ability to care for their babies, who can have symptoms such as irritability and difficulty feeding for months.

The approach “really empowers families to do what they do best, which is take care of each other,” Douglas Dodds, MD, a pediatrician who led the effort at Atrium, told this news organization.
 

Questioning the old protocols

Numerous state perinatal collaboratives, hospital associations, and health systems say the program is the new standard of care for infants with NAS and neonatal opioid withdrawal syndrome (NOWS).

Twenty-six hospitals have adopted Eat, Sleep, Console as part of a clinical trial sponsored by the National Institutes of Health and a program called Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). Researchers are comparing the approach to previous care protocols in regard to 12 outcomes, including time to medical readiness for discharge, frequency of opioid replacement therapy, and safety problems, such as seizures during treatment.

The transition has been swift. Less than a decade ago, most hospitals used the Finnegan Neonatal Abstinence Scoring System, which was developed in the 1970s to assess babies whose mothers had used heroin during pregnancy.

The Finnegan score entails monitoring babies every 3 hours for 21 symptoms, including high-pitched crying, sneezing, gastrointestinal problems, and yawning. If a baby scores an 8 or more three times in a row, most protocols using the traditional Finnegan approach recommend that providers move infants to an NICU, where they receive morphine or methadone. Once opioid replacement therapy is started, the protocols require a gradual weaning that lasts 3-4 weeks.

As the opioid epidemic grew and NICUs around the country began to fill with babies experiencing NAS or NOW, some clinicians began to question the Finnegan-driven approach.

“You have these miserable babies who are going through this really tough experience, and our first move is to separate them from their moms,” said Matthew Grossman, MD, a pediatric hospitalist at Yale New Haven Children’s Hospital, New Haven, Conn., who created Eat, Sleep, Console.

Dr. Grossman, associate professor and vice chair for quality in the department of pediatrics at Yale University, said he noticed that when mothers stayed overnight with their babies, the infants tended to have fewer withdrawal symptoms. Indeed, previous studies had demonstrated the benefits of breastfeeding and allowing mothers and babies to share a room.

“If you think of mom as a medicine, then you can’t put the baby in a unit where the mom can’t be there,” Dr. Grossman told this news organization. “It would be like taking a kid with pneumonia and putting him in a unit that doesn’t have antibiotics.”

Despite its prominence, the Finnegan score has never been validated for guiding the treatment of NAS. In addition, Finnegan scores can be inconsistent, and the assessment requires disturbing an infant to check signs such as its startle reflex, which, as Dr. Grossman and his fellow researchers pointed out, flies in the face of American Academy of Pediatrics’ recommendations to prioritize swaddling and minimize stimulation for infants with NAS.

By contrast, Eat, Sleep, Console offers a simplified assessment. Interventions are called for if a baby eats less than an ounce of food at a time/does not breastfeed, sleeps less than an hour at a stretch, or takes more than 10 minutes to be consoled. After nonpharmacologic interventions have been tried, doses of medication are used as needed. Babies who are doing well can be discharged in as few as 4 days.
 

Quashing bias against parents with substance abuse disorder

Even with the promise of shorter stays and better care, switching to nonpharmacologic care presents hurdles for hospitals. Among these is a lack of physical space for mothers to room with their babies in a quiet environment.

“In many community hospitals, the only place for infants to go is a neonatal intensive care unit, outside of the newborn nursery,” said Stephen Patrick, MD, MPH, associate professor and director of the Center for Child Health Policy at Vanderbilt University, Nashville, Tenn., who researches stigma associated with opioid use during pregnancy.

Administrators at SSM St. Mary’s Hospital in St. Louis initially balked at providing private rooms for mothers and their babies with NAS and NOWS, according to Kimberly Spence, MD, a neonatologist at SSM Health. She said the initial plan was to put the babies in a busy, brightly lit nursery.

But resistance waned as the hospital convinced health plans to pay for private rooms for the 5-7 days it typically takes a baby to go through withdrawal, said Dr. Spence, associate professor of pediatrics at Saint Louis University.

“We were able to provide enough data that this is evidence-based medicine and babies do better with their moms, and that ethically, this is the right thing to do, to reduce transfers to an NICU,” she said.

In addition, news stories about the family-centric approach and shorter stays for infants, along with SSM’s launch of an outpatient clinic to treat pregnant women with opioid use disorder, helped the system to attract more patients and increase its market share, said Dr. Spence.

Another challenge was getting physicians and nurses to set aside any judgments of parents with substance abuse disorder, according to Dr. Grossman and others.

“A lot of faculty and staff on the medical team didn’t feel like we should trust moms with their babies’ medical care” at SSM, Dr. Spence said.

Some hospitals conduct anti-bias training to teach providers that substance abuse is a disease that deserves proper medical treatment and not the moral failing of a patient. Such education may involve explaining that babies’ outcomes are improved when women undergo treatment with methadone or buprenorphine during pregnancy, even though use of those medications does pose a risk of NAS.

Creating a system that supports parents with substance abuse disorders may help to change perceptions. At Atrium Health, some staff members now enjoy working with these families because they can make a profound impact, Dr. Dodds said. He said they’ve learned that families suffering from substance abuse disorder “are not that different than any other family.”

Dr. Dodds, Dr. Patrick, Dr. Spence, and Dr. Grossman reported no relevant financial relationships.

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

Ob.gyns. will not have to travel to Texas to take the board certification exam this fall. 

The announcement from the American Board of Obstetrics & Gynecology follows worries from physicians that gathering in large groups for the examination would leave them vulnerable to physical or political retaliation in the wake of the Supreme Court’s decision to overturn Roe v. Wade.

ABOG is headquartered in Dallas; Texas is one of many states with a near-complete ban on abortion.

Though certification is voluntary, many doctors opt to take the 3-hour oral test to enhance their medical expertise beyond what their state requires. 

ABOG held board certification exams online during the pandemic, with plans to return to in-person testing this fall. However, last week, the board said that online testing will continue “due to the increase in COVID-19 cases across the country and concerns regarding the U.S. Supreme Court opinion on Dobbs v. Jackson Women’s Health Organization.”

More than 500 physicians petitioned against having in-person board certification exams last month in a letter addressed to the board.

“The state of Texas has severely restricted access to abortion and has allowed private citizens to take legal action against anyone suspected of assisting or performing terminations,” the letter says. “Due to the ‘aid and abet’ clause included in SB8, we may be targeted for legal or political retribution.”

SB8 is shorthand for the Texas Heartbeat Act, which authorizes anyone in the state of Texas to sue any individual whom they believe to have performed or induced an abortion, as well as people who aid or abet abortions in any way, such as paying for the abortion through their insurance.

Pregnant exam-takers also feared having to seek care for potential complications in Texas.

“We see no justifiable reason to mandate in-person oral board exams in a state that restricts basic healthcare of pregnant people and whose laws encourage vigilante targeting of physicians who perform abortions,” the letter continues.

Alice Abernathy, MD, a national clinician scholar in obstetrics and gynecology at the University of Pennsylvania, Philadelphia, signed the petition and would be required to travel to Texas for her certification exam next year if ABOG’s future exam cycles are held in person.

“My job is straightforward – I take care of patients. I will not expose myself to risk of prosecution for delivering the highest standard of comprehensive reproductive health care to my patients,” Dr. Abernathy told this news organization.

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

Ob.gyns. will not have to travel to Texas to take the board certification exam this fall. 

The announcement from the American Board of Obstetrics & Gynecology follows worries from physicians that gathering in large groups for the examination would leave them vulnerable to physical or political retaliation in the wake of the Supreme Court’s decision to overturn Roe v. Wade.

ABOG is headquartered in Dallas; Texas is one of many states with a near-complete ban on abortion.

Though certification is voluntary, many doctors opt to take the 3-hour oral test to enhance their medical expertise beyond what their state requires. 

ABOG held board certification exams online during the pandemic, with plans to return to in-person testing this fall. However, last week, the board said that online testing will continue “due to the increase in COVID-19 cases across the country and concerns regarding the U.S. Supreme Court opinion on Dobbs v. Jackson Women’s Health Organization.”

More than 500 physicians petitioned against having in-person board certification exams last month in a letter addressed to the board.

“The state of Texas has severely restricted access to abortion and has allowed private citizens to take legal action against anyone suspected of assisting or performing terminations,” the letter says. “Due to the ‘aid and abet’ clause included in SB8, we may be targeted for legal or political retribution.”

SB8 is shorthand for the Texas Heartbeat Act, which authorizes anyone in the state of Texas to sue any individual whom they believe to have performed or induced an abortion, as well as people who aid or abet abortions in any way, such as paying for the abortion through their insurance.

Pregnant exam-takers also feared having to seek care for potential complications in Texas.

“We see no justifiable reason to mandate in-person oral board exams in a state that restricts basic healthcare of pregnant people and whose laws encourage vigilante targeting of physicians who perform abortions,” the letter continues.

Alice Abernathy, MD, a national clinician scholar in obstetrics and gynecology at the University of Pennsylvania, Philadelphia, signed the petition and would be required to travel to Texas for her certification exam next year if ABOG’s future exam cycles are held in person.

“My job is straightforward – I take care of patients. I will not expose myself to risk of prosecution for delivering the highest standard of comprehensive reproductive health care to my patients,” Dr. Abernathy told this news organization.

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

Ob.gyns. will not have to travel to Texas to take the board certification exam this fall. 

The announcement from the American Board of Obstetrics & Gynecology follows worries from physicians that gathering in large groups for the examination would leave them vulnerable to physical or political retaliation in the wake of the Supreme Court’s decision to overturn Roe v. Wade.

ABOG is headquartered in Dallas; Texas is one of many states with a near-complete ban on abortion.

Though certification is voluntary, many doctors opt to take the 3-hour oral test to enhance their medical expertise beyond what their state requires. 

ABOG held board certification exams online during the pandemic, with plans to return to in-person testing this fall. However, last week, the board said that online testing will continue “due to the increase in COVID-19 cases across the country and concerns regarding the U.S. Supreme Court opinion on Dobbs v. Jackson Women’s Health Organization.”

More than 500 physicians petitioned against having in-person board certification exams last month in a letter addressed to the board.

“The state of Texas has severely restricted access to abortion and has allowed private citizens to take legal action against anyone suspected of assisting or performing terminations,” the letter says. “Due to the ‘aid and abet’ clause included in SB8, we may be targeted for legal or political retribution.”

SB8 is shorthand for the Texas Heartbeat Act, which authorizes anyone in the state of Texas to sue any individual whom they believe to have performed or induced an abortion, as well as people who aid or abet abortions in any way, such as paying for the abortion through their insurance.

Pregnant exam-takers also feared having to seek care for potential complications in Texas.

“We see no justifiable reason to mandate in-person oral board exams in a state that restricts basic healthcare of pregnant people and whose laws encourage vigilante targeting of physicians who perform abortions,” the letter continues.

Alice Abernathy, MD, a national clinician scholar in obstetrics and gynecology at the University of Pennsylvania, Philadelphia, signed the petition and would be required to travel to Texas for her certification exam next year if ABOG’s future exam cycles are held in person.

“My job is straightforward – I take care of patients. I will not expose myself to risk of prosecution for delivering the highest standard of comprehensive reproductive health care to my patients,” Dr. Abernathy told this news organization.

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

U.S. children appear to be failing an important test – of their hearts, not minds.

New research from the Ann & Robert H. Lurie Children’s Hospital of Chicago shows that heart health is a concern for many long before adulthood because fewer than one-third of children aged 2-19 years scored highly on the American Heart Association’s checklist for ideal cardiovascular fitness.

“This study gives us a new baseline for children’s heart health in the United States,” said Amanda Perak, MD, pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago and a coauthor of the study.

Dr. Perak and colleagues published their findings in the journal Circulation.

The researchers identified 9888 children who completed the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey between 2013 and 2018. They analyzed the available data using the AHA’s Life’s Essential 8 – a 100-point assessment of eight predictors for measuring heart health, including sleep, nicotine exposure, and blood glucose.

Data for only three metrics were available for all children in the study: diet, physical activity, and body mass index. As children aged, more metrics were averaged to obtain the overall cardiovascular health score. For instance, cholesterol/lipid levels become available at age 6 years, and blood pressure can be measured starting at age 8 years.

