CHEST President-Elect Steven Q. Simpson, MD, FCCP, is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Kansas. He is also senior advisor to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the US Department of Health and Human Services.

As we greet our new incoming CHEST President, we asked him for a few thoughts about his upcoming presidential year. He kindly offered these responses:
 

What would you like to accomplish as President of CHEST?

This is an interesting question, because a global pandemic and other developments in our world dictate that our organizational goals must adapt to a landscape that has shifted in recent months. My goals as President are somewhat different from what I stated when I ran for the office.

1. First, I will build on the efforts of my predecessors to ensure that CHEST is an inclusive and anti-racist organization. All CHEST members must have equal opportunities within our organization to advance their lives and their careers, regardless of race, ethnicity, sex, or gender. My goal is to examine our structures for participation and advancement to positions of leadership in the organization and to evaluate our educational and research offerings, all with the purpose of discovering and remedying places where we have been blind to our own systematic bias. Further, CHEST must advocate for and lead others to advocate for equality, for equal access to medical care, and for policies that promote them. We must be leaders in this arena, through both our voice and our actions.

2. We will build on CHEST’s new initiative to support the wellness of our members and to help us all perform at our best, day in and day out. I hope for our newly established Wellness Center to become a frequent stop for all CHEST members, myself included, to help us to sustain ourselves through the pandemic and beyond.

3. We must maintain both the quality and the feel of our educational and research offerings during this time when we cannot come together in person. My goal for us is that we use this time to embrace remote and nontemporally synchronous education, ie, web-based education, to make CHEST’s offerings the best anywhere. In the remainder of the 21st century, digital transformation of teaching and learning will advance tremendously, and our creative use of technology will become a norm. I hope that we never abandon in-person meetings, but using technology to improve information transfer and augmenting our members’ continuing education are clearly here to stay. My goal for us is that we maintain an atmosphere to both our in-person meetings and our remotely delivered meetings that makes generating new knowledge and learning what we generate enjoyable, even fun. I believe our digital transformation will make some interesting things possible over time.

4. My overall goal for CHEST in the coming year is not that we “make it through” the current pandemic, but that we emerge stronger, smarter, and better for the experience, and prepared for the next challenge(s).

Before COVID-19, I had goals for my presidency, and these issues have not disappeared. CHEST needs to be user- friendly for our members, from our website, to the ways in which we deliver education, to the type of research we develop and promote. On the research side, our members have long been interested in clinical research that informs and improves our patient care. My goal is to double down on promoting, supporting, and presenting research that serves exactly this purpose. We are growing our team-based education, and I have a special goal for CHEST to become the home for pulmonary, critical care, and sleep advanced practice providers. I care tremendously about our international members, and I will promote both international growth and catering of CHEST’s offerings to benefit our international members.
 

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

There is zero doubt that CHEST’s greatest strength is the people who gravitate to our organization. From pure clinicians to academicians; from clinical researchers to clinical educators to outcomes mavens—all levels of the health-care team. At every level of this organization are members who all want to be better at what we do, who want to figure out the ways for doing that, who want to explore the boundaries of what that means, and who want to help others to do the same. That goes, as well, for the professional staff who support the members, and who have adopted the motto, “CRUSH lung disease,” because they share our mission and are here to help us do it better.

The absolutely most enjoyable thing about leadership is having the opportunity to survey the landscape and see who’s looking for opportunity, who’s a rising star, who’s looking for people to mentor, then matching those people with opportunities and with jobs to do. Good people who are motivated by the right principles rise to the occasion. My job as President is to help ensure that the organization via the CHEST Board of Regents is addressing the correct problems with the right vision, to identify the right talented and dedicated members for the jobs, and then to support and stay out of their way as they make the vision a reality.
 

What are some challenges facing CHEST, and how will you address these challenges?

The major immediate challenges facing CHEST are pandemic-related, in terms of helping to ensure the well-being of our members, and in helping them to address the inequities and disparities in care for our patients of color, who have been hardest hit by the emergence of SARS-CoV-2. I addressed these with my goals, above. To be more specific, though, our board will be using various techniques, including dialogue with our members of color, to understand and address our own implicit biases, so that we can achieve the correct vision and tone of inclusion for all of our members. Also addressed in my goals is the isolation from one another that we are all experiencing because of the pandemic. This situation makes it difficult for us to maintain the style and tone of live learning experiences that our CHEST members are accustomed to. The challenge is to develop materials that can be interactive at a distance, and this likely includes gamification of educational content and employing virtual reality. CHEST Innovations is already working in this arena, and it will be our job as member volunteers to support those efforts. The isolation affects our international members, as well, and our ability to travel to maintain relationships. The nice thing is that web conferencing works just as well for international meetings as for meetings in the US, although somebody often has to go to bed very late or get up very early in the morning to make them work! The efforts are worth our time. Again, we will be working in various arenas to maintain and grow our international relationships.
 

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

We do not yet see clearly whether to expect a massive winter surge of COVID-19 infections. However, it is a reasonably likely possibility. My charge to our members and our new Fellows is first to stay safe, yourself, and to take care of your mental and physical well-being, so that you can be present and functioning at peak levels for your patients. Make sure your family is, likewise, being safe. Secondly, keep doing what you do, which is excellent patient care, excellent teaching, excellent research to push the boundaries of our knowledge. And finally, you’ve seen my ideas of the challenges facing CHEST. I want you to survey, yourself, and tell me what you think our challenges, goals, and responsibilities should be. And if anything I’ve said resonates with you, volunteer to help us address our challenges and keep CHEST the professional home that you deserve and that you will never want to leave. CHEST wants you and needs you. We are so happy you are with us!

CHEST President-Elect Steven Q. Simpson, MD, FCCP, is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Kansas. He is also senior advisor to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the US Department of Health and Human Services.

As we greet our new incoming CHEST President, we asked him for a few thoughts about his upcoming presidential year. He kindly offered these responses:
 

What would you like to accomplish as President of CHEST?

This is an interesting question, because a global pandemic and other developments in our world dictate that our organizational goals must adapt to a landscape that has shifted in recent months. My goals as President are somewhat different from what I stated when I ran for the office.

1. First, I will build on the efforts of my predecessors to ensure that CHEST is an inclusive and anti-racist organization. All CHEST members must have equal opportunities within our organization to advance their lives and their careers, regardless of race, ethnicity, sex, or gender. My goal is to examine our structures for participation and advancement to positions of leadership in the organization and to evaluate our educational and research offerings, all with the purpose of discovering and remedying places where we have been blind to our own systematic bias. Further, CHEST must advocate for and lead others to advocate for equality, for equal access to medical care, and for policies that promote them. We must be leaders in this arena, through both our voice and our actions.

2. We will build on CHEST’s new initiative to support the wellness of our members and to help us all perform at our best, day in and day out. I hope for our newly established Wellness Center to become a frequent stop for all CHEST members, myself included, to help us to sustain ourselves through the pandemic and beyond.

3. We must maintain both the quality and the feel of our educational and research offerings during this time when we cannot come together in person. My goal for us is that we use this time to embrace remote and nontemporally synchronous education, ie, web-based education, to make CHEST’s offerings the best anywhere. In the remainder of the 21st century, digital transformation of teaching and learning will advance tremendously, and our creative use of technology will become a norm. I hope that we never abandon in-person meetings, but using technology to improve information transfer and augmenting our members’ continuing education are clearly here to stay. My goal for us is that we maintain an atmosphere to both our in-person meetings and our remotely delivered meetings that makes generating new knowledge and learning what we generate enjoyable, even fun. I believe our digital transformation will make some interesting things possible over time.

4. My overall goal for CHEST in the coming year is not that we “make it through” the current pandemic, but that we emerge stronger, smarter, and better for the experience, and prepared for the next challenge(s).

Before COVID-19, I had goals for my presidency, and these issues have not disappeared. CHEST needs to be user- friendly for our members, from our website, to the ways in which we deliver education, to the type of research we develop and promote. On the research side, our members have long been interested in clinical research that informs and improves our patient care. My goal is to double down on promoting, supporting, and presenting research that serves exactly this purpose. We are growing our team-based education, and I have a special goal for CHEST to become the home for pulmonary, critical care, and sleep advanced practice providers. I care tremendously about our international members, and I will promote both international growth and catering of CHEST’s offerings to benefit our international members.
 

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

There is zero doubt that CHEST’s greatest strength is the people who gravitate to our organization. From pure clinicians to academicians; from clinical researchers to clinical educators to outcomes mavens—all levels of the health-care team. At every level of this organization are members who all want to be better at what we do, who want to figure out the ways for doing that, who want to explore the boundaries of what that means, and who want to help others to do the same. That goes, as well, for the professional staff who support the members, and who have adopted the motto, “CRUSH lung disease,” because they share our mission and are here to help us do it better.

The absolutely most enjoyable thing about leadership is having the opportunity to survey the landscape and see who’s looking for opportunity, who’s a rising star, who’s looking for people to mentor, then matching those people with opportunities and with jobs to do. Good people who are motivated by the right principles rise to the occasion. My job as President is to help ensure that the organization via the CHEST Board of Regents is addressing the correct problems with the right vision, to identify the right talented and dedicated members for the jobs, and then to support and stay out of their way as they make the vision a reality.
 

What are some challenges facing CHEST, and how will you address these challenges?

The major immediate challenges facing CHEST are pandemic-related, in terms of helping to ensure the well-being of our members, and in helping them to address the inequities and disparities in care for our patients of color, who have been hardest hit by the emergence of SARS-CoV-2. I addressed these with my goals, above. To be more specific, though, our board will be using various techniques, including dialogue with our members of color, to understand and address our own implicit biases, so that we can achieve the correct vision and tone of inclusion for all of our members. Also addressed in my goals is the isolation from one another that we are all experiencing because of the pandemic. This situation makes it difficult for us to maintain the style and tone of live learning experiences that our CHEST members are accustomed to. The challenge is to develop materials that can be interactive at a distance, and this likely includes gamification of educational content and employing virtual reality. CHEST Innovations is already working in this arena, and it will be our job as member volunteers to support those efforts. The isolation affects our international members, as well, and our ability to travel to maintain relationships. The nice thing is that web conferencing works just as well for international meetings as for meetings in the US, although somebody often has to go to bed very late or get up very early in the morning to make them work! The efforts are worth our time. Again, we will be working in various arenas to maintain and grow our international relationships.
 

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

We do not yet see clearly whether to expect a massive winter surge of COVID-19 infections. However, it is a reasonably likely possibility. My charge to our members and our new Fellows is first to stay safe, yourself, and to take care of your mental and physical well-being, so that you can be present and functioning at peak levels for your patients. Make sure your family is, likewise, being safe. Secondly, keep doing what you do, which is excellent patient care, excellent teaching, excellent research to push the boundaries of our knowledge. And finally, you’ve seen my ideas of the challenges facing CHEST. I want you to survey, yourself, and tell me what you think our challenges, goals, and responsibilities should be. And if anything I’ve said resonates with you, volunteer to help us address our challenges and keep CHEST the professional home that you deserve and that you will never want to leave. CHEST wants you and needs you. We are so happy you are with us!

CHEST President-Elect Steven Q. Simpson, MD, FCCP, is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Kansas. He is also senior advisor to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the US Department of Health and Human Services.

As we greet our new incoming CHEST President, we asked him for a few thoughts about his upcoming presidential year. He kindly offered these responses:
 

What would you like to accomplish as President of CHEST?

This is an interesting question, because a global pandemic and other developments in our world dictate that our organizational goals must adapt to a landscape that has shifted in recent months. My goals as President are somewhat different from what I stated when I ran for the office.

1. First, I will build on the efforts of my predecessors to ensure that CHEST is an inclusive and anti-racist organization. All CHEST members must have equal opportunities within our organization to advance their lives and their careers, regardless of race, ethnicity, sex, or gender. My goal is to examine our structures for participation and advancement to positions of leadership in the organization and to evaluate our educational and research offerings, all with the purpose of discovering and remedying places where we have been blind to our own systematic bias. Further, CHEST must advocate for and lead others to advocate for equality, for equal access to medical care, and for policies that promote them. We must be leaders in this arena, through both our voice and our actions.

2. We will build on CHEST’s new initiative to support the wellness of our members and to help us all perform at our best, day in and day out. I hope for our newly established Wellness Center to become a frequent stop for all CHEST members, myself included, to help us to sustain ourselves through the pandemic and beyond.

3. We must maintain both the quality and the feel of our educational and research offerings during this time when we cannot come together in person. My goal for us is that we use this time to embrace remote and nontemporally synchronous education, ie, web-based education, to make CHEST’s offerings the best anywhere. In the remainder of the 21st century, digital transformation of teaching and learning will advance tremendously, and our creative use of technology will become a norm. I hope that we never abandon in-person meetings, but using technology to improve information transfer and augmenting our members’ continuing education are clearly here to stay. My goal for us is that we maintain an atmosphere to both our in-person meetings and our remotely delivered meetings that makes generating new knowledge and learning what we generate enjoyable, even fun. I believe our digital transformation will make some interesting things possible over time.

4. My overall goal for CHEST in the coming year is not that we “make it through” the current pandemic, but that we emerge stronger, smarter, and better for the experience, and prepared for the next challenge(s).

Before COVID-19, I had goals for my presidency, and these issues have not disappeared. CHEST needs to be user- friendly for our members, from our website, to the ways in which we deliver education, to the type of research we develop and promote. On the research side, our members have long been interested in clinical research that informs and improves our patient care. My goal is to double down on promoting, supporting, and presenting research that serves exactly this purpose. We are growing our team-based education, and I have a special goal for CHEST to become the home for pulmonary, critical care, and sleep advanced practice providers. I care tremendously about our international members, and I will promote both international growth and catering of CHEST’s offerings to benefit our international members.
 

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

There is zero doubt that CHEST’s greatest strength is the people who gravitate to our organization. From pure clinicians to academicians; from clinical researchers to clinical educators to outcomes mavens—all levels of the health-care team. At every level of this organization are members who all want to be better at what we do, who want to figure out the ways for doing that, who want to explore the boundaries of what that means, and who want to help others to do the same. That goes, as well, for the professional staff who support the members, and who have adopted the motto, “CRUSH lung disease,” because they share our mission and are here to help us do it better.

The absolutely most enjoyable thing about leadership is having the opportunity to survey the landscape and see who’s looking for opportunity, who’s a rising star, who’s looking for people to mentor, then matching those people with opportunities and with jobs to do. Good people who are motivated by the right principles rise to the occasion. My job as President is to help ensure that the organization via the CHEST Board of Regents is addressing the correct problems with the right vision, to identify the right talented and dedicated members for the jobs, and then to support and stay out of their way as they make the vision a reality.
 

What are some challenges facing CHEST, and how will you address these challenges?

The major immediate challenges facing CHEST are pandemic-related, in terms of helping to ensure the well-being of our members, and in helping them to address the inequities and disparities in care for our patients of color, who have been hardest hit by the emergence of SARS-CoV-2. I addressed these with my goals, above. To be more specific, though, our board will be using various techniques, including dialogue with our members of color, to understand and address our own implicit biases, so that we can achieve the correct vision and tone of inclusion for all of our members. Also addressed in my goals is the isolation from one another that we are all experiencing because of the pandemic. This situation makes it difficult for us to maintain the style and tone of live learning experiences that our CHEST members are accustomed to. The challenge is to develop materials that can be interactive at a distance, and this likely includes gamification of educational content and employing virtual reality. CHEST Innovations is already working in this arena, and it will be our job as member volunteers to support those efforts. The isolation affects our international members, as well, and our ability to travel to maintain relationships. The nice thing is that web conferencing works just as well for international meetings as for meetings in the US, although somebody often has to go to bed very late or get up very early in the morning to make them work! The efforts are worth our time. Again, we will be working in various arenas to maintain and grow our international relationships.
 

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

We do not yet see clearly whether to expect a massive winter surge of COVID-19 infections. However, it is a reasonably likely possibility. My charge to our members and our new Fellows is first to stay safe, yourself, and to take care of your mental and physical well-being, so that you can be present and functioning at peak levels for your patients. Make sure your family is, likewise, being safe. Secondly, keep doing what you do, which is excellent patient care, excellent teaching, excellent research to push the boundaries of our knowledge. And finally, you’ve seen my ideas of the challenges facing CHEST. I want you to survey, yourself, and tell me what you think our challenges, goals, and responsibilities should be. And if anything I’ve said resonates with you, volunteer to help us address our challenges and keep CHEST the professional home that you deserve and that you will never want to leave. CHEST wants you and needs you. We are so happy you are with us!

The Food and Drug Administration has removed the boxed warning about the risk of leg and foot amputations for canagliflozin (Invokana, Invokamet, Janssen), a sodium-glucose cotransporter-2 (SGLT2) inhibitor for the treatment of type 2 diabetes, the agency announced Aug. 26.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

As previously reported by Medscape Medical News, the FDA added the boxed warning to the canagliflozin label in May 2017, after an approximately doubled risk for lower-extremity amputations with the drug compared with placebo was seen during two trials.

The FDA said the decision to remove the boxed warning was made following a review of new data from three clinical trials, which demonstrated additional heart- and kidney-related benefits and led to additional approved uses for canagliflozin.

In 2018, canagliflozin was approved to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes who have established cardiovascular disease.

In 2019, canagliflozin was approved to reduce the risk of end-stage kidney disease, worsening of kidney function, cardiovascular death, and heart failure hospitalization, in adults with type 2 diabetes and diabetic kidney disease.

“Collectively, these newly identified effects of canagliflozin on heart and kidney disease show significantly enhanced benefit of this medicine,” the FDA said.

The safety information from these trials, the FDA said, suggests that the risk of amputation, “while still increased with canagliflozin, is lower than previously described, particularly when appropriately monitored.”

The agency added: “Based upon these considerations, FDA concluded that the boxed warning should be removed.”

The FDA announcement said clinicians and patients should continue to be aware of the importance of preventive foot care and to monitor for new pain, tenderness, sores, ulcers, and infections in the legs and feet. Risk factors that may predispose patients to amputation should be considered when choosing antidiabetic medicines.

Health care professionals are encouraged to report adverse reactions with canagliflozin to the FDA’s MedWatch program.
 

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

The Food and Drug Administration has removed the boxed warning about the risk of leg and foot amputations for canagliflozin (Invokana, Invokamet, Janssen), a sodium-glucose cotransporter-2 (SGLT2) inhibitor for the treatment of type 2 diabetes, the agency announced Aug. 26.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

As previously reported by Medscape Medical News, the FDA added the boxed warning to the canagliflozin label in May 2017, after an approximately doubled risk for lower-extremity amputations with the drug compared with placebo was seen during two trials.

The FDA said the decision to remove the boxed warning was made following a review of new data from three clinical trials, which demonstrated additional heart- and kidney-related benefits and led to additional approved uses for canagliflozin.

In 2018, canagliflozin was approved to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes who have established cardiovascular disease.

In 2019, canagliflozin was approved to reduce the risk of end-stage kidney disease, worsening of kidney function, cardiovascular death, and heart failure hospitalization, in adults with type 2 diabetes and diabetic kidney disease.

“Collectively, these newly identified effects of canagliflozin on heart and kidney disease show significantly enhanced benefit of this medicine,” the FDA said.

The safety information from these trials, the FDA said, suggests that the risk of amputation, “while still increased with canagliflozin, is lower than previously described, particularly when appropriately monitored.”

The agency added: “Based upon these considerations, FDA concluded that the boxed warning should be removed.”

The FDA announcement said clinicians and patients should continue to be aware of the importance of preventive foot care and to monitor for new pain, tenderness, sores, ulcers, and infections in the legs and feet. Risk factors that may predispose patients to amputation should be considered when choosing antidiabetic medicines.

Health care professionals are encouraged to report adverse reactions with canagliflozin to the FDA’s MedWatch program.
 

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

The Food and Drug Administration has removed the boxed warning about the risk of leg and foot amputations for canagliflozin (Invokana, Invokamet, Janssen), a sodium-glucose cotransporter-2 (SGLT2) inhibitor for the treatment of type 2 diabetes, the agency announced Aug. 26.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

As previously reported by Medscape Medical News, the FDA added the boxed warning to the canagliflozin label in May 2017, after an approximately doubled risk for lower-extremity amputations with the drug compared with placebo was seen during two trials.

The FDA said the decision to remove the boxed warning was made following a review of new data from three clinical trials, which demonstrated additional heart- and kidney-related benefits and led to additional approved uses for canagliflozin.

In 2018, canagliflozin was approved to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes who have established cardiovascular disease.

In 2019, canagliflozin was approved to reduce the risk of end-stage kidney disease, worsening of kidney function, cardiovascular death, and heart failure hospitalization, in adults with type 2 diabetes and diabetic kidney disease.

“Collectively, these newly identified effects of canagliflozin on heart and kidney disease show significantly enhanced benefit of this medicine,” the FDA said.

The safety information from these trials, the FDA said, suggests that the risk of amputation, “while still increased with canagliflozin, is lower than previously described, particularly when appropriately monitored.”

The agency added: “Based upon these considerations, FDA concluded that the boxed warning should be removed.”

The FDA announcement said clinicians and patients should continue to be aware of the importance of preventive foot care and to monitor for new pain, tenderness, sores, ulcers, and infections in the legs and feet. Risk factors that may predispose patients to amputation should be considered when choosing antidiabetic medicines.

Health care professionals are encouraged to report adverse reactions with canagliflozin to the FDA’s MedWatch program.
 

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

Jerome Antone said he is one of the lucky ones.

Courtesy of Christopher Smith for KHN

After becoming ill with COVID-19, Mr. Antone was hospitalized only 65 miles away from his small Alabama town. He is the mayor of Georgiana – population 1,700.

“It hit our rural community so rabid,” Mr. Antone said. The town’s hospital closed last year. If hospitals in nearby communities don’t have beds available, “you may have to go 4 or 5 hours away.”

As COVID-19 continues to spread, an increasing number of rural communities find themselves without their hospital or on the brink of losing already cash-strapped facilities.

Eighteen rural hospitals closed last year and the first 3 months of 2020 were “really big months,” said Mark Holmes, PhD, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Many of the losses are in Southern states like Florida and Texas. More than 170 rural hospitals have closed nationwide since 2005, according to data collected by the Sheps Center.