Only 2.2% of children in the study had optimal heart health, according to the Life’s Essential 8 scoring system, which spans poor (0-49), moderate (50-79), and high (80-100). Fewer than one in three (29.1%) overall had high scores, and scores worsened with age.

In the 2- to 5-year age group, over half (56.5%) of the children had good heart health. However, only one-third (33.5%) of 6- to 11-year-olds scored highly. Meanwhile, only 14% of adolescents had good heart scores, Dr. Perak’s group found.

Heart health scores based on diet were lowest for every age group. In the youngest age group, the average cardiovascular health (CVH) score was about 61. In the 12- to 19-year age group, however, the average CVH score decreased to 28.5, the lowest measured score for any group in the study.

With such worrisome diet scores for the 12- to 19-year-old group, public health policies need to focus on changes, like removing sugar-sweetened beverage options from schools, according to Joseph Mahgerefteh, MD, director of preventive cardiology at the Mount Sinai Kravis Children’s Heart Center, New York. He added that parents and their children also have a role to play.

“Some of our teenagers forget they can drink water when they are thirsty, and it is not necessary to drink sugar-sweetened beverages for thirst,” Dr. Mahgerefteh, who was not involved in the study, said in an interview. “Fresh vegetable intake is so low to a degree that some of our patients refuse to have any type of vegetable in their diet.”

“As a physician community caring for these patients, we need to be much more aggressive with our counseling and referral of these patients,” added Barry Love, MD, director of the congenital cardiac catheterization program at the Mount Sinai Kravis Children’s Heart Center. “These youngsters will inevitably encounter the effect of these conditions – coronary artery disease and stroke – at a much earlier adult age.”

Dr. Perak, Dr. Mahgerefteh, and Dr. Love reported no relevant financial conflicts of interest.

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

U.S. children appear to be failing an important test – of their hearts, not minds.

New research from the Ann & Robert H. Lurie Children’s Hospital of Chicago shows that heart health is a concern for many long before adulthood because fewer than one-third of children aged 2-19 years scored highly on the American Heart Association’s checklist for ideal cardiovascular fitness.

“This study gives us a new baseline for children’s heart health in the United States,” said Amanda Perak, MD, pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago and a coauthor of the study.

Dr. Perak and colleagues published their findings in the journal Circulation.

The researchers identified 9888 children who completed the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey between 2013 and 2018. They analyzed the available data using the AHA’s Life’s Essential 8 – a 100-point assessment of eight predictors for measuring heart health, including sleep, nicotine exposure, and blood glucose.

Data for only three metrics were available for all children in the study: diet, physical activity, and body mass index. As children aged, more metrics were averaged to obtain the overall cardiovascular health score. For instance, cholesterol/lipid levels become available at age 6 years, and blood pressure can be measured starting at age 8 years.

Only 2.2% of children in the study had optimal heart health, according to the Life’s Essential 8 scoring system, which spans poor (0-49), moderate (50-79), and high (80-100). Fewer than one in three (29.1%) overall had high scores, and scores worsened with age.

In the 2- to 5-year age group, over half (56.5%) of the children had good heart health. However, only one-third (33.5%) of 6- to 11-year-olds scored highly. Meanwhile, only 14% of adolescents had good heart scores, Dr. Perak’s group found.

Heart health scores based on diet were lowest for every age group. In the youngest age group, the average cardiovascular health (CVH) score was about 61. In the 12- to 19-year age group, however, the average CVH score decreased to 28.5, the lowest measured score for any group in the study.

With such worrisome diet scores for the 12- to 19-year-old group, public health policies need to focus on changes, like removing sugar-sweetened beverage options from schools, according to Joseph Mahgerefteh, MD, director of preventive cardiology at the Mount Sinai Kravis Children’s Heart Center, New York. He added that parents and their children also have a role to play.

“Some of our teenagers forget they can drink water when they are thirsty, and it is not necessary to drink sugar-sweetened beverages for thirst,” Dr. Mahgerefteh, who was not involved in the study, said in an interview. “Fresh vegetable intake is so low to a degree that some of our patients refuse to have any type of vegetable in their diet.”

“As a physician community caring for these patients, we need to be much more aggressive with our counseling and referral of these patients,” added Barry Love, MD, director of the congenital cardiac catheterization program at the Mount Sinai Kravis Children’s Heart Center. “These youngsters will inevitably encounter the effect of these conditions – coronary artery disease and stroke – at a much earlier adult age.”

Dr. Perak, Dr. Mahgerefteh, and Dr. Love reported no relevant financial conflicts of interest.

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

U.S. children appear to be failing an important test – of their hearts, not minds.

New research from the Ann & Robert H. Lurie Children’s Hospital of Chicago shows that heart health is a concern for many long before adulthood because fewer than one-third of children aged 2-19 years scored highly on the American Heart Association’s checklist for ideal cardiovascular fitness.

“This study gives us a new baseline for children’s heart health in the United States,” said Amanda Perak, MD, pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago and a coauthor of the study.

Dr. Perak and colleagues published their findings in the journal Circulation.

The researchers identified 9888 children who completed the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey between 2013 and 2018. They analyzed the available data using the AHA’s Life’s Essential 8 – a 100-point assessment of eight predictors for measuring heart health, including sleep, nicotine exposure, and blood glucose.

Data for only three metrics were available for all children in the study: diet, physical activity, and body mass index. As children aged, more metrics were averaged to obtain the overall cardiovascular health score. For instance, cholesterol/lipid levels become available at age 6 years, and blood pressure can be measured starting at age 8 years.

Only 2.2% of children in the study had optimal heart health, according to the Life’s Essential 8 scoring system, which spans poor (0-49), moderate (50-79), and high (80-100). Fewer than one in three (29.1%) overall had high scores, and scores worsened with age.

In the 2- to 5-year age group, over half (56.5%) of the children had good heart health. However, only one-third (33.5%) of 6- to 11-year-olds scored highly. Meanwhile, only 14% of adolescents had good heart scores, Dr. Perak’s group found.

Heart health scores based on diet were lowest for every age group. In the youngest age group, the average cardiovascular health (CVH) score was about 61. In the 12- to 19-year age group, however, the average CVH score decreased to 28.5, the lowest measured score for any group in the study.

With such worrisome diet scores for the 12- to 19-year-old group, public health policies need to focus on changes, like removing sugar-sweetened beverage options from schools, according to Joseph Mahgerefteh, MD, director of preventive cardiology at the Mount Sinai Kravis Children’s Heart Center, New York. He added that parents and their children also have a role to play.

“Some of our teenagers forget they can drink water when they are thirsty, and it is not necessary to drink sugar-sweetened beverages for thirst,” Dr. Mahgerefteh, who was not involved in the study, said in an interview. “Fresh vegetable intake is so low to a degree that some of our patients refuse to have any type of vegetable in their diet.”

“As a physician community caring for these patients, we need to be much more aggressive with our counseling and referral of these patients,” added Barry Love, MD, director of the congenital cardiac catheterization program at the Mount Sinai Kravis Children’s Heart Center. “These youngsters will inevitably encounter the effect of these conditions – coronary artery disease and stroke – at a much earlier adult age.”

Dr. Perak, Dr. Mahgerefteh, and Dr. Love reported no relevant financial conflicts of interest.

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

Few people like to pay taxes, and physicians are no exception.

For the Medscape Physicians and Taxes Report 2022, physicians shared information about their tax debt as well as how they feel about the U.S. tax code, audits, and the prospects for the future.

Even though it may not always seem that way to physicians, their family tax bills – around $75,406 on average – are in line with the other top 10% of U.S. taxpayers, according to an examination of IRS data by the Tax Foundation. However, when it comes to local taxes, the Tax Foundation found that physicians pay more than average. (Forty-three states collect tax on individual incomes.)

The average physician’s family pays a 35% marginal tax rate, compared with the top marginal tax rate in the United States of 37%. (The marginal tax rate is the highest amount of tax charged on each additional dollar after the IRS bracket rates are applied to your income.)

According to Alexis Gallati, founder of Cerebral Tax Advisors, a Knoxville, Tenn.–based firm that caters to medical professionals, doctors also should pay attention to their effective tax rate, or the percentage of income they pay in taxes. It takes into account differing tax rates on ordinary income, capital gains, and other income sources, she says. “It gives a better 30,000-foot view of your tax situation.”

Some high-income families are required to pay the Alternative Minimum Tax (AMT), though in 2019 that applied to only one-tenth of U.S. households. The AMT is designed to make sure that high earners with many options for exemptions and deductions still contribute a minimum amount of tax. Only 13% of physicians surveyed said they paid the AMT, though 29% were unsure.
 

Filing taxes as painful as paying them

According to a 2021 Gallup poll, 50% of Americans think they pay too much tax. (About 44% think their tax bill is about right, and a kindhearted 4% think they pay too little.) Doctors are outliers on this one, with 75% saying they pay too much in taxes.

When asked what they would do to fix the tax system, the physicians in the Medscape survey had a wide array of proposed solutions, from “drop the corporate tax rate to nearly nothing to stimulate the economy” to “everyone should pay equitably. There are too many loopholes for the very wealthy.”

Some of the complaints were less about tax rates than the process of filing. One respondent said: “I would love for this system to not be our personal responsibility. Why should it be my duty to pay someone every year to do my taxes?”

About 48% of physicians prepare their own taxes (about the same percentage as the rest of the population), with most of those filing electronically, primarily because it saves time and the software is easy to use. Intuit TurboTax was the most popular online software, with 22% of respondents saying they currently used this product.

Of those who did pay someone to prepare their taxes, the complexity of their taxes cost them; the average respondent paid about three times the average rate for the service. In the long run, the cost might have been recouped.

Navjeet Chahal, managing partner and CEO of Chahal and Associates, a San Francisco–area firm specializing in working with physicians, points out that tax advisors don’t just fill out the forms; they proactively advise physicians about how they can limit their taxes. And indeed, most respondents feel that they got their money’s worth, with 70% saying their tax preparers charged a fair fee.

Though the physicians surveyed tended to think they pay too much tax, and several mentioned particular gripes with the system, the complexity of the tax code didn’t seem to be a big issue. While 82% of Americans polled in 2021 by Pew Research said they were bothered “a lot” or “some” by the complexity of the tax system, 68% of physicians agreed or slightly agreed that the U.S. tax system “makes sense.”
 

Gimme a break

Physicians are the beneficiaries of several types of tax breaks. Contributing to a pretax 401(k) account was the most common exemption, with 60% of physicians surveyed using this plan. Other tax breaks cited by respondents were: contributing to charity (54%), home mortgage interest (46%), and writing off business expenses (39%).

About one in five physicians has experienced an audit, but that risk has declined significantly in recent years, thanks to tighter IRS budgets. Overall, only about 1 in 167 U.S. taxpayers were audited in 2020, according to the IRS. Even for taxpayers reporting $5 million or more in income, the audit rate is only about 0.25%, the Government Accountability Office says.

The odds of a physician being summoned to a meeting with an auditor probably won’t increase for a few years, Mr. Gallati said. But the good news for doctors is bad news for lower-income Americans. “The IRS is woefully understaffed and underfunded, with the result that the agency is going for lower-hanging fruit and auditing more people in lower income brackets,” she said in an interview.

While one respondent described his experience with the IRS as “the audit from hell,” others thought it not so bad, with 72% saying the auditors treated them fairly. One respondent described the audit as “boring, short, and successful for me. The IRS owed me money.”

When it comes to taxes, physician respondents, on the whole, did not seem to be optimistic about the future. About 61% expect an increase in their tax rate because of Biden administration policies. One respondent veered into hyperbole with the comment: “I believe taxes will increase for physicians until they have no more money!”

Mr. Chahal doesn’t see it that way. He pointed out that recent attempts to raise taxes completely failed. “I personally don’t see that happening unless there’s a significant shift in the House and the Senate.”

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

Few people like to pay taxes, and physicians are no exception.

For the Medscape Physicians and Taxes Report 2022, physicians shared information about their tax debt as well as how they feel about the U.S. tax code, audits, and the prospects for the future.