It’s a dangerous scenario. “We know that a closure leads to higher mortality pretty quickly” among the populations served, said Dr. Holmes, who is also a professor at UNC Gillings School of Global Public Health. “That’s pretty clear.”

One 2019 study found that death rates in the surrounding communities increase nearly 6% after a rural hospital closes – and that’s when there’s not a pandemic.

Add to that what is known about the coronavirus: People who are obese or live with diabetes, hypertension, asthma, and other underlying health issues are more susceptible to COVID-19. Rural areas tend to have higher rates of these conditions. And rural residents are more likely to be older, sicker and poorer than those in urban areas. All this leaves rural communities particularly vulnerable to the coronavirus.

Congress approved billions in federal relief funds for health care providers. Initially, federal officials based what a hospital would get on its Medicare payments, but by late April they heeded criticism and carved out funds for rural hospitals and COVID-19 hot spots. Rural hospitals leapt at the chance to shore up already-negative budgets and prepare for the pandemic.

The funds “helped rural hospitals with the immediate storm,” said Don Williamson, MD, president of the Alabama Hospital Association. Nearly 80% of Alabama’s rural hospitals began the year with negative balance sheets and about 8 days’ worth of cash on hand.

Before the pandemic hit this year, hundreds of rural hospitals “were just trying to keep their doors open,” said Maggie Elehwany, vice president of government affairs with the National Rural Health Association. Then an estimated 70% of their income stopped as patients avoided the emergency room, doctor’s appointments, and elective surgeries.

“It was devastating,” Ms. Elehwany said.

Paul Taylor, chief executive of a 25-bed critical-access hospital and outpatient clinics in northwestern Arkansas, accepted millions in grants and loan money Congress approved this spring, largely through the CARES (Coronavirus Aid, Relief, and Economic Security) Act.

“For us, this was survival money and we spent it already,” Mr. Taylor said. With those funds, Ozarks Community Hospital increased surge capacity, expanding from 25 beds to 50 beds, adding negative pressure rooms and buying six ventilators. Taylor also ramped up COVID-19 testing at his hospital and clinics, located near some meat-processing plants.

Throughout June and July, Ozarks tested 1,000 patients a day and reported a 20% positive rate. The rate dropped to 16.9% in late July. But patients continue to avoid routine care.

Mr. Taylor said revenue is still constrained and he does not know how he will pay back $8 million that he borrowed from Medicare. The program allowed hospitals to borrow against future payments from the federal government, but stipulated that repayment would begin within 120 days.

For Mr. Taylor, this seems impossible. Medicare makes up 40% of Ozarks’ income. And he has to pay the loan back before he gets any more payments from Medicare. He’s hoping to refinance the hospital’s mortgage.

“If I get no relief and they take the money ... we won’t still be open,” Mr. Taylor said. Ozarks provides 625 jobs and serves an area with a population of about 75,000.

There are 1,300 small critical-access hospitals like Ozarks in rural America, and of those, 859 took advantage of the Medicare loans, sending about $3.1 billion into the local communities. But many rural communities have not yet experienced a surge in coronavirus cases – national leaders fear it will come as part of a new phase.

“There are pockets of rural America who say, ‘We haven’t seen a single COVID patient yet and we do not believe it’s real,’ ” Mr. Taylor said. “They will get hit sooner or later.”

Across the country, the reduced patient numbers and increased spending required to fight and prepare for the coronavirus was “like a knife cutting into a hospital’s blood supply,” said Ge Bai, PhD, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

Dr. Bai said the way the federal government reimbursed small rural hospitals through federal programs like Medicare before the pandemic was faulty and inefficient. “They are too weak to survive,” she said.

In rural Texas, about 2 hours from Dallas, Titus Regional Medical Center chief executive officer Terry Scoggin cut staff and furloughed workers even as his rural hospital faced down the pandemic. Titus Regional lost about $4 million last fiscal year and broke even each of the three years before that.

Mr. Scoggin said he did not cut from his clinical staff, though. Titus is now facing its second surge of the virus in the community. “The last 7 days, we’ve been testing 30% positive,” he said, including the case of his father, who contracted it at a nursing home and survived.

“It’s personal and this is real,” Mr. Scoggin said. “You know the people who are infected. You know the people who are passing away.”

Of his roughly 700 employees, 48 have tested positive for the virus and 1 has died. They are short on testing kits, medication, and supplies.

“Right now the staff is strained,” Mr. Scoggin said. “I’ve been blown away by their selflessness and unbelievable spirit. We’re resilient, we’re nimble, and we will make it. We don’t have a choice.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Jerome Antone said he is one of the lucky ones.

Courtesy of Christopher Smith for KHN

After becoming ill with COVID-19, Mr. Antone was hospitalized only 65 miles away from his small Alabama town. He is the mayor of Georgiana – population 1,700.

“It hit our rural community so rabid,” Mr. Antone said. The town’s hospital closed last year. If hospitals in nearby communities don’t have beds available, “you may have to go 4 or 5 hours away.”

As COVID-19 continues to spread, an increasing number of rural communities find themselves without their hospital or on the brink of losing already cash-strapped facilities.

Eighteen rural hospitals closed last year and the first 3 months of 2020 were “really big months,” said Mark Holmes, PhD, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Many of the losses are in Southern states like Florida and Texas. More than 170 rural hospitals have closed nationwide since 2005, according to data collected by the Sheps Center.

It’s a dangerous scenario. “We know that a closure leads to higher mortality pretty quickly” among the populations served, said Dr. Holmes, who is also a professor at UNC Gillings School of Global Public Health. “That’s pretty clear.”

One 2019 study found that death rates in the surrounding communities increase nearly 6% after a rural hospital closes – and that’s when there’s not a pandemic.

Add to that what is known about the coronavirus: People who are obese or live with diabetes, hypertension, asthma, and other underlying health issues are more susceptible to COVID-19. Rural areas tend to have higher rates of these conditions. And rural residents are more likely to be older, sicker and poorer than those in urban areas. All this leaves rural communities particularly vulnerable to the coronavirus.

Congress approved billions in federal relief funds for health care providers. Initially, federal officials based what a hospital would get on its Medicare payments, but by late April they heeded criticism and carved out funds for rural hospitals and COVID-19 hot spots. Rural hospitals leapt at the chance to shore up already-negative budgets and prepare for the pandemic.

The funds “helped rural hospitals with the immediate storm,” said Don Williamson, MD, president of the Alabama Hospital Association. Nearly 80% of Alabama’s rural hospitals began the year with negative balance sheets and about 8 days’ worth of cash on hand.

Before the pandemic hit this year, hundreds of rural hospitals “were just trying to keep their doors open,” said Maggie Elehwany, vice president of government affairs with the National Rural Health Association. Then an estimated 70% of their income stopped as patients avoided the emergency room, doctor’s appointments, and elective surgeries.

“It was devastating,” Ms. Elehwany said.

Paul Taylor, chief executive of a 25-bed critical-access hospital and outpatient clinics in northwestern Arkansas, accepted millions in grants and loan money Congress approved this spring, largely through the CARES (Coronavirus Aid, Relief, and Economic Security) Act.

“For us, this was survival money and we spent it already,” Mr. Taylor said. With those funds, Ozarks Community Hospital increased surge capacity, expanding from 25 beds to 50 beds, adding negative pressure rooms and buying six ventilators. Taylor also ramped up COVID-19 testing at his hospital and clinics, located near some meat-processing plants.

Throughout June and July, Ozarks tested 1,000 patients a day and reported a 20% positive rate. The rate dropped to 16.9% in late July. But patients continue to avoid routine care.

Mr. Taylor said revenue is still constrained and he does not know how he will pay back $8 million that he borrowed from Medicare. The program allowed hospitals to borrow against future payments from the federal government, but stipulated that repayment would begin within 120 days.

For Mr. Taylor, this seems impossible. Medicare makes up 40% of Ozarks’ income. And he has to pay the loan back before he gets any more payments from Medicare. He’s hoping to refinance the hospital’s mortgage.

“If I get no relief and they take the money ... we won’t still be open,” Mr. Taylor said. Ozarks provides 625 jobs and serves an area with a population of about 75,000.

There are 1,300 small critical-access hospitals like Ozarks in rural America, and of those, 859 took advantage of the Medicare loans, sending about $3.1 billion into the local communities. But many rural communities have not yet experienced a surge in coronavirus cases – national leaders fear it will come as part of a new phase.

“There are pockets of rural America who say, ‘We haven’t seen a single COVID patient yet and we do not believe it’s real,’ ” Mr. Taylor said. “They will get hit sooner or later.”

Across the country, the reduced patient numbers and increased spending required to fight and prepare for the coronavirus was “like a knife cutting into a hospital’s blood supply,” said Ge Bai, PhD, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

Dr. Bai said the way the federal government reimbursed small rural hospitals through federal programs like Medicare before the pandemic was faulty and inefficient. “They are too weak to survive,” she said.

In rural Texas, about 2 hours from Dallas, Titus Regional Medical Center chief executive officer Terry Scoggin cut staff and furloughed workers even as his rural hospital faced down the pandemic. Titus Regional lost about $4 million last fiscal year and broke even each of the three years before that.

Mr. Scoggin said he did not cut from his clinical staff, though. Titus is now facing its second surge of the virus in the community. “The last 7 days, we’ve been testing 30% positive,” he said, including the case of his father, who contracted it at a nursing home and survived.

“It’s personal and this is real,” Mr. Scoggin said. “You know the people who are infected. You know the people who are passing away.”

Of his roughly 700 employees, 48 have tested positive for the virus and 1 has died. They are short on testing kits, medication, and supplies.

“Right now the staff is strained,” Mr. Scoggin said. “I’ve been blown away by their selflessness and unbelievable spirit. We’re resilient, we’re nimble, and we will make it. We don’t have a choice.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Jerome Antone said he is one of the lucky ones.

Courtesy of Christopher Smith for KHN

After becoming ill with COVID-19, Mr. Antone was hospitalized only 65 miles away from his small Alabama town. He is the mayor of Georgiana – population 1,700.

“It hit our rural community so rabid,” Mr. Antone said. The town’s hospital closed last year. If hospitals in nearby communities don’t have beds available, “you may have to go 4 or 5 hours away.”

As COVID-19 continues to spread, an increasing number of rural communities find themselves without their hospital or on the brink of losing already cash-strapped facilities.

Eighteen rural hospitals closed last year and the first 3 months of 2020 were “really big months,” said Mark Holmes, PhD, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Many of the losses are in Southern states like Florida and Texas. More than 170 rural hospitals have closed nationwide since 2005, according to data collected by the Sheps Center.

It’s a dangerous scenario. “We know that a closure leads to higher mortality pretty quickly” among the populations served, said Dr. Holmes, who is also a professor at UNC Gillings School of Global Public Health. “That’s pretty clear.”

One 2019 study found that death rates in the surrounding communities increase nearly 6% after a rural hospital closes – and that’s when there’s not a pandemic.

Add to that what is known about the coronavirus: People who are obese or live with diabetes, hypertension, asthma, and other underlying health issues are more susceptible to COVID-19. Rural areas tend to have higher rates of these conditions. And rural residents are more likely to be older, sicker and poorer than those in urban areas. All this leaves rural communities particularly vulnerable to the coronavirus.