Even though it may not always seem that way to physicians, their family tax bills – around $75,406 on average – are in line with the other top 10% of U.S. taxpayers, according to an examination of IRS data by the Tax Foundation. However, when it comes to local taxes, the Tax Foundation found that physicians pay more than average. (Forty-three states collect tax on individual incomes.)

The average physician’s family pays a 35% marginal tax rate, compared with the top marginal tax rate in the United States of 37%. (The marginal tax rate is the highest amount of tax charged on each additional dollar after the IRS bracket rates are applied to your income.)

According to Alexis Gallati, founder of Cerebral Tax Advisors, a Knoxville, Tenn.–based firm that caters to medical professionals, doctors also should pay attention to their effective tax rate, or the percentage of income they pay in taxes. It takes into account differing tax rates on ordinary income, capital gains, and other income sources, she says. “It gives a better 30,000-foot view of your tax situation.”

Some high-income families are required to pay the Alternative Minimum Tax (AMT), though in 2019 that applied to only one-tenth of U.S. households. The AMT is designed to make sure that high earners with many options for exemptions and deductions still contribute a minimum amount of tax. Only 13% of physicians surveyed said they paid the AMT, though 29% were unsure.
 

Filing taxes as painful as paying them

According to a 2021 Gallup poll, 50% of Americans think they pay too much tax. (About 44% think their tax bill is about right, and a kindhearted 4% think they pay too little.) Doctors are outliers on this one, with 75% saying they pay too much in taxes.

When asked what they would do to fix the tax system, the physicians in the Medscape survey had a wide array of proposed solutions, from “drop the corporate tax rate to nearly nothing to stimulate the economy” to “everyone should pay equitably. There are too many loopholes for the very wealthy.”

Some of the complaints were less about tax rates than the process of filing. One respondent said: “I would love for this system to not be our personal responsibility. Why should it be my duty to pay someone every year to do my taxes?”

About 48% of physicians prepare their own taxes (about the same percentage as the rest of the population), with most of those filing electronically, primarily because it saves time and the software is easy to use. Intuit TurboTax was the most popular online software, with 22% of respondents saying they currently used this product.

Of those who did pay someone to prepare their taxes, the complexity of their taxes cost them; the average respondent paid about three times the average rate for the service. In the long run, the cost might have been recouped.

Navjeet Chahal, managing partner and CEO of Chahal and Associates, a San Francisco–area firm specializing in working with physicians, points out that tax advisors don’t just fill out the forms; they proactively advise physicians about how they can limit their taxes. And indeed, most respondents feel that they got their money’s worth, with 70% saying their tax preparers charged a fair fee.

Though the physicians surveyed tended to think they pay too much tax, and several mentioned particular gripes with the system, the complexity of the tax code didn’t seem to be a big issue. While 82% of Americans polled in 2021 by Pew Research said they were bothered “a lot” or “some” by the complexity of the tax system, 68% of physicians agreed or slightly agreed that the U.S. tax system “makes sense.”
 

Gimme a break

Physicians are the beneficiaries of several types of tax breaks. Contributing to a pretax 401(k) account was the most common exemption, with 60% of physicians surveyed using this plan. Other tax breaks cited by respondents were: contributing to charity (54%), home mortgage interest (46%), and writing off business expenses (39%).

About one in five physicians has experienced an audit, but that risk has declined significantly in recent years, thanks to tighter IRS budgets. Overall, only about 1 in 167 U.S. taxpayers were audited in 2020, according to the IRS. Even for taxpayers reporting $5 million or more in income, the audit rate is only about 0.25%, the Government Accountability Office says.

The odds of a physician being summoned to a meeting with an auditor probably won’t increase for a few years, Mr. Gallati said. But the good news for doctors is bad news for lower-income Americans. “The IRS is woefully understaffed and underfunded, with the result that the agency is going for lower-hanging fruit and auditing more people in lower income brackets,” she said in an interview.

While one respondent described his experience with the IRS as “the audit from hell,” others thought it not so bad, with 72% saying the auditors treated them fairly. One respondent described the audit as “boring, short, and successful for me. The IRS owed me money.”

When it comes to taxes, physician respondents, on the whole, did not seem to be optimistic about the future. About 61% expect an increase in their tax rate because of Biden administration policies. One respondent veered into hyperbole with the comment: “I believe taxes will increase for physicians until they have no more money!”

Mr. Chahal doesn’t see it that way. He pointed out that recent attempts to raise taxes completely failed. “I personally don’t see that happening unless there’s a significant shift in the House and the Senate.”

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

Few people like to pay taxes, and physicians are no exception.

For the Medscape Physicians and Taxes Report 2022, physicians shared information about their tax debt as well as how they feel about the U.S. tax code, audits, and the prospects for the future.

Even though it may not always seem that way to physicians, their family tax bills – around $75,406 on average – are in line with the other top 10% of U.S. taxpayers, according to an examination of IRS data by the Tax Foundation. However, when it comes to local taxes, the Tax Foundation found that physicians pay more than average. (Forty-three states collect tax on individual incomes.)

The average physician’s family pays a 35% marginal tax rate, compared with the top marginal tax rate in the United States of 37%. (The marginal tax rate is the highest amount of tax charged on each additional dollar after the IRS bracket rates are applied to your income.)

According to Alexis Gallati, founder of Cerebral Tax Advisors, a Knoxville, Tenn.–based firm that caters to medical professionals, doctors also should pay attention to their effective tax rate, or the percentage of income they pay in taxes. It takes into account differing tax rates on ordinary income, capital gains, and other income sources, she says. “It gives a better 30,000-foot view of your tax situation.”

Some high-income families are required to pay the Alternative Minimum Tax (AMT), though in 2019 that applied to only one-tenth of U.S. households. The AMT is designed to make sure that high earners with many options for exemptions and deductions still contribute a minimum amount of tax. Only 13% of physicians surveyed said they paid the AMT, though 29% were unsure.
 

Filing taxes as painful as paying them

According to a 2021 Gallup poll, 50% of Americans think they pay too much tax. (About 44% think their tax bill is about right, and a kindhearted 4% think they pay too little.) Doctors are outliers on this one, with 75% saying they pay too much in taxes.

When asked what they would do to fix the tax system, the physicians in the Medscape survey had a wide array of proposed solutions, from “drop the corporate tax rate to nearly nothing to stimulate the economy” to “everyone should pay equitably. There are too many loopholes for the very wealthy.”

Some of the complaints were less about tax rates than the process of filing. One respondent said: “I would love for this system to not be our personal responsibility. Why should it be my duty to pay someone every year to do my taxes?”

About 48% of physicians prepare their own taxes (about the same percentage as the rest of the population), with most of those filing electronically, primarily because it saves time and the software is easy to use. Intuit TurboTax was the most popular online software, with 22% of respondents saying they currently used this product.

Of those who did pay someone to prepare their taxes, the complexity of their taxes cost them; the average respondent paid about three times the average rate for the service. In the long run, the cost might have been recouped.

Navjeet Chahal, managing partner and CEO of Chahal and Associates, a San Francisco–area firm specializing in working with physicians, points out that tax advisors don’t just fill out the forms; they proactively advise physicians about how they can limit their taxes. And indeed, most respondents feel that they got their money’s worth, with 70% saying their tax preparers charged a fair fee.

Though the physicians surveyed tended to think they pay too much tax, and several mentioned particular gripes with the system, the complexity of the tax code didn’t seem to be a big issue. While 82% of Americans polled in 2021 by Pew Research said they were bothered “a lot” or “some” by the complexity of the tax system, 68% of physicians agreed or slightly agreed that the U.S. tax system “makes sense.”
 

Gimme a break

Physicians are the beneficiaries of several types of tax breaks. Contributing to a pretax 401(k) account was the most common exemption, with 60% of physicians surveyed using this plan. Other tax breaks cited by respondents were: contributing to charity (54%), home mortgage interest (46%), and writing off business expenses (39%).

About one in five physicians has experienced an audit, but that risk has declined significantly in recent years, thanks to tighter IRS budgets. Overall, only about 1 in 167 U.S. taxpayers were audited in 2020, according to the IRS. Even for taxpayers reporting $5 million or more in income, the audit rate is only about 0.25%, the Government Accountability Office says.

The odds of a physician being summoned to a meeting with an auditor probably won’t increase for a few years, Mr. Gallati said. But the good news for doctors is bad news for lower-income Americans. “The IRS is woefully understaffed and underfunded, with the result that the agency is going for lower-hanging fruit and auditing more people in lower income brackets,” she said in an interview.

While one respondent described his experience with the IRS as “the audit from hell,” others thought it not so bad, with 72% saying the auditors treated them fairly. One respondent described the audit as “boring, short, and successful for me. The IRS owed me money.”

When it comes to taxes, physician respondents, on the whole, did not seem to be optimistic about the future. About 61% expect an increase in their tax rate because of Biden administration policies. One respondent veered into hyperbole with the comment: “I believe taxes will increase for physicians until they have no more money!”

Mr. Chahal doesn’t see it that way. He pointed out that recent attempts to raise taxes completely failed. “I personally don’t see that happening unless there’s a significant shift in the House and the Senate.”

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

INDIANAPOLIS – Onset of recurrent reactive infectious mucocutaneous eruption (RIME) was most common among males between the ages of 11 and 12 years, which is younger than previously described, in a single-center retrospective study. In addition, 71% of patients with recurrent disease experienced 1-2 recurrences – episodes that were generally milder and occurred at variable intervals.

Those are among key findings from the study of 50 patients with RIME, presented by Catherina X. Pan at the annual meeting of the Society for Pediatric Dermatology.

Reactive infectious mucocutaneous eruption (RIME) is a novel term encompassing an array of rare, parainfectious mucositis diseases, noted Ms. Pan, a fourth-year medical student at Harvard Medical School, Boston. Previously known as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), common clinical characteristics of RIME include less than 10% body surface area involvement of polymorphic skin lesions (vesiculobullous or targetoid macules/papules); erosive oral, genital, and/or ocular mucositis involving more than two sites, and evidence of prior infection including but not limited to upper respiratory infection, fever, and cough.

In addition to M. pneumoniae, other pathogens have been implicated, she said. “While the underlying etiology of the disease is not entirely clear, it’s become increasingly known that RIME tends to recur in a subset of patients.”

A cohort study of 13 patients with RIME found that Black race, male sex, and older age were predominant among the five patients who developed recurrent disease.

The estimated recurrence rate is between 8% and 38%, but the clinical characteristics of patients who develop recurrent RIME tend to be poorly understood, Ms. Pan said.

Along with her mentor, Sadaf Hussain, MD, of the department of dermatology at Boston Children’s Hospital, Ms. Pan conducted a retrospective chart review to characterize the clinical history and course of disease in patients diagnosed with recurrent RIME. They extracted data between January of 2000 and March of 2022 using ICD-10 codes used by board-certified dermatologists at Boston Children’s Hospital, as well as a text search for RIME or MIRM in the dermatology notes. Patients were included if they had a RIME/MIRM diagnosis by a board-certified dermatologist and/or infection on PCR/serology and mucositis involvement with limited skin involvement.

The study population included 50 patients: 24 with recurrent RIME and 26 with isolated RIME. The majority (66%) were male, and the mean age of RIME onset was between 11 and 12 years old, which is up to two years younger than previously reported in the case series of 13 patients. Most of the study participants (79%) were White, but there were no significant differences in patients who had recurrent RIME and those who had isolated RIME in terms of age, sex, or race.
 

Isolated vs. recurrent RIME

However, compared with patients who had isolated RIME, a greater proportion of those with recurrent RIME had a history of atopic disease (46% vs. 23%, respectively; P = .136), as well as a history of tonsillectomy and adenoidectomy (25% vs. 4%; P = .045). “This has not been previously observed, but it may generate a hypothesis that patients with a history of frequent infection as well as amplified immune responses may be associated with disease recurrence,” Ms. Pan said.

The average number of episodes among patients with recurrent RIME was 3.5 and the interval between episodes was variable, at a mean of 10.2 months. Ms. Pan reported that 71% of recurrent RIME patients experienced 1-2 episodes, although one patient experienced 9 episodes.

Clinically, episodes among all patients with RIME were characterized by infectious prodromal symptoms (69%), oral lesions (95%), ocular lesions (60%), genital lesions (41%) and cutaneous lesions (40%). However, RIME recurrences were less severe and more atypical, with 49% involving only one mucosal surface and 29% involving two mucosal surfaces. Also, except for oral lesions, rates of infectious prodromal symptoms and other lesions significantly decreased among recurrences compared with initial RIME.

“Notably, we found that M. pneumoniae was the most common known cause of RIME, particularly among the initial episodes,” Ms. Pan said. “However, 61% of recurrent RIME episodes did not have a known cause in terms of infectious etiology. And, concordant with prior studies, we also found decreased severity [of RIME recurrences] as indicated by decreased rates of emergency department presentation, hospitalization, and duration of hospitalization.”

In other findings, psychiatric complications such as anxiety and depression followed the onset of RIME in 33% of those with recurrent disease and 22% of those with isolated disease. In addition, the three most common treatments among all 50 patients were systemic steroids, topical steroids, and M. pneumoniae-specific antibiotics.

“While RIME is considered as typically milder than Stevens-Johnson syndrome and toxic epidermal necrolysis with low mortality rates, it can lead to severe complications including conjunctival shrinkage, corneal ulceration and scarring, blindness, and oral, ocular, urogenital synechiae,” Ms. Pan noted. “Increased use of corticosteroids and steroid-sparing agents such as IVIG have also been observed. Multidisciplinary care with ophthalmology, urology, and mental health services is critical.”

She acknowledged certain limitations of the study, including its retrospective, single-center design, and the possibility that milder cases may have been excluded due to a lack of accurate diagnosis or referral.

Carrie C. Coughlin, MD, who was asked to comment on the study results, pointed out that nearly half (24) of patients in the cohort experienced recurrent RIME. “This is a high proportion, suggesting counseling about the possibility of recurrence is more important than previously thought,” said Dr. Coughlin, director of the section of pediatric dermatology Washington University/St. Louis Children’s Hospital.

“Fortunately, recurrent cases tended to be less severe. However, many patients had more than one recurrence, making this challenging for affected patients.”

The researchers reported having no financial disclosures. Dr. Coughlin is on the board of the Pediatric Dermatology Research Alliance (PeDRA) and the International Immunosuppression and Transplant Skin Cancer Collaborative.

INDIANAPOLIS – Onset of recurrent reactive infectious mucocutaneous eruption (RIME) was most common among males between the ages of 11 and 12 years, which is younger than previously described, in a single-center retrospective study. In addition, 71% of patients with recurrent disease experienced 1-2 recurrences – episodes that were generally milder and occurred at variable intervals.

Those are among key findings from the study of 50 patients with RIME, presented by Catherina X. Pan at the annual meeting of the Society for Pediatric Dermatology.

Reactive infectious mucocutaneous eruption (RIME) is a novel term encompassing an array of rare, parainfectious mucositis diseases, noted Ms. Pan, a fourth-year medical student at Harvard Medical School, Boston. Previously known as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), common clinical characteristics of RIME include less than 10% body surface area involvement of polymorphic skin lesions (vesiculobullous or targetoid macules/papules); erosive oral, genital, and/or ocular mucositis involving more than two sites, and evidence of prior infection including but not limited to upper respiratory infection, fever, and cough.

In addition to M. pneumoniae, other pathogens have been implicated, she said. “While the underlying etiology of the disease is not entirely clear, it’s become increasingly known that RIME tends to recur in a subset of patients.”

A cohort study of 13 patients with RIME found that Black race, male sex, and older age were predominant among the five patients who developed recurrent disease.

The estimated recurrence rate is between 8% and 38%, but the clinical characteristics of patients who develop recurrent RIME tend to be poorly understood, Ms. Pan said.

Along with her mentor, Sadaf Hussain, MD, of the department of dermatology at Boston Children’s Hospital, Ms. Pan conducted a retrospective chart review to characterize the clinical history and course of disease in patients diagnosed with recurrent RIME. They extracted data between January of 2000 and March of 2022 using ICD-10 codes used by board-certified dermatologists at Boston Children’s Hospital, as well as a text search for RIME or MIRM in the dermatology notes. Patients were included if they had a RIME/MIRM diagnosis by a board-certified dermatologist and/or infection on PCR/serology and mucositis involvement with limited skin involvement.

The study population included 50 patients: 24 with recurrent RIME and 26 with isolated RIME. The majority (66%) were male, and the mean age of RIME onset was between 11 and 12 years old, which is up to two years younger than previously reported in the case series of 13 patients. Most of the study participants (79%) were White, but there were no significant differences in patients who had recurrent RIME and those who had isolated RIME in terms of age, sex, or race.
 

Isolated vs. recurrent RIME

However, compared with patients who had isolated RIME, a greater proportion of those with recurrent RIME had a history of atopic disease (46% vs. 23%, respectively; P = .136), as well as a history of tonsillectomy and adenoidectomy (25% vs. 4%; P = .045). “This has not been previously observed, but it may generate a hypothesis that patients with a history of frequent infection as well as amplified immune responses may be associated with disease recurrence,” Ms. Pan said.

The average number of episodes among patients with recurrent RIME was 3.5 and the interval between episodes was variable, at a mean of 10.2 months. Ms. Pan reported that 71% of recurrent RIME patients experienced 1-2 episodes, although one patient experienced 9 episodes.

Clinically, episodes among all patients with RIME were characterized by infectious prodromal symptoms (69%), oral lesions (95%), ocular lesions (60%), genital lesions (41%) and cutaneous lesions (40%). However, RIME recurrences were less severe and more atypical, with 49% involving only one mucosal surface and 29% involving two mucosal surfaces. Also, except for oral lesions, rates of infectious prodromal symptoms and other lesions significantly decreased among recurrences compared with initial RIME.

“Notably, we found that M. pneumoniae was the most common known cause of RIME, particularly among the initial episodes,” Ms. Pan said. “However, 61% of recurrent RIME episodes did not have a known cause in terms of infectious etiology. And, concordant with prior studies, we also found decreased severity [of RIME recurrences] as indicated by decreased rates of emergency department presentation, hospitalization, and duration of hospitalization.”

In other findings, psychiatric complications such as anxiety and depression followed the onset of RIME in 33% of those with recurrent disease and 22% of those with isolated disease. In addition, the three most common treatments among all 50 patients were systemic steroids, topical steroids, and M. pneumoniae-specific antibiotics.

“While RIME is considered as typically milder than Stevens-Johnson syndrome and toxic epidermal necrolysis with low mortality rates, it can lead to severe complications including conjunctival shrinkage, corneal ulceration and scarring, blindness, and oral, ocular, urogenital synechiae,” Ms. Pan noted. “Increased use of corticosteroids and steroid-sparing agents such as IVIG have also been observed. Multidisciplinary care with ophthalmology, urology, and mental health services is critical.”

She acknowledged certain limitations of the study, including its retrospective, single-center design, and the possibility that milder cases may have been excluded due to a lack of accurate diagnosis or referral.

Carrie C. Coughlin, MD, who was asked to comment on the study results, pointed out that nearly half (24) of patients in the cohort experienced recurrent RIME. “This is a high proportion, suggesting counseling about the possibility of recurrence is more important than previously thought,” said Dr. Coughlin, director of the section of pediatric dermatology Washington University/St. Louis Children’s Hospital.

“Fortunately, recurrent cases tended to be less severe. However, many patients had more than one recurrence, making this challenging for affected patients.”

The researchers reported having no financial disclosures. Dr. Coughlin is on the board of the Pediatric Dermatology Research Alliance (PeDRA) and the International Immunosuppression and Transplant Skin Cancer Collaborative.

INDIANAPOLIS – Onset of recurrent reactive infectious mucocutaneous eruption (RIME) was most common among males between the ages of 11 and 12 years, which is younger than previously described, in a single-center retrospective study. In addition, 71% of patients with recurrent disease experienced 1-2 recurrences – episodes that were generally milder and occurred at variable intervals.

Those are among key findings from the study of 50 patients with RIME, presented by Catherina X. Pan at the annual meeting of the Society for Pediatric Dermatology.

Reactive infectious mucocutaneous eruption (RIME) is a novel term encompassing an array of rare, parainfectious mucositis diseases, noted Ms. Pan, a fourth-year medical student at Harvard Medical School, Boston. Previously known as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), common clinical characteristics of RIME include less than 10% body surface area involvement of polymorphic skin lesions (vesiculobullous or targetoid macules/papules); erosive oral, genital, and/or ocular mucositis involving more than two sites, and evidence of prior infection including but not limited to upper respiratory infection, fever, and cough.

In addition to M. pneumoniae, other pathogens have been implicated, she said. “While the underlying etiology of the disease is not entirely clear, it’s become increasingly known that RIME tends to recur in a subset of patients.”

A cohort study of 13 patients with RIME found that Black race, male sex, and older age were predominant among the five patients who developed recurrent disease.

The estimated recurrence rate is between 8% and 38%, but the clinical characteristics of patients who develop recurrent RIME tend to be poorly understood, Ms. Pan said.

Along with her mentor, Sadaf Hussain, MD, of the department of dermatology at Boston Children’s Hospital, Ms. Pan conducted a retrospective chart review to characterize the clinical history and course of disease in patients diagnosed with recurrent RIME. They extracted data between January of 2000 and March of 2022 using ICD-10 codes used by board-certified dermatologists at Boston Children’s Hospital, as well as a text search for RIME or MIRM in the dermatology notes. Patients were included if they had a RIME/MIRM diagnosis by a board-certified dermatologist and/or infection on PCR/serology and mucositis involvement with limited skin involvement.

The study population included 50 patients: 24 with recurrent RIME and 26 with isolated RIME. The majority (66%) were male, and the mean age of RIME onset was between 11 and 12 years old, which is up to two years younger than previously reported in the case series of 13 patients. Most of the study participants (79%) were White, but there were no significant differences in patients who had recurrent RIME and those who had isolated RIME in terms of age, sex, or race.
 

Isolated vs. recurrent RIME

However, compared with patients who had isolated RIME, a greater proportion of those with recurrent RIME had a history of atopic disease (46% vs. 23%, respectively; P = .136), as well as a history of tonsillectomy and adenoidectomy (25% vs. 4%; P = .045). “This has not been previously observed, but it may generate a hypothesis that patients with a history of frequent infection as well as amplified immune responses may be associated with disease recurrence,” Ms. Pan said.

The average number of episodes among patients with recurrent RIME was 3.5 and the interval between episodes was variable, at a mean of 10.2 months. Ms. Pan reported that 71% of recurrent RIME patients experienced 1-2 episodes, although one patient experienced 9 episodes.

Clinically, episodes among all patients with RIME were characterized by infectious prodromal symptoms (69%), oral lesions (95%), ocular lesions (60%), genital lesions (41%) and cutaneous lesions (40%). However, RIME recurrences were less severe and more atypical, with 49% involving only one mucosal surface and 29% involving two mucosal surfaces. Also, except for oral lesions, rates of infectious prodromal symptoms and other lesions significantly decreased among recurrences compared with initial RIME.

“Notably, we found that M. pneumoniae was the most common known cause of RIME, particularly among the initial episodes,” Ms. Pan said. “However, 61% of recurrent RIME episodes did not have a known cause in terms of infectious etiology. And, concordant with prior studies, we also found decreased severity [of RIME recurrences] as indicated by decreased rates of emergency department presentation, hospitalization, and duration of hospitalization.”

In other findings, psychiatric complications such as anxiety and depression followed the onset of RIME in 33% of those with recurrent disease and 22% of those with isolated disease. In addition, the three most common treatments among all 50 patients were systemic steroids, topical steroids, and M. pneumoniae-specific antibiotics.

“While RIME is considered as typically milder than Stevens-Johnson syndrome and toxic epidermal necrolysis with low mortality rates, it can lead to severe complications including conjunctival shrinkage, corneal ulceration and scarring, blindness, and oral, ocular, urogenital synechiae,” Ms. Pan noted. “Increased use of corticosteroids and steroid-sparing agents such as IVIG have also been observed. Multidisciplinary care with ophthalmology, urology, and mental health services is critical.”

She acknowledged certain limitations of the study, including its retrospective, single-center design, and the possibility that milder cases may have been excluded due to a lack of accurate diagnosis or referral.