Congress approved billions in federal relief funds for health care providers. Initially, federal officials based what a hospital would get on its Medicare payments, but by late April they heeded criticism and carved out funds for rural hospitals and COVID-19 hot spots. Rural hospitals leapt at the chance to shore up already-negative budgets and prepare for the pandemic.

The funds “helped rural hospitals with the immediate storm,” said Don Williamson, MD, president of the Alabama Hospital Association. Nearly 80% of Alabama’s rural hospitals began the year with negative balance sheets and about 8 days’ worth of cash on hand.

Before the pandemic hit this year, hundreds of rural hospitals “were just trying to keep their doors open,” said Maggie Elehwany, vice president of government affairs with the National Rural Health Association. Then an estimated 70% of their income stopped as patients avoided the emergency room, doctor’s appointments, and elective surgeries.

“It was devastating,” Ms. Elehwany said.

Paul Taylor, chief executive of a 25-bed critical-access hospital and outpatient clinics in northwestern Arkansas, accepted millions in grants and loan money Congress approved this spring, largely through the CARES (Coronavirus Aid, Relief, and Economic Security) Act.

“For us, this was survival money and we spent it already,” Mr. Taylor said. With those funds, Ozarks Community Hospital increased surge capacity, expanding from 25 beds to 50 beds, adding negative pressure rooms and buying six ventilators. Taylor also ramped up COVID-19 testing at his hospital and clinics, located near some meat-processing plants.

Throughout June and July, Ozarks tested 1,000 patients a day and reported a 20% positive rate. The rate dropped to 16.9% in late July. But patients continue to avoid routine care.

Mr. Taylor said revenue is still constrained and he does not know how he will pay back $8 million that he borrowed from Medicare. The program allowed hospitals to borrow against future payments from the federal government, but stipulated that repayment would begin within 120 days.

For Mr. Taylor, this seems impossible. Medicare makes up 40% of Ozarks’ income. And he has to pay the loan back before he gets any more payments from Medicare. He’s hoping to refinance the hospital’s mortgage.

“If I get no relief and they take the money ... we won’t still be open,” Mr. Taylor said. Ozarks provides 625 jobs and serves an area with a population of about 75,000.

There are 1,300 small critical-access hospitals like Ozarks in rural America, and of those, 859 took advantage of the Medicare loans, sending about $3.1 billion into the local communities. But many rural communities have not yet experienced a surge in coronavirus cases – national leaders fear it will come as part of a new phase.

“There are pockets of rural America who say, ‘We haven’t seen a single COVID patient yet and we do not believe it’s real,’ ” Mr. Taylor said. “They will get hit sooner or later.”

Across the country, the reduced patient numbers and increased spending required to fight and prepare for the coronavirus was “like a knife cutting into a hospital’s blood supply,” said Ge Bai, PhD, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

Dr. Bai said the way the federal government reimbursed small rural hospitals through federal programs like Medicare before the pandemic was faulty and inefficient. “They are too weak to survive,” she said.

In rural Texas, about 2 hours from Dallas, Titus Regional Medical Center chief executive officer Terry Scoggin cut staff and furloughed workers even as his rural hospital faced down the pandemic. Titus Regional lost about $4 million last fiscal year and broke even each of the three years before that.

Mr. Scoggin said he did not cut from his clinical staff, though. Titus is now facing its second surge of the virus in the community. “The last 7 days, we’ve been testing 30% positive,” he said, including the case of his father, who contracted it at a nursing home and survived.

“It’s personal and this is real,” Mr. Scoggin said. “You know the people who are infected. You know the people who are passing away.”

Of his roughly 700 employees, 48 have tested positive for the virus and 1 has died. They are short on testing kits, medication, and supplies.

“Right now the staff is strained,” Mr. Scoggin said. “I’ve been blown away by their selflessness and unbelievable spirit. We’re resilient, we’re nimble, and we will make it. We don’t have a choice.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Pregnancy and the postpartum period are a “very vulnerable time for mental disorders,” according to Henry A. Nasrallah, MD.

Courtney Hale/Getty Images

“Those changes that are helping pregnancy can also have psychiatric and psychopathological implications,” Dr. Nasrallah said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Numerous dramatic changes in physiology, immune functions, cognition, neuroplasticity, and behavior occur during pregnancy, noted Dr. Nasrallah of the University of Cincinnati. For example, the volume of the brain actually decreases during pregnancy, but brain size recovers over the 6 months after delivery. “Clearly, this is a transitional and a transient phenomenon,” he said. “The decrease in brain volume is associated with changes in brain metabolism and an increase in intracellular pH after delivery.”

But these changes can also carry risks for psychiatric disorders, Dr. Nasrallah explained. Changes in the hippocampus, which is “very plastic throughout adulthood,” have been linked to aging, cognition, pregnancy, and motherhood. “The hippocampus is the ‘Grand Central Station’ of memory in the brain, and the hippocampus is affected by neurodegenerative and psychiatric disorders, which disproportionately affect women,” he said at the meeting, presented by Global Academy for Medical Education.

Dr. Nasrallah said the hippocampus has particular susceptibility during pregnancy and in the postpartum period, or in women who have previously been pregnant.

Gender of the fetus can even affect the health of the mother, he added. In women who are pregnant with male fetuses, working memory and spatial ability are higher than in women who are pregnant with female fetuses, Dr. Nasrallah said. This is tied to higher numbers of proinflammatory cytokines present in male fetuses. In female fetuses, there are lower levels of interferon-gamma and interleukin (IL)-12 in the first trimester, and higher levels of IL-1 beta, tumor necrosis factor B, IL-5, and IL-10 in the second trimester.

In particular, the perinatal period is a time of great risk for depression and anxiety. Women are also at risk for postpartum depression, particularly women with bipolar disorder, Dr. Nasrallah said.

“Cytokine interleukin-10 and interleukin-6 are both increased during psychosis and during depression, so you can see the vulnerability for developing postpartum depression.” Some women “have other genes that make them susceptible for mood disorders, and the pregnancy can push them over the edge,” he said.

If women have bipolar disorder prior to delivery, “they have a very high risk of postpartum depression, possibly because of this immune dysregulation that serves the pregnancy, but unfortunately makes the woman vulnerable for postpartum psychiatric disorders,” Dr. Nasrallah said.

The effects of having children extend into middle age, Dr. Nasrallah said. Research has shown giving birth to more than one to two children can affect a woman’s risk for Alzheimer’s disease and risk for early-onset of the disease. Women who have three or fewer children later in life are also more likely to live longer, he said. In general, a longer reproductive period, duration of breastfeeding, and low number of pregnancies result in better cognition, while younger age at first pregnancy leads to worse cognition.

So-called pregnancy brain causes some cognitive functions to decline, and women may experience trouble concentrating and memory disturbance. “Other functions increase for the sake of the baby,” including a high reaction to threatening stimuli, absent-mindedness, motivation, reward, fear, executive functions, social cognition, salience, and attachment, Dr. Nasrallah said. In some cases, hormone-driven remodeling of the maternal brain can cause postpartum psychosis, which can reduce the anterior cingulate cortex, left parahippocampal gyrus volume, and left superior temporal gyrus volume.

Most changes in the brain, however, appear to be temporary, Dr. Nasrallah noted. Executive function improves 2-6 months after delivery, which includes goal and directed behavior, working memory, inhibitory function, and cognitive flexibility. In the postpartum period, “the gray matter increases in the first 3-4 months, especially in the brain areas that are involved in maternal behavior that includes amygdala, hypothalamus, and prefrontal cortex,” he added. “All of those changes correlate with positive maternal attachment, and so that makes it easier for the mother to bond with the baby.

“Don’t think of it as a negative,” he said. “The decline in brain volume is actually associated with better mothering and increased attachment between the mother and the baby, which is vital for survival of the baby.”

Global Academy and this news organization are owned by the same parent company. Dr. Nasrallah reports no relevant financial disclosures.

Pregnancy and the postpartum period are a “very vulnerable time for mental disorders,” according to Henry A. Nasrallah, MD.

Courtney Hale/Getty Images

“Those changes that are helping pregnancy can also have psychiatric and psychopathological implications,” Dr. Nasrallah said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Numerous dramatic changes in physiology, immune functions, cognition, neuroplasticity, and behavior occur during pregnancy, noted Dr. Nasrallah of the University of Cincinnati. For example, the volume of the brain actually decreases during pregnancy, but brain size recovers over the 6 months after delivery. “Clearly, this is a transitional and a transient phenomenon,” he said. “The decrease in brain volume is associated with changes in brain metabolism and an increase in intracellular pH after delivery.”

But these changes can also carry risks for psychiatric disorders, Dr. Nasrallah explained. Changes in the hippocampus, which is “very plastic throughout adulthood,” have been linked to aging, cognition, pregnancy, and motherhood. “The hippocampus is the ‘Grand Central Station’ of memory in the brain, and the hippocampus is affected by neurodegenerative and psychiatric disorders, which disproportionately affect women,” he said at the meeting, presented by Global Academy for Medical Education.

Dr. Nasrallah said the hippocampus has particular susceptibility during pregnancy and in the postpartum period, or in women who have previously been pregnant.

Gender of the fetus can even affect the health of the mother, he added. In women who are pregnant with male fetuses, working memory and spatial ability are higher than in women who are pregnant with female fetuses, Dr. Nasrallah said. This is tied to higher numbers of proinflammatory cytokines present in male fetuses. In female fetuses, there are lower levels of interferon-gamma and interleukin (IL)-12 in the first trimester, and higher levels of IL-1 beta, tumor necrosis factor B, IL-5, and IL-10 in the second trimester.

In particular, the perinatal period is a time of great risk for depression and anxiety. Women are also at risk for postpartum depression, particularly women with bipolar disorder, Dr. Nasrallah said.

“Cytokine interleukin-10 and interleukin-6 are both increased during psychosis and during depression, so you can see the vulnerability for developing postpartum depression.” Some women “have other genes that make them susceptible for mood disorders, and the pregnancy can push them over the edge,” he said.

If women have bipolar disorder prior to delivery, “they have a very high risk of postpartum depression, possibly because of this immune dysregulation that serves the pregnancy, but unfortunately makes the woman vulnerable for postpartum psychiatric disorders,” Dr. Nasrallah said.

The effects of having children extend into middle age, Dr. Nasrallah said. Research has shown giving birth to more than one to two children can affect a woman’s risk for Alzheimer’s disease and risk for early-onset of the disease. Women who have three or fewer children later in life are also more likely to live longer, he said. In general, a longer reproductive period, duration of breastfeeding, and low number of pregnancies result in better cognition, while younger age at first pregnancy leads to worse cognition.

So-called pregnancy brain causes some cognitive functions to decline, and women may experience trouble concentrating and memory disturbance. “Other functions increase for the sake of the baby,” including a high reaction to threatening stimuli, absent-mindedness, motivation, reward, fear, executive functions, social cognition, salience, and attachment, Dr. Nasrallah said. In some cases, hormone-driven remodeling of the maternal brain can cause postpartum psychosis, which can reduce the anterior cingulate cortex, left parahippocampal gyrus volume, and left superior temporal gyrus volume.