Carrie C. Coughlin, MD, who was asked to comment on the study results, pointed out that nearly half (24) of patients in the cohort experienced recurrent RIME. “This is a high proportion, suggesting counseling about the possibility of recurrence is more important than previously thought,” said Dr. Coughlin, director of the section of pediatric dermatology Washington University/St. Louis Children’s Hospital.

“Fortunately, recurrent cases tended to be less severe. However, many patients had more than one recurrence, making this challenging for affected patients.”

The researchers reported having no financial disclosures. Dr. Coughlin is on the board of the Pediatric Dermatology Research Alliance (PeDRA) and the International Immunosuppression and Transplant Skin Cancer Collaborative.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

Anand S. Iyer, MD, MSPH, frequently hears his patients with chronic obstructive pulmonary disease (COPD) express fear and hopelessness and describe panic and other symptoms of anxiety. He sees anxiety affect the course of COPD, worsening symptoms and outcomes.

“I had questions about what we are doing [to help patients], so I began looking into the role of palliative care to help patients assess and manage these complex emotional and psychological symptoms,” said Dr. Iyer, assistant professor in the division of pulmonology, allergy, and critical care medicine at the University of Alabama at Birmingham.

His research is now focused on the integration of palliative care principles in COPD care. For Dr. Iyer and others engaged in research and/or patient care, finding ways of identifying and managing anxiety in patients with COPD – and other chronic lung diseases – is a calling of growing urgency.

More has been published about anxiety in patients with COPD than in other pulmonary conditions – and in COPD, anxiety has long been established as a prevalent comorbidity. Prevalence rates vary from about 1 in 4, to 1 in 2 or higher, depending on the instruments used and whether clinical DSM-based diagnoses are made, Dr. Iyer said.

A 2013 systematic review of 10 studies that utilized clinical interviews based on DSM criteria, for instance, found a prevalence of clinical anxiety of 10%-55% among inpatients and 13%-46% among outpatients with COPD. The results were similar, investigators said, to studies using self-report screening tools (Respiratory Care 2013;58[5]:858-66).

In the 16 years since an ACCP workshop panel on anxiety and depression in COPD reported higher prevalence rates than for other chronic diseases and detailed a host of problems and research needs (CHEST. 2008;134;43S-56), investigators have more fully documented links to COPD outcomes, showing, for instance, that anxiety predicts exacerbations, hospitalizations, poorer adherence to therapies, poorer quality of life and higher mortality.

Dr. Iyer and other experts say anxiety is still too often a neglected comorbidity. “It’s still underdiagnosed and therefore undertreated,” said Nick Hanania, MD, MS, professor of medicine and director of the Airways Clinical Research Center at Baylor College of Medicine, Houston.

The literature on optimal approaches for management remains limited, and the role of pharmacotherapy for anxiety (and depression) in the context of COPD has not been well investigated. But there have been some advances: Screening tools have been further studied, questionnaires specific to COPD have been developed, and pulmonary rehabilitation (PR) and cognitive behavioral therapy (CBT) have both been shown to be effective in decreasing anxiety.

Researchers and academic clinicians are talking, meanwhile, about how to have to important conversations about anxiety with patients who have COPD and other chronic lung conditions, and how improve care in the face of significant health system challenges.
 

Understanding anxiety in COPD

Anxiety is often intertwined with dyspnea in a bidirectional and complex relationship, but anxiety in COPD is not always acute or limited to times of acute exacerbations.

“There’s not only the acute experience of shortness of breath or a lung change episode, but there’s an anticipation that can occur, psychologically and socially,” said Lauren Garvin, PhD, of the department of psychiatry at the University of Iowa, Iowa City. Patients worry, “what if I’m short of breath in a particular situation? What if my devices fail when I’m out somewhere?”

Patients are often living “in a state of heightened surveillance of the body,” she noted, which can be exhausting and can impact functioning.

It’s also important to appreciate that anxiety is “a continuum of experience,” said Karin Hoth, PhD, associate professor of psychiatry at the medical school, whose research includes projects focusing on psychological adjustment in COPD.

“Research historically categorizes anxiety as ‘have or don’t have.’ But there’s a continuum of experience that we’re moving toward understanding and recognizing in research,” she said. “Anxiety is part of a patient’s whole experience, no matter where one falls on the continuum.”

Female sex, current smoking, greater airflow restrictions – and in some studies, younger age – have all been associated with a greater risk of anxiety in COPD. (It may well be that women receive more attention, leaving men with higher rates of undiagnosed anxiety, Dr. Hoth said.)

Dr. Iyer stresses the complex relationship between smoking – the No. 1 cause of COPD – and anxiety. Smoking has been associated in multiple studies with an increased risk of anxiety (Brain and Behavior. 2013;3[3]:302-26), he said. (A study led by Dr. Iyer found a similar frequency of anxiety symptoms in smokers with and without COPD [Journal of Psychosomatic Research. 2019;118:18-26].)

Some patients with COPD and anxiety may smoke in order to ease their anxiety, he said, making management of anxiety an important part of the smoking cessation desired for COPD improvement.

COPD medications such as bronchodilators may cause transient symptoms of anxiety, but these are rare and short-lived, Dr. Iyer said.
 

Screening tools and conversations

“It’s not just us not thinking about anxiety that’s the problem, it’s also patients thinking that it’s just the disease [causing their anxiety symptoms],” said Dr. Hanania, a member of the 2006 ACCP panel and an author of numerous papers on COPD and anxiety and depression. “There’s quite a bit of overlap between COPD symptoms and anxiety and depression symptoms, and unless you use structured questionnaires, you may not pick it up,” he said.

Screening tools include the Generalized Anxiety Disorder 7-item (GAD-7) scale, the PHQ-9 for depression and anxiety, and the longer Primary Care Evaluation of Mental Disorders (PRIME-MD). The Hospital Anxiety and Depression Scale (HADS), Dr. Iyer noted, has been well validated for use in ambulatory settings.

Validated screening tools specific to anxiety in COPD are also now an option. Abebaw M. Yohannes, PhD, MSc, FCCP, professor in the department of physical therapy at Azuza Pacific University in Orange, Calif., and the author of numerous studies on COPD and anxiety, developed one of these tools – the 10-item Anxiety Inventory for Respiratory Disease (AIR) scale – out of concern that other surveys contain overlapping somatic symptoms (Chest. 2013;144[5]:1587-96).

“We removed the physical symptoms [of anxiety] that often manifest in patients with COPD,” he said.

Dr. Iyer said screening tools can effectively “highlight which person might be dealing with high levels of anxiety symptoms that might meet a threshold of clinical significance and require collaborative or interprofessional management,” including with psychologists and psychiatrists.

They can also open the door to conversation with patients. “I’ll often bluntly ask, do you feel anxious? Do you feel scared, or hopeless about what the future holds for you?,” he said. “Anxiety about the future plays a big role, and helping patients navigate the illness and understand early how it might look … can ease the level of anxiety.”

Asking patients about their experiences in managing their symptoms and about their psychological and emotional well-being can help to normalize anxiety – and it can be therapeutic, said Dr. Hoth and Dr. Garvin. Asking “how it’s going with the things that really matter in [their] life” is often a good question, they said.

Patients “won’t be offended if you ask,” said Dr. Hoth. “They view their mood and [whole] well-being as part of their medical condition.”

Time is a challenge, she said, but “conversation can be done little by little, as part of a philosophy of engaging the patient around their whole functioning, even if there’s not [a need or] a route to refer just then.”

Such early and integrated conversation borrows from the palliative care model. “Palliative care is a specialty, but it can also be an approach to care,” Dr. Iyer said. He is leading a National Institutes of Health–funded study on nurse-coach–led early palliative care for older adults with COPD and wants to see training opportunities for pulmonologists to learn basic palliative care skills that would equip them to better guide management of mild-moderate anxiety and other complex symptoms.
 

Pulmonary rehabilitation

For many patients with COPD who have anxiety and/or depressive symptoms, referral for nonpharmacologic therapies such as psychotherapy, cognitive-behavioral therapy (CBT), and pulmonary rehabilitation (PR) is “one of the best things you can do,” Dr. Iyer said.

“If patients haven’t done pulmonary rehabilitation, get them in. And if they have done it before, get them back into it again,” he emphasized. “Accredited programs give a holistic approach to improving your strength, your breathlessness, your mindset and understanding of your breathlessness, and your own levels of security.”

Studies addressing the impact of PR and CBT on anxiety have been mostly small and observational but have yielded encouraging findings. A 2017 review reported that PR and CBT were effective in the treatment of anxiety and dyspnea, in the short term, in the majority of 47 studies (JAMA. 2017;18[12]:1096.e1-1096.e17). And a 2019 systematic review and meta-analysis focused on PR reported that, across 11 studies comprising 734 patients, PR conferred significant benefits for anxiety and depression compared with usual care (CHEST. 2019;156[1]:80-91).

Dr. Yohannes, Dr. Hanania, and colleagues recently reported on 734 patients with clinically stable COPD who completed a community-based 8-week PR program of 2 hours a week: 1 hour of exercise and 1 hour of education, the latter of which covered anxiety, panic management, and relaxation.

Patients who had severe dyspnea and comorbid anxiety and depression prior to PR – one-third of the group compared with 20% having anxiety alone and 5% having depression alone – had the most significant improvements in dyspnea scores and anxiety and depression scores (Respir Med. Apr 9. doi: 10.1016/j.rmed.2022.106850.)

The problem is, pulmonary rehabilitation is under-reimbursed and not widely accessible. It’s logistically challenging for patients to attend therapy 2-3 times a week. And according to a recently published study by Dr. Yohannes, Dr. Hanania, and colleagues, patients with more anxiety and dyspnea may be at higher risk of dropping out (Respir Med. 2022 Jan 20. doi: 10.1016/j.rmed.2022.10674). Moreover, Dr. Iyer said, there is a shortage of programs that are accredited.

Telehealth may help on some of these fronts. The efficacy of real-time video PR for COPD is being investigated in a randomized NIH trial (now in the recruitment phase) led by pulmonologist Surya P. Bhatt, MD, also at the University of Alabama at Birmingham.

Researchers also need to investigate issues of sustainability – to learn what “works best in the long run,” Dr. Iyer said.

Dr. Yohannes and Dr. Hanania are encouraged by a recent finding that patients with COPD who completed 8 weeks of PR maintained improvements in anxiety and quality-of-life scores at 2 years. (Improvements in dyspnea and other outcomes did not persist.) (CHEST. 2021;159[3]:967-74). Prospective studies contrasting maintenance programs with no maintenance following PR, are needed, they wrote.
 

Understanding psychological interventions

Dr. Hoth and Dr. Garvin advise their pulmonologist colleagues to feel as confident as possible in describing for patients what CBT and other psychological therapies entail.

“A person [with COPD] who is experiencing something on the continuum of anxiety might be really turning inward and [assessing] unwanted internal experiences” and accompanying thoughts, sensations, emotional impacts and behaviors, Dr. Garvin said.

Among the goals, she said, are to “make shifts around those internal experiences that might invoke some more tolerance or that might shift their relationship with the experiences, or even with the diagnosis itself and all the uncertainties it carries.”

Psychological therapies can involve social support, or “breath and grounding work,” she said. “There are lots of different approaches from different providers.”

Dr. Yohannes advocates incorporating principles of CBT into PR. “In the absence of one-on-one or group [stand-alone] CBT … the principles are worth incorporating as part of the education piece [of PR],” he said. “CBT helps patients to refocus their attention. … and gives them self-confidence to engage in exercise and to function a bit more in their daily activities.”

None of those interviewed for this story reported having any relevant conflicts of interest.

Anand S. Iyer, MD, MSPH, frequently hears his patients with chronic obstructive pulmonary disease (COPD) express fear and hopelessness and describe panic and other symptoms of anxiety. He sees anxiety affect the course of COPD, worsening symptoms and outcomes.

“I had questions about what we are doing [to help patients], so I began looking into the role of palliative care to help patients assess and manage these complex emotional and psychological symptoms,” said Dr. Iyer, assistant professor in the division of pulmonology, allergy, and critical care medicine at the University of Alabama at Birmingham.

His research is now focused on the integration of palliative care principles in COPD care. For Dr. Iyer and others engaged in research and/or patient care, finding ways of identifying and managing anxiety in patients with COPD – and other chronic lung diseases – is a calling of growing urgency.

More has been published about anxiety in patients with COPD than in other pulmonary conditions – and in COPD, anxiety has long been established as a prevalent comorbidity. Prevalence rates vary from about 1 in 4, to 1 in 2 or higher, depending on the instruments used and whether clinical DSM-based diagnoses are made, Dr. Iyer said.

A 2013 systematic review of 10 studies that utilized clinical interviews based on DSM criteria, for instance, found a prevalence of clinical anxiety of 10%-55% among inpatients and 13%-46% among outpatients with COPD. The results were similar, investigators said, to studies using self-report screening tools (Respiratory Care 2013;58[5]:858-66).

In the 16 years since an ACCP workshop panel on anxiety and depression in COPD reported higher prevalence rates than for other chronic diseases and detailed a host of problems and research needs (CHEST. 2008;134;43S-56), investigators have more fully documented links to COPD outcomes, showing, for instance, that anxiety predicts exacerbations, hospitalizations, poorer adherence to therapies, poorer quality of life and higher mortality.

Dr. Iyer and other experts say anxiety is still too often a neglected comorbidity. “It’s still underdiagnosed and therefore undertreated,” said Nick Hanania, MD, MS, professor of medicine and director of the Airways Clinical Research Center at Baylor College of Medicine, Houston.

The literature on optimal approaches for management remains limited, and the role of pharmacotherapy for anxiety (and depression) in the context of COPD has not been well investigated. But there have been some advances: Screening tools have been further studied, questionnaires specific to COPD have been developed, and pulmonary rehabilitation (PR) and cognitive behavioral therapy (CBT) have both been shown to be effective in decreasing anxiety.

Researchers and academic clinicians are talking, meanwhile, about how to have to important conversations about anxiety with patients who have COPD and other chronic lung conditions, and how improve care in the face of significant health system challenges.
 

Understanding anxiety in COPD

Anxiety is often intertwined with dyspnea in a bidirectional and complex relationship, but anxiety in COPD is not always acute or limited to times of acute exacerbations.

“There’s not only the acute experience of shortness of breath or a lung change episode, but there’s an anticipation that can occur, psychologically and socially,” said Lauren Garvin, PhD, of the department of psychiatry at the University of Iowa, Iowa City. Patients worry, “what if I’m short of breath in a particular situation? What if my devices fail when I’m out somewhere?”

Patients are often living “in a state of heightened surveillance of the body,” she noted, which can be exhausting and can impact functioning.

It’s also important to appreciate that anxiety is “a continuum of experience,” said Karin Hoth, PhD, associate professor of psychiatry at the medical school, whose research includes projects focusing on psychological adjustment in COPD.

“Research historically categorizes anxiety as ‘have or don’t have.’ But there’s a continuum of experience that we’re moving toward understanding and recognizing in research,” she said. “Anxiety is part of a patient’s whole experience, no matter where one falls on the continuum.”

Female sex, current smoking, greater airflow restrictions – and in some studies, younger age – have all been associated with a greater risk of anxiety in COPD. (It may well be that women receive more attention, leaving men with higher rates of undiagnosed anxiety, Dr. Hoth said.)

Dr. Iyer stresses the complex relationship between smoking – the No. 1 cause of COPD – and anxiety. Smoking has been associated in multiple studies with an increased risk of anxiety (Brain and Behavior. 2013;3[3]:302-26), he said. (A study led by Dr. Iyer found a similar frequency of anxiety symptoms in smokers with and without COPD [Journal of Psychosomatic Research. 2019;118:18-26].)

Some patients with COPD and anxiety may smoke in order to ease their anxiety, he said, making management of anxiety an important part of the smoking cessation desired for COPD improvement.

COPD medications such as bronchodilators may cause transient symptoms of anxiety, but these are rare and short-lived, Dr. Iyer said.
 

Screening tools and conversations

“It’s not just us not thinking about anxiety that’s the problem, it’s also patients thinking that it’s just the disease [causing their anxiety symptoms],” said Dr. Hanania, a member of the 2006 ACCP panel and an author of numerous papers on COPD and anxiety and depression. “There’s quite a bit of overlap between COPD symptoms and anxiety and depression symptoms, and unless you use structured questionnaires, you may not pick it up,” he said.

Screening tools include the Generalized Anxiety Disorder 7-item (GAD-7) scale, the PHQ-9 for depression and anxiety, and the longer Primary Care Evaluation of Mental Disorders (PRIME-MD). The Hospital Anxiety and Depression Scale (HADS), Dr. Iyer noted, has been well validated for use in ambulatory settings.

Validated screening tools specific to anxiety in COPD are also now an option. Abebaw M. Yohannes, PhD, MSc, FCCP, professor in the department of physical therapy at Azuza Pacific University in Orange, Calif., and the author of numerous studies on COPD and anxiety, developed one of these tools – the 10-item Anxiety Inventory for Respiratory Disease (AIR) scale – out of concern that other surveys contain overlapping somatic symptoms (Chest. 2013;144[5]:1587-96).

“We removed the physical symptoms [of anxiety] that often manifest in patients with COPD,” he said.

Dr. Iyer said screening tools can effectively “highlight which person might be dealing with high levels of anxiety symptoms that might meet a threshold of clinical significance and require collaborative or interprofessional management,” including with psychologists and psychiatrists.

They can also open the door to conversation with patients. “I’ll often bluntly ask, do you feel anxious? Do you feel scared, or hopeless about what the future holds for you?,” he said. “Anxiety about the future plays a big role, and helping patients navigate the illness and understand early how it might look … can ease the level of anxiety.”

Asking patients about their experiences in managing their symptoms and about their psychological and emotional well-being can help to normalize anxiety – and it can be therapeutic, said Dr. Hoth and Dr. Garvin. Asking “how it’s going with the things that really matter in [their] life” is often a good question, they said.

Patients “won’t be offended if you ask,” said Dr. Hoth. “They view their mood and [whole] well-being as part of their medical condition.”

Time is a challenge, she said, but “conversation can be done little by little, as part of a philosophy of engaging the patient around their whole functioning, even if there’s not [a need or] a route to refer just then.”

Such early and integrated conversation borrows from the palliative care model. “Palliative care is a specialty, but it can also be an approach to care,” Dr. Iyer said. He is leading a National Institutes of Health–funded study on nurse-coach–led early palliative care for older adults with COPD and wants to see training opportunities for pulmonologists to learn basic palliative care skills that would equip them to better guide management of mild-moderate anxiety and other complex symptoms.
 

Pulmonary rehabilitation

For many patients with COPD who have anxiety and/or depressive symptoms, referral for nonpharmacologic therapies such as psychotherapy, cognitive-behavioral therapy (CBT), and pulmonary rehabilitation (PR) is “one of the best things you can do,” Dr. Iyer said.

“If patients haven’t done pulmonary rehabilitation, get them in. And if they have done it before, get them back into it again,” he emphasized. “Accredited programs give a holistic approach to improving your strength, your breathlessness, your mindset and understanding of your breathlessness, and your own levels of security.”

Studies addressing the impact of PR and CBT on anxiety have been mostly small and observational but have yielded encouraging findings. A 2017 review reported that PR and CBT were effective in the treatment of anxiety and dyspnea, in the short term, in the majority of 47 studies (JAMA. 2017;18[12]:1096.e1-1096.e17). And a 2019 systematic review and meta-analysis focused on PR reported that, across 11 studies comprising 734 patients, PR conferred significant benefits for anxiety and depression compared with usual care (CHEST. 2019;156[1]:80-91).

Dr. Yohannes, Dr. Hanania, and colleagues recently reported on 734 patients with clinically stable COPD who completed a community-based 8-week PR program of 2 hours a week: 1 hour of exercise and 1 hour of education, the latter of which covered anxiety, panic management, and relaxation.

Patients who had severe dyspnea and comorbid anxiety and depression prior to PR – one-third of the group compared with 20% having anxiety alone and 5% having depression alone – had the most significant improvements in dyspnea scores and anxiety and depression scores (Respir Med. Apr 9. doi: 10.1016/j.rmed.2022.106850.)

The problem is, pulmonary rehabilitation is under-reimbursed and not widely accessible. It’s logistically challenging for patients to attend therapy 2-3 times a week. And according to a recently published study by Dr. Yohannes, Dr. Hanania, and colleagues, patients with more anxiety and dyspnea may be at higher risk of dropping out (Respir Med. 2022 Jan 20. doi: 10.1016/j.rmed.2022.10674). Moreover, Dr. Iyer said, there is a shortage of programs that are accredited.

Telehealth may help on some of these fronts. The efficacy of real-time video PR for COPD is being investigated in a randomized NIH trial (now in the recruitment phase) led by pulmonologist Surya P. Bhatt, MD, also at the University of Alabama at Birmingham.

Researchers also need to investigate issues of sustainability – to learn what “works best in the long run,” Dr. Iyer said.

Dr. Yohannes and Dr. Hanania are encouraged by a recent finding that patients with COPD who completed 8 weeks of PR maintained improvements in anxiety and quality-of-life scores at 2 years. (Improvements in dyspnea and other outcomes did not persist.) (CHEST. 2021;159[3]:967-74). Prospective studies contrasting maintenance programs with no maintenance following PR, are needed, they wrote.
 

Understanding psychological interventions

Dr. Hoth and Dr. Garvin advise their pulmonologist colleagues to feel as confident as possible in describing for patients what CBT and other psychological therapies entail.

“A person [with COPD] who is experiencing something on the continuum of anxiety might be really turning inward and [assessing] unwanted internal experiences” and accompanying thoughts, sensations, emotional impacts and behaviors, Dr. Garvin said.

Among the goals, she said, are to “make shifts around those internal experiences that might invoke some more tolerance or that might shift their relationship with the experiences, or even with the diagnosis itself and all the uncertainties it carries.”

Psychological therapies can involve social support, or “breath and grounding work,” she said. “There are lots of different approaches from different providers.”

Dr. Yohannes advocates incorporating principles of CBT into PR. “In the absence of one-on-one or group [stand-alone] CBT … the principles are worth incorporating as part of the education piece [of PR],” he said. “CBT helps patients to refocus their attention. … and gives them self-confidence to engage in exercise and to function a bit more in their daily activities.”

None of those interviewed for this story reported having any relevant conflicts of interest.

Anand S. Iyer, MD, MSPH, frequently hears his patients with chronic obstructive pulmonary disease (COPD) express fear and hopelessness and describe panic and other symptoms of anxiety. He sees anxiety affect the course of COPD, worsening symptoms and outcomes.

“I had questions about what we are doing [to help patients], so I began looking into the role of palliative care to help patients assess and manage these complex emotional and psychological symptoms,” said Dr. Iyer, assistant professor in the division of pulmonology, allergy, and critical care medicine at the University of Alabama at Birmingham.

His research is now focused on the integration of palliative care principles in COPD care. For Dr. Iyer and others engaged in research and/or patient care, finding ways of identifying and managing anxiety in patients with COPD – and other chronic lung diseases – is a calling of growing urgency.

More has been published about anxiety in patients with COPD than in other pulmonary conditions – and in COPD, anxiety has long been established as a prevalent comorbidity. Prevalence rates vary from about 1 in 4, to 1 in 2 or higher, depending on the instruments used and whether clinical DSM-based diagnoses are made, Dr. Iyer said.

A 2013 systematic review of 10 studies that utilized clinical interviews based on DSM criteria, for instance, found a prevalence of clinical anxiety of 10%-55% among inpatients and 13%-46% among outpatients with COPD. The results were similar, investigators said, to studies using self-report screening tools (Respiratory Care 2013;58[5]:858-66).

In the 16 years since an ACCP workshop panel on anxiety and depression in COPD reported higher prevalence rates than for other chronic diseases and detailed a host of problems and research needs (CHEST. 2008;134;43S-56), investigators have more fully documented links to COPD outcomes, showing, for instance, that anxiety predicts exacerbations, hospitalizations, poorer adherence to therapies, poorer quality of life and higher mortality.