Most changes in the brain, however, appear to be temporary, Dr. Nasrallah noted. Executive function improves 2-6 months after delivery, which includes goal and directed behavior, working memory, inhibitory function, and cognitive flexibility. In the postpartum period, “the gray matter increases in the first 3-4 months, especially in the brain areas that are involved in maternal behavior that includes amygdala, hypothalamus, and prefrontal cortex,” he added. “All of those changes correlate with positive maternal attachment, and so that makes it easier for the mother to bond with the baby.

“Don’t think of it as a negative,” he said. “The decline in brain volume is actually associated with better mothering and increased attachment between the mother and the baby, which is vital for survival of the baby.”

Global Academy and this news organization are owned by the same parent company. Dr. Nasrallah reports no relevant financial disclosures.

Pregnancy and the postpartum period are a “very vulnerable time for mental disorders,” according to Henry A. Nasrallah, MD.

Courtney Hale/Getty Images

“Those changes that are helping pregnancy can also have psychiatric and psychopathological implications,” Dr. Nasrallah said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Numerous dramatic changes in physiology, immune functions, cognition, neuroplasticity, and behavior occur during pregnancy, noted Dr. Nasrallah of the University of Cincinnati. For example, the volume of the brain actually decreases during pregnancy, but brain size recovers over the 6 months after delivery. “Clearly, this is a transitional and a transient phenomenon,” he said. “The decrease in brain volume is associated with changes in brain metabolism and an increase in intracellular pH after delivery.”

But these changes can also carry risks for psychiatric disorders, Dr. Nasrallah explained. Changes in the hippocampus, which is “very plastic throughout adulthood,” have been linked to aging, cognition, pregnancy, and motherhood. “The hippocampus is the ‘Grand Central Station’ of memory in the brain, and the hippocampus is affected by neurodegenerative and psychiatric disorders, which disproportionately affect women,” he said at the meeting, presented by Global Academy for Medical Education.

Dr. Nasrallah said the hippocampus has particular susceptibility during pregnancy and in the postpartum period, or in women who have previously been pregnant.

Gender of the fetus can even affect the health of the mother, he added. In women who are pregnant with male fetuses, working memory and spatial ability are higher than in women who are pregnant with female fetuses, Dr. Nasrallah said. This is tied to higher numbers of proinflammatory cytokines present in male fetuses. In female fetuses, there are lower levels of interferon-gamma and interleukin (IL)-12 in the first trimester, and higher levels of IL-1 beta, tumor necrosis factor B, IL-5, and IL-10 in the second trimester.

In particular, the perinatal period is a time of great risk for depression and anxiety. Women are also at risk for postpartum depression, particularly women with bipolar disorder, Dr. Nasrallah said.

“Cytokine interleukin-10 and interleukin-6 are both increased during psychosis and during depression, so you can see the vulnerability for developing postpartum depression.” Some women “have other genes that make them susceptible for mood disorders, and the pregnancy can push them over the edge,” he said.

If women have bipolar disorder prior to delivery, “they have a very high risk of postpartum depression, possibly because of this immune dysregulation that serves the pregnancy, but unfortunately makes the woman vulnerable for postpartum psychiatric disorders,” Dr. Nasrallah said.

The effects of having children extend into middle age, Dr. Nasrallah said. Research has shown giving birth to more than one to two children can affect a woman’s risk for Alzheimer’s disease and risk for early-onset of the disease. Women who have three or fewer children later in life are also more likely to live longer, he said. In general, a longer reproductive period, duration of breastfeeding, and low number of pregnancies result in better cognition, while younger age at first pregnancy leads to worse cognition.

So-called pregnancy brain causes some cognitive functions to decline, and women may experience trouble concentrating and memory disturbance. “Other functions increase for the sake of the baby,” including a high reaction to threatening stimuli, absent-mindedness, motivation, reward, fear, executive functions, social cognition, salience, and attachment, Dr. Nasrallah said. In some cases, hormone-driven remodeling of the maternal brain can cause postpartum psychosis, which can reduce the anterior cingulate cortex, left parahippocampal gyrus volume, and left superior temporal gyrus volume.

Most changes in the brain, however, appear to be temporary, Dr. Nasrallah noted. Executive function improves 2-6 months after delivery, which includes goal and directed behavior, working memory, inhibitory function, and cognitive flexibility. In the postpartum period, “the gray matter increases in the first 3-4 months, especially in the brain areas that are involved in maternal behavior that includes amygdala, hypothalamus, and prefrontal cortex,” he added. “All of those changes correlate with positive maternal attachment, and so that makes it easier for the mother to bond with the baby.

“Don’t think of it as a negative,” he said. “The decline in brain volume is actually associated with better mothering and increased attachment between the mother and the baby, which is vital for survival of the baby.”

Global Academy and this news organization are owned by the same parent company. Dr. Nasrallah reports no relevant financial disclosures.

Melasma has such a high recurrence rate that, once the facial hyperpigmentation has been cleared, it’s best that treatment never entirely stops, Amit G. Pandya, MD, said at the virtual annual meeting of the American Academy of Dermatology.

He recommended alternating between a less-intensive maintenance therapy regimen in the winter months and an acute care regimen in the sunnier summer months. But in order to treat melasma effectively, it is first necessary to differentiate it from the numerous other possible causes of facial hyperpigmentation. And that is largely a matter of location.



Location, location, location

Melasma has a distinctive symmetric bilateral distribution: “Melasma likes the central area of the forehead, whereas the lateral areas of the forehead are more involved in lichen planus pigmentosus. Melanoma likes the area above the eyebrow or under the eyebrow. However, it does not go below the superior orbital rim or above the inferior orbital rim,”said Dr. Pandya, a dermatologist at the Palo Alto Medical Foundation in Sunnyvale, Calif., who is also on the faculty at the University of Texas Southwestern Medical Center, Dallas.

Melasma is common on the bridge of the nose, but usually not along the nasolabial fold, where hyperpigmentation is much more likely to be due to seborrheic dermatitis or drug-induced hyperpigmentation. Melasma doesn’t affect the tip of the nose; that’s more likely a sign of sarcoidosis or drug-induced hyperpigmentation. Melasma is common on the zygomatic prominence, while acanthosis nigricans favors the concave area below the zygomatic prominence. And melasma stays above the mandible; pigmentation below the mandible is more suggestive of poikiloderma of Civatte. Lentigines are scattered broadly across sun-exposed areas of the face. They also tend to be less symmetrical than melasma, the dermatologist continued.



Acute treatment

Dr. Pandya’s acute treatment algorithm begins with topical 4% hydroquinone in patients who’ve never been on it before. A response to the drug, which blocks the tyrosine-to-melanin pathway, takes 4-6 weeks, with maximum effect not seen until 3-6 months or longer. Bluish-grey ochronosis is a rare side effect at the 4% concentration but becomes more common at higher concentrations or when the drug is used in combination therapy.

“Hydroquinone is a workhorse, the oldest and most effective depigmenting agent,” he said.

If the patient hasn’t responded positively by 3 months, Dr. Pandya moves on to daily use of the triple-drug combination of fluocinolone acetonide 0.01%/hydroquinone 4%/tretinoin 0.05% known as Tri-Luma, a kinder, gentler descendant of the 45-year-old Kligman-Willis compounded formula comprised of 0.1% dexamethasone, 5% hydroquinone, and 0.1% tretinoin.

If Tri-Luma also proves ineffective, Dr. Pandya turns to oral tranexamic acid. This is off-label therapy for the drug, a plasmin inhibitor, which is approved for the treatment of menorrhagia. But oral tranexamic acid is widely used for treatment of melasma in East Asia, and Dr. Pandya and others have evaluated it in placebo-controlled clinical trials. His conclusion is that oral tranexamic acid appears to be safe and effective for treatment of melasma.

“The drug is not approved for melasma, it’s approved for menorrhagia, so every doctor has to decide how much risk they want to take. The evidence suggests 500 mg per day is a good dose,” he said.

The collective clinical trials experience with oral tranexamic acid for melasma shows a side effect profile consisting of mild GI upset, headache, and myalgia. While increased thromboembolic risk is a theoretic concern, it hasn’t been an issue in the published studies, which typically exclude patients with a history of thromboembolic disease from enrollment. Patient satisfaction with the oral agent is high, according to Dr. Pandya.

In one randomized, open-label, 40-patient study, oral tranexamic acid plus a triple-combination cream featuring fluocinolone 0.01%, hydroquinone 2%, and tretinoin 0.05%, applied once a day, was significantly more effective and faster-acting than the topical therapy alone. At 8 weeks, the dual-therapy group averaged an 88% improvement in the Melasma Activity and Severity Index (MASI) scores, compared with 55% with the topical therapy alone (Indian J Dermatol. Sep-Oct 2015;60[5]:520).

Cysteamine 5% cream, which is available over the counter as Cyspera but is pricey, showed promising efficacy in a 40-patient, randomized, double-blind trial (J Dermatolog Treat. 2018 Mar;29[2]:182-9). Dr. Pandya said he’s looking forward to seeing further studies.

Chemical peels can be used, but multiple treatment sessions using a superficial peeling agent are required, and even then “the efficacy is usually not profound,” according to Dr. Pandya. Together with two colleagues he recently published a comprehensive systematic review of 113 published studies of all treatments for melasma in nearly 7,000 patients (Am J Clin Dermatol. 2020 Apr;21(2):173-225).

Newer lasers with various pulse lengths, fluences, wave lengths, and treatment frequency show “some promise,” but there have also been published reports of hypopigmentation and rebound hyperpigmentation. The optimal laser regimen remains elusive, he said.



Maintenance therapy

Dr. Pandya usually switches from hydroquinone to a different topical tyrosinase inhibitor for maintenance therapy, such as kojic acid, arbutin, or azelaic acid, all available OTC in many formulations. Alternatively, he might drop down to 2% hydroquinone for the winter months. Another option is triple-combination cream applied two or three times per week. A topical formulation of tranexamic acid is available, but studies of this agent in patients with melasma have yielded mixed results.

“I don’t think topical tranexamic acid is going to harm the patient, but I don’t think the efficacy is as good as with oral tranexamic acid,” he said.



Slap that melasma in irons

A comprehensive melasma management plan requires year-round frequent daily application of a broad spectrum sunscreen. And since it’s now evident that visible-wavelength light can worsen melasma through mechanisms similar to UVA and UVB, which are long recognized as the major drivers of the hyperpigmentation disorder, serious consideration should be given to the use of a tinted broad-spectrum sunscreen or makeup containing more than 3% iron oxide, which blocks visible light. In contrast, zinc oxide does not, Dr. Pandya noted.

In one influential study, aminolevulinic acid was applied on the arms of 20 patients; two sunscreens were applied on areas where the ALA was applied, and on one area, no sunscreen was applied. The minimal phototoxic dose of visible blue light was doubled with application of a broad-spectrum sunscreen containing titanium dioxide, zinc oxide, and 0.2% iron oxide, compared with no sunscreen, but increased 21-fold using a sunscreen containing titanium dioxide, zinc oxide, and 3.2% iron oxide (Dermatol Surg. 2008 Nov;34[11]:1469-76).

Moreover, in a double-blind, randomized trial including 61 patients with melasma, all on background 4% hydroquinone, those assigned to a broad-spectrum sunscreen containing iron oxide had a 78% improvement in MASI scores at 8 weeks, compared with a 62% improvement with a broad-spectrum UV-only sunscreen. Both sunscreens had a sun protection factor of at least 50 (Photodermatol Photoimmunol Photomed. 2014 Feb;30[1]:35-42).