Dr. Iyer and other experts say anxiety is still too often a neglected comorbidity. “It’s still underdiagnosed and therefore undertreated,” said Nick Hanania, MD, MS, professor of medicine and director of the Airways Clinical Research Center at Baylor College of Medicine, Houston.

The literature on optimal approaches for management remains limited, and the role of pharmacotherapy for anxiety (and depression) in the context of COPD has not been well investigated. But there have been some advances: Screening tools have been further studied, questionnaires specific to COPD have been developed, and pulmonary rehabilitation (PR) and cognitive behavioral therapy (CBT) have both been shown to be effective in decreasing anxiety.

Researchers and academic clinicians are talking, meanwhile, about how to have to important conversations about anxiety with patients who have COPD and other chronic lung conditions, and how improve care in the face of significant health system challenges.
 

Understanding anxiety in COPD

Anxiety is often intertwined with dyspnea in a bidirectional and complex relationship, but anxiety in COPD is not always acute or limited to times of acute exacerbations.

“There’s not only the acute experience of shortness of breath or a lung change episode, but there’s an anticipation that can occur, psychologically and socially,” said Lauren Garvin, PhD, of the department of psychiatry at the University of Iowa, Iowa City. Patients worry, “what if I’m short of breath in a particular situation? What if my devices fail when I’m out somewhere?”

Patients are often living “in a state of heightened surveillance of the body,” she noted, which can be exhausting and can impact functioning.

It’s also important to appreciate that anxiety is “a continuum of experience,” said Karin Hoth, PhD, associate professor of psychiatry at the medical school, whose research includes projects focusing on psychological adjustment in COPD.

“Research historically categorizes anxiety as ‘have or don’t have.’ But there’s a continuum of experience that we’re moving toward understanding and recognizing in research,” she said. “Anxiety is part of a patient’s whole experience, no matter where one falls on the continuum.”

Female sex, current smoking, greater airflow restrictions – and in some studies, younger age – have all been associated with a greater risk of anxiety in COPD. (It may well be that women receive more attention, leaving men with higher rates of undiagnosed anxiety, Dr. Hoth said.)

Dr. Iyer stresses the complex relationship between smoking – the No. 1 cause of COPD – and anxiety. Smoking has been associated in multiple studies with an increased risk of anxiety (Brain and Behavior. 2013;3[3]:302-26), he said. (A study led by Dr. Iyer found a similar frequency of anxiety symptoms in smokers with and without COPD [Journal of Psychosomatic Research. 2019;118:18-26].)

Some patients with COPD and anxiety may smoke in order to ease their anxiety, he said, making management of anxiety an important part of the smoking cessation desired for COPD improvement.

COPD medications such as bronchodilators may cause transient symptoms of anxiety, but these are rare and short-lived, Dr. Iyer said.
 

Screening tools and conversations

“It’s not just us not thinking about anxiety that’s the problem, it’s also patients thinking that it’s just the disease [causing their anxiety symptoms],” said Dr. Hanania, a member of the 2006 ACCP panel and an author of numerous papers on COPD and anxiety and depression. “There’s quite a bit of overlap between COPD symptoms and anxiety and depression symptoms, and unless you use structured questionnaires, you may not pick it up,” he said.

Screening tools include the Generalized Anxiety Disorder 7-item (GAD-7) scale, the PHQ-9 for depression and anxiety, and the longer Primary Care Evaluation of Mental Disorders (PRIME-MD). The Hospital Anxiety and Depression Scale (HADS), Dr. Iyer noted, has been well validated for use in ambulatory settings.

Validated screening tools specific to anxiety in COPD are also now an option. Abebaw M. Yohannes, PhD, MSc, FCCP, professor in the department of physical therapy at Azuza Pacific University in Orange, Calif., and the author of numerous studies on COPD and anxiety, developed one of these tools – the 10-item Anxiety Inventory for Respiratory Disease (AIR) scale – out of concern that other surveys contain overlapping somatic symptoms (Chest. 2013;144[5]:1587-96).

“We removed the physical symptoms [of anxiety] that often manifest in patients with COPD,” he said.

Dr. Iyer said screening tools can effectively “highlight which person might be dealing with high levels of anxiety symptoms that might meet a threshold of clinical significance and require collaborative or interprofessional management,” including with psychologists and psychiatrists.

They can also open the door to conversation with patients. “I’ll often bluntly ask, do you feel anxious? Do you feel scared, or hopeless about what the future holds for you?,” he said. “Anxiety about the future plays a big role, and helping patients navigate the illness and understand early how it might look … can ease the level of anxiety.”

Asking patients about their experiences in managing their symptoms and about their psychological and emotional well-being can help to normalize anxiety – and it can be therapeutic, said Dr. Hoth and Dr. Garvin. Asking “how it’s going with the things that really matter in [their] life” is often a good question, they said.

Patients “won’t be offended if you ask,” said Dr. Hoth. “They view their mood and [whole] well-being as part of their medical condition.”

Time is a challenge, she said, but “conversation can be done little by little, as part of a philosophy of engaging the patient around their whole functioning, even if there’s not [a need or] a route to refer just then.”

Such early and integrated conversation borrows from the palliative care model. “Palliative care is a specialty, but it can also be an approach to care,” Dr. Iyer said. He is leading a National Institutes of Health–funded study on nurse-coach–led early palliative care for older adults with COPD and wants to see training opportunities for pulmonologists to learn basic palliative care skills that would equip them to better guide management of mild-moderate anxiety and other complex symptoms.
 

Pulmonary rehabilitation

For many patients with COPD who have anxiety and/or depressive symptoms, referral for nonpharmacologic therapies such as psychotherapy, cognitive-behavioral therapy (CBT), and pulmonary rehabilitation (PR) is “one of the best things you can do,” Dr. Iyer said.

“If patients haven’t done pulmonary rehabilitation, get them in. And if they have done it before, get them back into it again,” he emphasized. “Accredited programs give a holistic approach to improving your strength, your breathlessness, your mindset and understanding of your breathlessness, and your own levels of security.”

Studies addressing the impact of PR and CBT on anxiety have been mostly small and observational but have yielded encouraging findings. A 2017 review reported that PR and CBT were effective in the treatment of anxiety and dyspnea, in the short term, in the majority of 47 studies (JAMA. 2017;18[12]:1096.e1-1096.e17). And a 2019 systematic review and meta-analysis focused on PR reported that, across 11 studies comprising 734 patients, PR conferred significant benefits for anxiety and depression compared with usual care (CHEST. 2019;156[1]:80-91).

Dr. Yohannes, Dr. Hanania, and colleagues recently reported on 734 patients with clinically stable COPD who completed a community-based 8-week PR program of 2 hours a week: 1 hour of exercise and 1 hour of education, the latter of which covered anxiety, panic management, and relaxation.

Patients who had severe dyspnea and comorbid anxiety and depression prior to PR – one-third of the group compared with 20% having anxiety alone and 5% having depression alone – had the most significant improvements in dyspnea scores and anxiety and depression scores (Respir Med. Apr 9. doi: 10.1016/j.rmed.2022.106850.)

The problem is, pulmonary rehabilitation is under-reimbursed and not widely accessible. It’s logistically challenging for patients to attend therapy 2-3 times a week. And according to a recently published study by Dr. Yohannes, Dr. Hanania, and colleagues, patients with more anxiety and dyspnea may be at higher risk of dropping out (Respir Med. 2022 Jan 20. doi: 10.1016/j.rmed.2022.10674). Moreover, Dr. Iyer said, there is a shortage of programs that are accredited.

Telehealth may help on some of these fronts. The efficacy of real-time video PR for COPD is being investigated in a randomized NIH trial (now in the recruitment phase) led by pulmonologist Surya P. Bhatt, MD, also at the University of Alabama at Birmingham.

Researchers also need to investigate issues of sustainability – to learn what “works best in the long run,” Dr. Iyer said.

Dr. Yohannes and Dr. Hanania are encouraged by a recent finding that patients with COPD who completed 8 weeks of PR maintained improvements in anxiety and quality-of-life scores at 2 years. (Improvements in dyspnea and other outcomes did not persist.) (CHEST. 2021;159[3]:967-74). Prospective studies contrasting maintenance programs with no maintenance following PR, are needed, they wrote.
 

Understanding psychological interventions

Dr. Hoth and Dr. Garvin advise their pulmonologist colleagues to feel as confident as possible in describing for patients what CBT and other psychological therapies entail.

“A person [with COPD] who is experiencing something on the continuum of anxiety might be really turning inward and [assessing] unwanted internal experiences” and accompanying thoughts, sensations, emotional impacts and behaviors, Dr. Garvin said.

Among the goals, she said, are to “make shifts around those internal experiences that might invoke some more tolerance or that might shift their relationship with the experiences, or even with the diagnosis itself and all the uncertainties it carries.”

Psychological therapies can involve social support, or “breath and grounding work,” she said. “There are lots of different approaches from different providers.”

Dr. Yohannes advocates incorporating principles of CBT into PR. “In the absence of one-on-one or group [stand-alone] CBT … the principles are worth incorporating as part of the education piece [of PR],” he said. “CBT helps patients to refocus their attention. … and gives them self-confidence to engage in exercise and to function a bit more in their daily activities.”

None of those interviewed for this story reported having any relevant conflicts of interest.

In June of this year, the World Health Organization launched a policy report to confront the increasingly strong and lasting impacts that climate change is having directly and indirectly on people’s mental health and psychosocial well-being.

In addition to the increasingly high incidence of mental disorders (for instance, emotional distress, stress, depression, and suicidal behavior) affecting people worldwide, the WHO warned of new, emerging syndromes that are directly related to climate change, such as “ecotrauma.” This term refers to anxiety in the face of the apocalyptic scenario predicted to result from the transformation of ecosystems by anthropogenic activity.

Two weeks after the release of the policy report, which integrates key policies for countries to address one of the biggest challenges, the WHO published its largest review of global mental health since the turn of the century. The work provides a model for governments, academics, health professionals, and civil society to become key players when dealing with the mental health problems that our society is going through.

Bernhard_Staehli/Thinkstock

As the document highlights, almost 1 billion people, including 14% of the world’s adolescents, were living with a mental health disorder in 2019. Suicide accounted for more than 1 in 100 deaths, and 58% of cases occurred before age 50 years. Mental health disorders are already the leading cause of disability in the world, and people with serious but preventable diseases die on average 10-20 years earlier than the general population.

The COVID-19 crisis has significantly aggravated mental health disorders, especially in populations such as minors. Consequently, many experts refer to this public health phenomenon as the new major pandemic. “I’m not sure it’s correct to call a set of mental health problems a pandemic, but the reality is that many countries are ignoring or largely forgetting this crisis,” Sarah Sheppard, WHO communications officer, told this news organization. According to Ms. Sheppard, “stigma and lack of understanding are key drivers of these problems and have been one of the reasons for the lack of mental health funding for decades. Mental health receives less than 1% of international health aid.” We recently interviewed Ms. Sheppard about these challenges.

Univadis: As the data provided in the recently released Mental Health and Climate Change Policy Brief indicate, there are large gaps in many countries between mental health needs and the services and systems available to address them. Where can we start to change this reality?

Ms. Sheppard: The simplest answer to improve the situation we face begins with a change in people’s priorities when it comes to valuing mental health. This would lead to greater investment in human and financial resources for mental health services and systems. However, the challenge lies in the complexity of the problem. In the report we just published, we provide comprehensive recommendations on how to transform mental health systems for all, such as trying to integrate climate change considerations into policies and programs for mental health or building on existing global commitments, including the Sustainable Development Goals (SDGs) or the Paris Agreement.

Univadis: Is there evidence that mental illnesses and disorders affect some populations more than others, such as women, for example?

Ms. Sheppard: The prevalence of mental disorders varies according to conditions and according to sex and age. In general, I don’t think we can say that mental health conditions or disorders affect women more than men. There are groups at risk, but vulnerability depends on the context and varies a lot. Of course, social determinants such as poverty, unstable housing, and exposure to adversity can significantly increase risk.

Univadis: According to the statistics recently provided by the WHO, changes in the environment are directly and indirectly affecting people’s mental health and psychosocial well-being. The new report highlights the gap between countries when it comes to addressing this complex problem. Is there any country that is carrying out political or innovative initiatives in this regard?