Numerous sunscreen and makeup products containing more than 3% iron oxide are available OTC in various tints. It’s a matter of finding a color that matches the patient’s skin.

Concern has been raised that exposure to the visible blue light emitted by computer screens and cell phones could worsen melasma. Dr. Pandya noted that reassurance on that score was recently provided by French investigators. They measured the intensity of visible light at the wavelengths emitted by computer screens and laptops and determined that it was 100- to 1,000-fold less than sunlight in the same spectrum. They also conducted a prospective, randomized, split-face trial in 12 melasma patients. One side of the face was exposed to the visible blue light at the same wavelengths emitted by device screens, but at far greater intensity. Blinded evaluators found no split-face difference in modified MASI scores.

“These results suggest that at a 20-cm distance, a maximized use of a high-intensity computer screen for 8 hours per day during a 5-day period does not worsen melasma lesions. Although it is very unlikely that similar exposure during a longer period would start to affect melasma lesions, such a possibility cannot be ruled out,” according to the investigators (J Am Acad Dermatol. 2019 Dec 27;S0190-9622(19)33324-9. doi: 10.1016/j.jaad.2019.12.047).

Dr. Pandya reported serving as a consultant to Incyte, Pfizer, Viela Bio, and Villaris.

bjancin@mdedge.com

Melasma has such a high recurrence rate that, once the facial hyperpigmentation has been cleared, it’s best that treatment never entirely stops, Amit G. Pandya, MD, said at the virtual annual meeting of the American Academy of Dermatology.

He recommended alternating between a less-intensive maintenance therapy regimen in the winter months and an acute care regimen in the sunnier summer months. But in order to treat melasma effectively, it is first necessary to differentiate it from the numerous other possible causes of facial hyperpigmentation. And that is largely a matter of location.



Location, location, location

Melasma has a distinctive symmetric bilateral distribution: “Melasma likes the central area of the forehead, whereas the lateral areas of the forehead are more involved in lichen planus pigmentosus. Melanoma likes the area above the eyebrow or under the eyebrow. However, it does not go below the superior orbital rim or above the inferior orbital rim,”said Dr. Pandya, a dermatologist at the Palo Alto Medical Foundation in Sunnyvale, Calif., who is also on the faculty at the University of Texas Southwestern Medical Center, Dallas.

Melasma is common on the bridge of the nose, but usually not along the nasolabial fold, where hyperpigmentation is much more likely to be due to seborrheic dermatitis or drug-induced hyperpigmentation. Melasma doesn’t affect the tip of the nose; that’s more likely a sign of sarcoidosis or drug-induced hyperpigmentation. Melasma is common on the zygomatic prominence, while acanthosis nigricans favors the concave area below the zygomatic prominence. And melasma stays above the mandible; pigmentation below the mandible is more suggestive of poikiloderma of Civatte. Lentigines are scattered broadly across sun-exposed areas of the face. They also tend to be less symmetrical than melasma, the dermatologist continued.



Acute treatment

Dr. Pandya’s acute treatment algorithm begins with topical 4% hydroquinone in patients who’ve never been on it before. A response to the drug, which blocks the tyrosine-to-melanin pathway, takes 4-6 weeks, with maximum effect not seen until 3-6 months or longer. Bluish-grey ochronosis is a rare side effect at the 4% concentration but becomes more common at higher concentrations or when the drug is used in combination therapy.

“Hydroquinone is a workhorse, the oldest and most effective depigmenting agent,” he said.

If the patient hasn’t responded positively by 3 months, Dr. Pandya moves on to daily use of the triple-drug combination of fluocinolone acetonide 0.01%/hydroquinone 4%/tretinoin 0.05% known as Tri-Luma, a kinder, gentler descendant of the 45-year-old Kligman-Willis compounded formula comprised of 0.1% dexamethasone, 5% hydroquinone, and 0.1% tretinoin.

If Tri-Luma also proves ineffective, Dr. Pandya turns to oral tranexamic acid. This is off-label therapy for the drug, a plasmin inhibitor, which is approved for the treatment of menorrhagia. But oral tranexamic acid is widely used for treatment of melasma in East Asia, and Dr. Pandya and others have evaluated it in placebo-controlled clinical trials. His conclusion is that oral tranexamic acid appears to be safe and effective for treatment of melasma.

“The drug is not approved for melasma, it’s approved for menorrhagia, so every doctor has to decide how much risk they want to take. The evidence suggests 500 mg per day is a good dose,” he said.

The collective clinical trials experience with oral tranexamic acid for melasma shows a side effect profile consisting of mild GI upset, headache, and myalgia. While increased thromboembolic risk is a theoretic concern, it hasn’t been an issue in the published studies, which typically exclude patients with a history of thromboembolic disease from enrollment. Patient satisfaction with the oral agent is high, according to Dr. Pandya.

In one randomized, open-label, 40-patient study, oral tranexamic acid plus a triple-combination cream featuring fluocinolone 0.01%, hydroquinone 2%, and tretinoin 0.05%, applied once a day, was significantly more effective and faster-acting than the topical therapy alone. At 8 weeks, the dual-therapy group averaged an 88% improvement in the Melasma Activity and Severity Index (MASI) scores, compared with 55% with the topical therapy alone (Indian J Dermatol. Sep-Oct 2015;60[5]:520).

Cysteamine 5% cream, which is available over the counter as Cyspera but is pricey, showed promising efficacy in a 40-patient, randomized, double-blind trial (J Dermatolog Treat. 2018 Mar;29[2]:182-9). Dr. Pandya said he’s looking forward to seeing further studies.

Chemical peels can be used, but multiple treatment sessions using a superficial peeling agent are required, and even then “the efficacy is usually not profound,” according to Dr. Pandya. Together with two colleagues he recently published a comprehensive systematic review of 113 published studies of all treatments for melasma in nearly 7,000 patients (Am J Clin Dermatol. 2020 Apr;21(2):173-225).

Newer lasers with various pulse lengths, fluences, wave lengths, and treatment frequency show “some promise,” but there have also been published reports of hypopigmentation and rebound hyperpigmentation. The optimal laser regimen remains elusive, he said.



Maintenance therapy

Dr. Pandya usually switches from hydroquinone to a different topical tyrosinase inhibitor for maintenance therapy, such as kojic acid, arbutin, or azelaic acid, all available OTC in many formulations. Alternatively, he might drop down to 2% hydroquinone for the winter months. Another option is triple-combination cream applied two or three times per week. A topical formulation of tranexamic acid is available, but studies of this agent in patients with melasma have yielded mixed results.

“I don’t think topical tranexamic acid is going to harm the patient, but I don’t think the efficacy is as good as with oral tranexamic acid,” he said.



Slap that melasma in irons

A comprehensive melasma management plan requires year-round frequent daily application of a broad spectrum sunscreen. And since it’s now evident that visible-wavelength light can worsen melasma through mechanisms similar to UVA and UVB, which are long recognized as the major drivers of the hyperpigmentation disorder, serious consideration should be given to the use of a tinted broad-spectrum sunscreen or makeup containing more than 3% iron oxide, which blocks visible light. In contrast, zinc oxide does not, Dr. Pandya noted.

In one influential study, aminolevulinic acid was applied on the arms of 20 patients; two sunscreens were applied on areas where the ALA was applied, and on one area, no sunscreen was applied. The minimal phototoxic dose of visible blue light was doubled with application of a broad-spectrum sunscreen containing titanium dioxide, zinc oxide, and 0.2% iron oxide, compared with no sunscreen, but increased 21-fold using a sunscreen containing titanium dioxide, zinc oxide, and 3.2% iron oxide (Dermatol Surg. 2008 Nov;34[11]:1469-76).

Moreover, in a double-blind, randomized trial including 61 patients with melasma, all on background 4% hydroquinone, those assigned to a broad-spectrum sunscreen containing iron oxide had a 78% improvement in MASI scores at 8 weeks, compared with a 62% improvement with a broad-spectrum UV-only sunscreen. Both sunscreens had a sun protection factor of at least 50 (Photodermatol Photoimmunol Photomed. 2014 Feb;30[1]:35-42).

Numerous sunscreen and makeup products containing more than 3% iron oxide are available OTC in various tints. It’s a matter of finding a color that matches the patient’s skin.

Concern has been raised that exposure to the visible blue light emitted by computer screens and cell phones could worsen melasma. Dr. Pandya noted that reassurance on that score was recently provided by French investigators. They measured the intensity of visible light at the wavelengths emitted by computer screens and laptops and determined that it was 100- to 1,000-fold less than sunlight in the same spectrum. They also conducted a prospective, randomized, split-face trial in 12 melasma patients. One side of the face was exposed to the visible blue light at the same wavelengths emitted by device screens, but at far greater intensity. Blinded evaluators found no split-face difference in modified MASI scores.

“These results suggest that at a 20-cm distance, a maximized use of a high-intensity computer screen for 8 hours per day during a 5-day period does not worsen melasma lesions. Although it is very unlikely that similar exposure during a longer period would start to affect melasma lesions, such a possibility cannot be ruled out,” according to the investigators (J Am Acad Dermatol. 2019 Dec 27;S0190-9622(19)33324-9. doi: 10.1016/j.jaad.2019.12.047).

Dr. Pandya reported serving as a consultant to Incyte, Pfizer, Viela Bio, and Villaris.

bjancin@mdedge.com

Melasma has such a high recurrence rate that, once the facial hyperpigmentation has been cleared, it’s best that treatment never entirely stops, Amit G. Pandya, MD, said at the virtual annual meeting of the American Academy of Dermatology.

He recommended alternating between a less-intensive maintenance therapy regimen in the winter months and an acute care regimen in the sunnier summer months. But in order to treat melasma effectively, it is first necessary to differentiate it from the numerous other possible causes of facial hyperpigmentation. And that is largely a matter of location.



Location, location, location

Melasma has a distinctive symmetric bilateral distribution: “Melasma likes the central area of the forehead, whereas the lateral areas of the forehead are more involved in lichen planus pigmentosus. Melanoma likes the area above the eyebrow or under the eyebrow. However, it does not go below the superior orbital rim or above the inferior orbital rim,”said Dr. Pandya, a dermatologist at the Palo Alto Medical Foundation in Sunnyvale, Calif., who is also on the faculty at the University of Texas Southwestern Medical Center, Dallas.

Melasma is common on the bridge of the nose, but usually not along the nasolabial fold, where hyperpigmentation is much more likely to be due to seborrheic dermatitis or drug-induced hyperpigmentation. Melasma doesn’t affect the tip of the nose; that’s more likely a sign of sarcoidosis or drug-induced hyperpigmentation. Melasma is common on the zygomatic prominence, while acanthosis nigricans favors the concave area below the zygomatic prominence. And melasma stays above the mandible; pigmentation below the mandible is more suggestive of poikiloderma of Civatte. Lentigines are scattered broadly across sun-exposed areas of the face. They also tend to be less symmetrical than melasma, the dermatologist continued.