Ms. Sheppard: Yes, there are many case studies in the policy brief that highlight important work in the area. There are strong examples that are highlighted in the summary. One of them is India and its resilient cities program. Focused on the reduction of disaster risk, climate resilience, and mental health and psychosocial support at city level, this project resulted from a collaboration between the United Nations Development Program and the Indian National Institute of Mental Health and Neurosciences, which began in 2017.

Univadis: In addition to its effects on mental health, we are seeing how climate change is causing the appearance and resurgence of zoonoses, such as the pandemic caused by coronavirus and now monkeypox.

Ms. Sheppard: Mike Ryan, head of emergency situations at WHO, stated at the beginning of June that the increase in zoonoses raises the risk of new pandemics. Infections transmitted from animals to humans, such as Ebola, COVID-19, or monkeypox, have multiplied in recent years. Climate change alters the conditions for pathogens and zoonotic disease vectors and their distribution. The intensification of travel, for example, allows them to spread more quickly and in a more uncontrolled way.

Human health, including mental health, is connected to animal health. As various materials available to us from our World Health Day 2022 campaign examine, the links between planetary health and human health are inextricable.

Univadis: How is it possible that while scientific progress advances and more powerful and efficient technologies are developed, we become increasingly vulnerable to environmental phenomena?

Ms. Sheppard: Scientific advancement improves our understanding of the quality and scale of the health impacts of climate change, including the identification of the most vulnerable groups, as well as the adaptation and mitigation measures that would work to reduce the consequences on health. At the same time, climate change is widespread, rapid, and intensifying. Technological advances have a role to play in mitigation, particularly those tools that reduce our dependence on burning fossil fuels, as well as adaptation to climate change. For example, early warning systems for extreme weather events could reduce those vulnerabilities your question mentioned.

On the other hand, the measures proposed by the latest report on mental health and climate change have multiple effects. Some are particularly powerful and are not overly dependent on new technology. These include changing our mode of transport to low-emission, physically active ways to get around (walking, cycling), the benefits of which are already more than proven for both the environment and human health.

This article was translated from Univadis Spain.

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

In June of this year, the World Health Organization launched a policy report to confront the increasingly strong and lasting impacts that climate change is having directly and indirectly on people’s mental health and psychosocial well-being.

In addition to the increasingly high incidence of mental disorders (for instance, emotional distress, stress, depression, and suicidal behavior) affecting people worldwide, the WHO warned of new, emerging syndromes that are directly related to climate change, such as “ecotrauma.” This term refers to anxiety in the face of the apocalyptic scenario predicted to result from the transformation of ecosystems by anthropogenic activity.

Two weeks after the release of the policy report, which integrates key policies for countries to address one of the biggest challenges, the WHO published its largest review of global mental health since the turn of the century. The work provides a model for governments, academics, health professionals, and civil society to become key players when dealing with the mental health problems that our society is going through.

Bernhard_Staehli/Thinkstock

As the document highlights, almost 1 billion people, including 14% of the world’s adolescents, were living with a mental health disorder in 2019. Suicide accounted for more than 1 in 100 deaths, and 58% of cases occurred before age 50 years. Mental health disorders are already the leading cause of disability in the world, and people with serious but preventable diseases die on average 10-20 years earlier than the general population.

The COVID-19 crisis has significantly aggravated mental health disorders, especially in populations such as minors. Consequently, many experts refer to this public health phenomenon as the new major pandemic. “I’m not sure it’s correct to call a set of mental health problems a pandemic, but the reality is that many countries are ignoring or largely forgetting this crisis,” Sarah Sheppard, WHO communications officer, told this news organization. According to Ms. Sheppard, “stigma and lack of understanding are key drivers of these problems and have been one of the reasons for the lack of mental health funding for decades. Mental health receives less than 1% of international health aid.” We recently interviewed Ms. Sheppard about these challenges.

Univadis: As the data provided in the recently released Mental Health and Climate Change Policy Brief indicate, there are large gaps in many countries between mental health needs and the services and systems available to address them. Where can we start to change this reality?

Ms. Sheppard: The simplest answer to improve the situation we face begins with a change in people’s priorities when it comes to valuing mental health. This would lead to greater investment in human and financial resources for mental health services and systems. However, the challenge lies in the complexity of the problem. In the report we just published, we provide comprehensive recommendations on how to transform mental health systems for all, such as trying to integrate climate change considerations into policies and programs for mental health or building on existing global commitments, including the Sustainable Development Goals (SDGs) or the Paris Agreement.

Univadis: Is there evidence that mental illnesses and disorders affect some populations more than others, such as women, for example?

Ms. Sheppard: The prevalence of mental disorders varies according to conditions and according to sex and age. In general, I don’t think we can say that mental health conditions or disorders affect women more than men. There are groups at risk, but vulnerability depends on the context and varies a lot. Of course, social determinants such as poverty, unstable housing, and exposure to adversity can significantly increase risk.

Univadis: According to the statistics recently provided by the WHO, changes in the environment are directly and indirectly affecting people’s mental health and psychosocial well-being. The new report highlights the gap between countries when it comes to addressing this complex problem. Is there any country that is carrying out political or innovative initiatives in this regard?

Ms. Sheppard: Yes, there are many case studies in the policy brief that highlight important work in the area. There are strong examples that are highlighted in the summary. One of them is India and its resilient cities program. Focused on the reduction of disaster risk, climate resilience, and mental health and psychosocial support at city level, this project resulted from a collaboration between the United Nations Development Program and the Indian National Institute of Mental Health and Neurosciences, which began in 2017.

Univadis: In addition to its effects on mental health, we are seeing how climate change is causing the appearance and resurgence of zoonoses, such as the pandemic caused by coronavirus and now monkeypox.

Ms. Sheppard: Mike Ryan, head of emergency situations at WHO, stated at the beginning of June that the increase in zoonoses raises the risk of new pandemics. Infections transmitted from animals to humans, such as Ebola, COVID-19, or monkeypox, have multiplied in recent years. Climate change alters the conditions for pathogens and zoonotic disease vectors and their distribution. The intensification of travel, for example, allows them to spread more quickly and in a more uncontrolled way.

Human health, including mental health, is connected to animal health. As various materials available to us from our World Health Day 2022 campaign examine, the links between planetary health and human health are inextricable.

Univadis: How is it possible that while scientific progress advances and more powerful and efficient technologies are developed, we become increasingly vulnerable to environmental phenomena?

Ms. Sheppard: Scientific advancement improves our understanding of the quality and scale of the health impacts of climate change, including the identification of the most vulnerable groups, as well as the adaptation and mitigation measures that would work to reduce the consequences on health. At the same time, climate change is widespread, rapid, and intensifying. Technological advances have a role to play in mitigation, particularly those tools that reduce our dependence on burning fossil fuels, as well as adaptation to climate change. For example, early warning systems for extreme weather events could reduce those vulnerabilities your question mentioned.

On the other hand, the measures proposed by the latest report on mental health and climate change have multiple effects. Some are particularly powerful and are not overly dependent on new technology. These include changing our mode of transport to low-emission, physically active ways to get around (walking, cycling), the benefits of which are already more than proven for both the environment and human health.

This article was translated from Univadis Spain.

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

In June of this year, the World Health Organization launched a policy report to confront the increasingly strong and lasting impacts that climate change is having directly and indirectly on people’s mental health and psychosocial well-being.

In addition to the increasingly high incidence of mental disorders (for instance, emotional distress, stress, depression, and suicidal behavior) affecting people worldwide, the WHO warned of new, emerging syndromes that are directly related to climate change, such as “ecotrauma.” This term refers to anxiety in the face of the apocalyptic scenario predicted to result from the transformation of ecosystems by anthropogenic activity.

Two weeks after the release of the policy report, which integrates key policies for countries to address one of the biggest challenges, the WHO published its largest review of global mental health since the turn of the century. The work provides a model for governments, academics, health professionals, and civil society to become key players when dealing with the mental health problems that our society is going through.

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As the document highlights, almost 1 billion people, including 14% of the world’s adolescents, were living with a mental health disorder in 2019. Suicide accounted for more than 1 in 100 deaths, and 58% of cases occurred before age 50 years. Mental health disorders are already the leading cause of disability in the world, and people with serious but preventable diseases die on average 10-20 years earlier than the general population.

The COVID-19 crisis has significantly aggravated mental health disorders, especially in populations such as minors. Consequently, many experts refer to this public health phenomenon as the new major pandemic. “I’m not sure it’s correct to call a set of mental health problems a pandemic, but the reality is that many countries are ignoring or largely forgetting this crisis,” Sarah Sheppard, WHO communications officer, told this news organization. According to Ms. Sheppard, “stigma and lack of understanding are key drivers of these problems and have been one of the reasons for the lack of mental health funding for decades. Mental health receives less than 1% of international health aid.” We recently interviewed Ms. Sheppard about these challenges.

Univadis: As the data provided in the recently released Mental Health and Climate Change Policy Brief indicate, there are large gaps in many countries between mental health needs and the services and systems available to address them. Where can we start to change this reality?

Ms. Sheppard: The simplest answer to improve the situation we face begins with a change in people’s priorities when it comes to valuing mental health. This would lead to greater investment in human and financial resources for mental health services and systems. However, the challenge lies in the complexity of the problem. In the report we just published, we provide comprehensive recommendations on how to transform mental health systems for all, such as trying to integrate climate change considerations into policies and programs for mental health or building on existing global commitments, including the Sustainable Development Goals (SDGs) or the Paris Agreement.

Univadis: Is there evidence that mental illnesses and disorders affect some populations more than others, such as women, for example?

Ms. Sheppard: The prevalence of mental disorders varies according to conditions and according to sex and age. In general, I don’t think we can say that mental health conditions or disorders affect women more than men. There are groups at risk, but vulnerability depends on the context and varies a lot. Of course, social determinants such as poverty, unstable housing, and exposure to adversity can significantly increase risk.

Univadis: According to the statistics recently provided by the WHO, changes in the environment are directly and indirectly affecting people’s mental health and psychosocial well-being. The new report highlights the gap between countries when it comes to addressing this complex problem. Is there any country that is carrying out political or innovative initiatives in this regard?

Ms. Sheppard: Yes, there are many case studies in the policy brief that highlight important work in the area. There are strong examples that are highlighted in the summary. One of them is India and its resilient cities program. Focused on the reduction of disaster risk, climate resilience, and mental health and psychosocial support at city level, this project resulted from a collaboration between the United Nations Development Program and the Indian National Institute of Mental Health and Neurosciences, which began in 2017.

Univadis: In addition to its effects on mental health, we are seeing how climate change is causing the appearance and resurgence of zoonoses, such as the pandemic caused by coronavirus and now monkeypox.

Ms. Sheppard: Mike Ryan, head of emergency situations at WHO, stated at the beginning of June that the increase in zoonoses raises the risk of new pandemics. Infections transmitted from animals to humans, such as Ebola, COVID-19, or monkeypox, have multiplied in recent years. Climate change alters the conditions for pathogens and zoonotic disease vectors and their distribution. The intensification of travel, for example, allows them to spread more quickly and in a more uncontrolled way.

Human health, including mental health, is connected to animal health. As various materials available to us from our World Health Day 2022 campaign examine, the links between planetary health and human health are inextricable.

Univadis: How is it possible that while scientific progress advances and more powerful and efficient technologies are developed, we become increasingly vulnerable to environmental phenomena?

Ms. Sheppard: Scientific advancement improves our understanding of the quality and scale of the health impacts of climate change, including the identification of the most vulnerable groups, as well as the adaptation and mitigation measures that would work to reduce the consequences on health. At the same time, climate change is widespread, rapid, and intensifying. Technological advances have a role to play in mitigation, particularly those tools that reduce our dependence on burning fossil fuels, as well as adaptation to climate change. For example, early warning systems for extreme weather events could reduce those vulnerabilities your question mentioned.

On the other hand, the measures proposed by the latest report on mental health and climate change have multiple effects. Some are particularly powerful and are not overly dependent on new technology. These include changing our mode of transport to low-emission, physically active ways to get around (walking, cycling), the benefits of which are already more than proven for both the environment and human health.

This article was translated from Univadis Spain.

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