Acute treatment

Dr. Pandya’s acute treatment algorithm begins with topical 4% hydroquinone in patients who’ve never been on it before. A response to the drug, which blocks the tyrosine-to-melanin pathway, takes 4-6 weeks, with maximum effect not seen until 3-6 months or longer. Bluish-grey ochronosis is a rare side effect at the 4% concentration but becomes more common at higher concentrations or when the drug is used in combination therapy.

“Hydroquinone is a workhorse, the oldest and most effective depigmenting agent,” he said.

If the patient hasn’t responded positively by 3 months, Dr. Pandya moves on to daily use of the triple-drug combination of fluocinolone acetonide 0.01%/hydroquinone 4%/tretinoin 0.05% known as Tri-Luma, a kinder, gentler descendant of the 45-year-old Kligman-Willis compounded formula comprised of 0.1% dexamethasone, 5% hydroquinone, and 0.1% tretinoin.

If Tri-Luma also proves ineffective, Dr. Pandya turns to oral tranexamic acid. This is off-label therapy for the drug, a plasmin inhibitor, which is approved for the treatment of menorrhagia. But oral tranexamic acid is widely used for treatment of melasma in East Asia, and Dr. Pandya and others have evaluated it in placebo-controlled clinical trials. His conclusion is that oral tranexamic acid appears to be safe and effective for treatment of melasma.

“The drug is not approved for melasma, it’s approved for menorrhagia, so every doctor has to decide how much risk they want to take. The evidence suggests 500 mg per day is a good dose,” he said.

The collective clinical trials experience with oral tranexamic acid for melasma shows a side effect profile consisting of mild GI upset, headache, and myalgia. While increased thromboembolic risk is a theoretic concern, it hasn’t been an issue in the published studies, which typically exclude patients with a history of thromboembolic disease from enrollment. Patient satisfaction with the oral agent is high, according to Dr. Pandya.

In one randomized, open-label, 40-patient study, oral tranexamic acid plus a triple-combination cream featuring fluocinolone 0.01%, hydroquinone 2%, and tretinoin 0.05%, applied once a day, was significantly more effective and faster-acting than the topical therapy alone. At 8 weeks, the dual-therapy group averaged an 88% improvement in the Melasma Activity and Severity Index (MASI) scores, compared with 55% with the topical therapy alone (Indian J Dermatol. Sep-Oct 2015;60[5]:520).

Cysteamine 5% cream, which is available over the counter as Cyspera but is pricey, showed promising efficacy in a 40-patient, randomized, double-blind trial (J Dermatolog Treat. 2018 Mar;29[2]:182-9). Dr. Pandya said he’s looking forward to seeing further studies.

Chemical peels can be used, but multiple treatment sessions using a superficial peeling agent are required, and even then “the efficacy is usually not profound,” according to Dr. Pandya. Together with two colleagues he recently published a comprehensive systematic review of 113 published studies of all treatments for melasma in nearly 7,000 patients (Am J Clin Dermatol. 2020 Apr;21(2):173-225).

Newer lasers with various pulse lengths, fluences, wave lengths, and treatment frequency show “some promise,” but there have also been published reports of hypopigmentation and rebound hyperpigmentation. The optimal laser regimen remains elusive, he said.



Maintenance therapy

Dr. Pandya usually switches from hydroquinone to a different topical tyrosinase inhibitor for maintenance therapy, such as kojic acid, arbutin, or azelaic acid, all available OTC in many formulations. Alternatively, he might drop down to 2% hydroquinone for the winter months. Another option is triple-combination cream applied two or three times per week. A topical formulation of tranexamic acid is available, but studies of this agent in patients with melasma have yielded mixed results.

“I don’t think topical tranexamic acid is going to harm the patient, but I don’t think the efficacy is as good as with oral tranexamic acid,” he said.



Slap that melasma in irons

A comprehensive melasma management plan requires year-round frequent daily application of a broad spectrum sunscreen. And since it’s now evident that visible-wavelength light can worsen melasma through mechanisms similar to UVA and UVB, which are long recognized as the major drivers of the hyperpigmentation disorder, serious consideration should be given to the use of a tinted broad-spectrum sunscreen or makeup containing more than 3% iron oxide, which blocks visible light. In contrast, zinc oxide does not, Dr. Pandya noted.

In one influential study, aminolevulinic acid was applied on the arms of 20 patients; two sunscreens were applied on areas where the ALA was applied, and on one area, no sunscreen was applied. The minimal phototoxic dose of visible blue light was doubled with application of a broad-spectrum sunscreen containing titanium dioxide, zinc oxide, and 0.2% iron oxide, compared with no sunscreen, but increased 21-fold using a sunscreen containing titanium dioxide, zinc oxide, and 3.2% iron oxide (Dermatol Surg. 2008 Nov;34[11]:1469-76).

Moreover, in a double-blind, randomized trial including 61 patients with melasma, all on background 4% hydroquinone, those assigned to a broad-spectrum sunscreen containing iron oxide had a 78% improvement in MASI scores at 8 weeks, compared with a 62% improvement with a broad-spectrum UV-only sunscreen. Both sunscreens had a sun protection factor of at least 50 (Photodermatol Photoimmunol Photomed. 2014 Feb;30[1]:35-42).

Numerous sunscreen and makeup products containing more than 3% iron oxide are available OTC in various tints. It’s a matter of finding a color that matches the patient’s skin.

Concern has been raised that exposure to the visible blue light emitted by computer screens and cell phones could worsen melasma. Dr. Pandya noted that reassurance on that score was recently provided by French investigators. They measured the intensity of visible light at the wavelengths emitted by computer screens and laptops and determined that it was 100- to 1,000-fold less than sunlight in the same spectrum. They also conducted a prospective, randomized, split-face trial in 12 melasma patients. One side of the face was exposed to the visible blue light at the same wavelengths emitted by device screens, but at far greater intensity. Blinded evaluators found no split-face difference in modified MASI scores.

“These results suggest that at a 20-cm distance, a maximized use of a high-intensity computer screen for 8 hours per day during a 5-day period does not worsen melasma lesions. Although it is very unlikely that similar exposure during a longer period would start to affect melasma lesions, such a possibility cannot be ruled out,” according to the investigators (J Am Acad Dermatol. 2019 Dec 27;S0190-9622(19)33324-9. doi: 10.1016/j.jaad.2019.12.047).

Dr. Pandya reported serving as a consultant to Incyte, Pfizer, Viela Bio, and Villaris.

bjancin@mdedge.com

A large postmarketing surveillance study of topical calcineurin inhibitor exposure in adults with atopic dermatitis has found no increased risk of developing keratinocyte carcinomas overall or with basal cell or squamous cell carcinomas associated with treatment.

The results also suggest dose, frequency, and exposure duration to the topical calcineurin inhibitors (TCIs) tacrolimus and pimecrolimus are not associated with an increased risk of keratinocyte carcinomas (KCs), basal cell carcinomas (BCCs), and squamous cell carcinomas (SCCs) in patients with atopic dermatitis (AD), according to Maryam M. Asgari, MD, MPH, professor of dermatology, Harvard Medical School, Boston, and colleagues. In 2006, the Food and Drug Administration announced the addition of the boxed warning to the labeling of TCIs regarding a possible risk of cancer associated with use of pimecrolimus (Elidel) and with tacrolimus (Protopic), because of an increased risk of KCs associated with oral calcineurin inhibitors and reports of skin cancer in patients on TCIs.

“Controversy has surrounded the association between TCI exposure and KC risk since the black-box warning was issued by the FDA. A hypothesized mechanism of action for TCIs increasing KC risk includes a direct effect of calcineurin inhibition on DNA repair and apoptosis, which could influence keratinocyte carcinogenesis,” the authors of the study wrote in JAMA Dermatology. But, they added, there have been “conflicting results” in research exploring this association.

In the retrospective cohort study, Dr. Asgari and coauthors evaluated 93,746 adult patients with AD at Kaiser Permanente Northern California, diagnosed between January 2002 and December 2013, comparing skin cancer risk among 7,033 patients exposed to TCIs, 73,674 patients taking topical corticosteroids, and 46,141 patients who had not been exposed to TCIs or topical corticosteroids. Results were adjusted in a multivariate Cox regression analysis for age, gender, race/ethnicity, calendar year, number of dermatology visits per year, history of KCs, immunosuppression, prior systemic AD treatment, autoimmune disease, treatment with ultraviolet therapy, chemotherapy, and radiotherapy.

The researchers also examined how TCI dose, frequency and exposure duration impacted skin cancer risk. Patients were grouped by high-dose (0.1%) and low-dose (0.03%) formulations of tacrolimus; and the 1% formulation of pimecrolimus. Frequency of use was defined as low (once daily or less) or high (twice daily or more), and exposure duration was based on short- (less than 2 years), moderate- (2-4 years), and long-term (4 years or more) use. Patients were at least 40 years old (mean age, 58.5 years), 58.7% were women, 50.5% were White, 20.6% were Asian, 12.2% were Hispanic, and 7.9% were Black. They were followed for a mean of 7.70 years.

Compared with patients who were exposed to topical corticosteroids, there was no association between risk of KCs and exposure to TCIs in patients with AD (adjusted hazard ratio, 1.02; 95% confidence interval, 0.93-1.13). There were also no significant differences in risk of BCCs and TCI exposure (aHR, 1.01; 95% CI, 0.90-1.14) and risk of SCCs and TCI exposure (aHR, 0.94; 95% CI, 0.82-1.08), compared with patients exposed to topical corticosteroids.

Results were similar for risk of KCs (aHR, 1.03; 95% CI, 0.92-1.14), BCCs (aHR, 1.04; 95% CI, 0.91-1.19), and SCCs (aHR, 0.91; 95% CI, 0.78-1.06) when patients exposed to TCIs were compared with those with AD who were unexposed to any medication. In secondary analyses, Dr. Asgari and coauthors found no association with overall risk of KCs, or risk of BCCs or SCCs, and the dose, frequency, or exposure duration to TCIs.

“Our findings appear to support those of smaller postmarketing surveillance studies of TCI and KC risk and may provide some reassurance about the safety profile of this class of topical agents in the treatment of AD,” they concluded.

In an interview, Jonathan Silverberg, MD, PhD, MPH, associate professor of dermatology, George Washington University, Washington, said initial concerns surrounding TCIs were based on high doses potentially increasing the risk of malignancy, and off-label use of TCIs for inflammatory skin diseases other than AD.

“However, the FDA’s concerns may not have been justified,” he said. The manufacturers of pimecrolimus and tacrolimus have published results of 10-year observational registries that assess cancer risk, which “found no evidence of any associations between TCIs and malignancy,” noted Dr. Silverberg, who is also director of clinical research and contact dermatitis at George Washington University.

Elizabeth Hughes, MD, a dermatologist in private practice in San Antonio, said in an interview that initial enthusiasm was “huge” for use of TCIs like tacrolimus in patients with AD when they first became available, especially in the pediatric population, for whom clinicians are hesitant to use long-term strong topical steroids. However, parents of children taking the medication soon became concerned about potential side effects.

“The TCIs can be absorbed to a small extent through body surface area, so it was not a big leap to become concerned that infants and small children could absorb enough ... into the bloodstream to give a similar side effect profile as oral tacrolimus,” she said.

The addition of the boxed warning in 2006 was frustrating for dermatologists “because a medication we needed very much for a young population now was ‘labeled’ and parents were scared to use it,” Dr. Hughes explained.

Dr. Silverberg noted that, while the results of the new study are unlikely to change clinical practice, they are reassuring, and provide real-world data and “further confirmation of previous studies showing no associations between AD and malignancy.”

“Since AD and skin cancer are both commonly managed by dermatologists, there is potential for increased surveillance and detection of skin cancers in AD patients. So, the greatest chance of seeing a false-positive signal for malignancy would likely occur with skin cancers,” he pointed out. “Yet, even in the case of skin cancers, there were no demonstrable signals.”

Based on the results, “I think it is definitely reasonable to reconsider” the TCI boxed warning, but there isn’t much precedent for boxed warnings to be removed from labeling, Dr. Silverberg commented. “Unfortunately, the black-box warning may persist despite a lot of reassuring data.”

In a related editorial, Aaron M. Drucker, MD, ScM, and Mina Tadrous, PharmD, PhD, of the University of Toronto, said the boxed warning “had the intent of helping patients and clinicians understand possible risks,” but also carried the “potential for harm” if patients discontinued or did not adhere to treatment. “Safety warnings on topical medications could lead to undertreatment of atopic dermatitis, reduced quality of life and, potentially, increased use of more toxic systemic medications.”

Long-term studies of medications and cancer risk are challenging to perform, having to account for dose-response relationships, confounding by indication, and time bias, among other factors, and this study “recognizes and attempts to address many of these challenges,” Dr. Drucker and Dr. Tadrous wrote.

These results are similar to previous studies that have “consistently reported no or minimal association between TCI use and skin cancer,” they noted, adding that, “if an association exists, it is likely very small, meaning that skin cancer attributable to TCI use is rare. Clinicians can use this evidence to counsel and reassure patients for whom the benefits of ongoing treatment with TCIs may outweigh the harms.”

This study was funded by a grant from Valeant Pharmaceuticals. Dr. Asgari reported receiving grants from Valeant during the study, and from Pfizer not related to the study. The other authors reported no relevant conflicts of interest. Dr. Drucker reported relationships with the Canadian Agency for Drugs and Technology in Health, CME Outfitters, Eczema Society of Canada, Sanofi, Regeneron, and RTI Health Solutions in the form of paid fees, consultancies, honoraria, educational grants, and other compensation paid to him and/or his institution. Dr. Tadrous reported no relevant disclosures. Dr. Silverberg reported receiving honoraria for advisory board, speaker, and consultant services from numerous pharmaceutical manufacturers, and research grants for investigator services from GlaxoSmithKline and Galderma. Dr. Hughes Tichy reported no relevant financial disclosures. Dr. Silverberg is a member of the Dermatology News editorial advisory board.

SOURCE: Asgari MM et al. JAMA Dermatol. 2020 Aug 12. doi: 10.1001/jamadermatol.2020.2240.

A large postmarketing surveillance study of topical calcineurin inhibitor exposure in adults with atopic dermatitis has found no increased risk of developing keratinocyte carcinomas overall or with basal cell or squamous cell carcinomas associated with treatment.

The results also suggest dose, frequency, and exposure duration to the topical calcineurin inhibitors (TCIs) tacrolimus and pimecrolimus are not associated with an increased risk of keratinocyte carcinomas (KCs), basal cell carcinomas (BCCs), and squamous cell carcinomas (SCCs) in patients with atopic dermatitis (AD), according to Maryam M. Asgari, MD, MPH, professor of dermatology, Harvard Medical School, Boston, and colleagues. In 2006, the Food and Drug Administration announced the addition of the boxed warning to the labeling of TCIs regarding a possible risk of cancer associated with use of pimecrolimus (Elidel) and with tacrolimus (Protopic), because of an increased risk of KCs associated with oral calcineurin inhibitors and reports of skin cancer in patients on TCIs.

“Controversy has surrounded the association between TCI exposure and KC risk since the black-box warning was issued by the FDA. A hypothesized mechanism of action for TCIs increasing KC risk includes a direct effect of calcineurin inhibition on DNA repair and apoptosis, which could influence keratinocyte carcinogenesis,” the authors of the study wrote in JAMA Dermatology. But, they added, there have been “conflicting results” in research exploring this association.

In the retrospective cohort study, Dr. Asgari and coauthors evaluated 93,746 adult patients with AD at Kaiser Permanente Northern California, diagnosed between January 2002 and December 2013, comparing skin cancer risk among 7,033 patients exposed to TCIs, 73,674 patients taking topical corticosteroids, and 46,141 patients who had not been exposed to TCIs or topical corticosteroids. Results were adjusted in a multivariate Cox regression analysis for age, gender, race/ethnicity, calendar year, number of dermatology visits per year, history of KCs, immunosuppression, prior systemic AD treatment, autoimmune disease, treatment with ultraviolet therapy, chemotherapy, and radiotherapy.

The researchers also examined how TCI dose, frequency and exposure duration impacted skin cancer risk. Patients were grouped by high-dose (0.1%) and low-dose (0.03%) formulations of tacrolimus; and the 1% formulation of pimecrolimus. Frequency of use was defined as low (once daily or less) or high (twice daily or more), and exposure duration was based on short- (less than 2 years), moderate- (2-4 years), and long-term (4 years or more) use. Patients were at least 40 years old (mean age, 58.5 years), 58.7% were women, 50.5% were White, 20.6% were Asian, 12.2% were Hispanic, and 7.9% were Black. They were followed for a mean of 7.70 years.

Compared with patients who were exposed to topical corticosteroids, there was no association between risk of KCs and exposure to TCIs in patients with AD (adjusted hazard ratio, 1.02; 95% confidence interval, 0.93-1.13). There were also no significant differences in risk of BCCs and TCI exposure (aHR, 1.01; 95% CI, 0.90-1.14) and risk of SCCs and TCI exposure (aHR, 0.94; 95% CI, 0.82-1.08), compared with patients exposed to topical corticosteroids.

Results were similar for risk of KCs (aHR, 1.03; 95% CI, 0.92-1.14), BCCs (aHR, 1.04; 95% CI, 0.91-1.19), and SCCs (aHR, 0.91; 95% CI, 0.78-1.06) when patients exposed to TCIs were compared with those with AD who were unexposed to any medication. In secondary analyses, Dr. Asgari and coauthors found no association with overall risk of KCs, or risk of BCCs or SCCs, and the dose, frequency, or exposure duration to TCIs.

“Our findings appear to support those of smaller postmarketing surveillance studies of TCI and KC risk and may provide some reassurance about the safety profile of this class of topical agents in the treatment of AD,” they concluded.

In an interview, Jonathan Silverberg, MD, PhD, MPH, associate professor of dermatology, George Washington University, Washington, said initial concerns surrounding TCIs were based on high doses potentially increasing the risk of malignancy, and off-label use of TCIs for inflammatory skin diseases other than AD.

“However, the FDA’s concerns may not have been justified,” he said. The manufacturers of pimecrolimus and tacrolimus have published results of 10-year observational registries that assess cancer risk, which “found no evidence of any associations between TCIs and malignancy,” noted Dr. Silverberg, who is also director of clinical research and contact dermatitis at George Washington University.

Elizabeth Hughes, MD, a dermatologist in private practice in San Antonio, said in an interview that initial enthusiasm was “huge” for use of TCIs like tacrolimus in patients with AD when they first became available, especially in the pediatric population, for whom clinicians are hesitant to use long-term strong topical steroids. However, parents of children taking the medication soon became concerned about potential side effects.

“The TCIs can be absorbed to a small extent through body surface area, so it was not a big leap to become concerned that infants and small children could absorb enough ... into the bloodstream to give a similar side effect profile as oral tacrolimus,” she said.

The addition of the boxed warning in 2006 was frustrating for dermatologists “because a medication we needed very much for a young population now was ‘labeled’ and parents were scared to use it,” Dr. Hughes explained.

Dr. Silverberg noted that, while the results of the new study are unlikely to change clinical practice, they are reassuring, and provide real-world data and “further confirmation of previous studies showing no associations between AD and malignancy.”

“Since AD and skin cancer are both commonly managed by dermatologists, there is potential for increased surveillance and detection of skin cancers in AD patients. So, the greatest chance of seeing a false-positive signal for malignancy would likely occur with skin cancers,” he pointed out. “Yet, even in the case of skin cancers, there were no demonstrable signals.”

Based on the results, “I think it is definitely reasonable to reconsider” the TCI boxed warning, but there isn’t much precedent for boxed warnings to be removed from labeling, Dr. Silverberg commented. “Unfortunately, the black-box warning may persist despite a lot of reassuring data.”

In a related editorial, Aaron M. Drucker, MD, ScM, and Mina Tadrous, PharmD, PhD, of the University of Toronto, said the boxed warning “had the intent of helping patients and clinicians understand possible risks,” but also carried the “potential for harm” if patients discontinued or did not adhere to treatment. “Safety warnings on topical medications could lead to undertreatment of atopic dermatitis, reduced quality of life and, potentially, increased use of more toxic systemic medications.”

Long-term studies of medications and cancer risk are challenging to perform, having to account for dose-response relationships, confounding by indication, and time bias, among other factors, and this study “recognizes and attempts to address many of these challenges,” Dr. Drucker and Dr. Tadrous wrote.

These results are similar to previous studies that have “consistently reported no or minimal association between TCI use and skin cancer,” they noted, adding that, “if an association exists, it is likely very small, meaning that skin cancer attributable to TCI use is rare. Clinicians can use this evidence to counsel and reassure patients for whom the benefits of ongoing treatment with TCIs may outweigh the harms.”

This study was funded by a grant from Valeant Pharmaceuticals. Dr. Asgari reported receiving grants from Valeant during the study, and from Pfizer not related to the study. The other authors reported no relevant conflicts of interest. Dr. Drucker reported relationships with the Canadian Agency for Drugs and Technology in Health, CME Outfitters, Eczema Society of Canada, Sanofi, Regeneron, and RTI Health Solutions in the form of paid fees, consultancies, honoraria, educational grants, and other compensation paid to him and/or his institution. Dr. Tadrous reported no relevant disclosures. Dr. Silverberg reported receiving honoraria for advisory board, speaker, and consultant services from numerous pharmaceutical manufacturers, and research grants for investigator services from GlaxoSmithKline and Galderma. Dr. Hughes Tichy reported no relevant financial disclosures. Dr. Silverberg is a member of the Dermatology News editorial advisory board.

SOURCE: Asgari MM et al. JAMA Dermatol. 2020 Aug 12. doi: 10.1001/jamadermatol.2020.2240.

A large postmarketing surveillance study of topical calcineurin inhibitor exposure in adults with atopic dermatitis has found no increased risk of developing keratinocyte carcinomas overall or with basal cell or squamous cell carcinomas associated with treatment.

The results also suggest dose, frequency, and exposure duration to the topical calcineurin inhibitors (TCIs) tacrolimus and pimecrolimus are not associated with an increased risk of keratinocyte carcinomas (KCs), basal cell carcinomas (BCCs), and squamous cell carcinomas (SCCs) in patients with atopic dermatitis (AD), according to Maryam M. Asgari, MD, MPH, professor of dermatology, Harvard Medical School, Boston, and colleagues. In 2006, the Food and Drug Administration announced the addition of the boxed warning to the labeling of TCIs regarding a possible risk of cancer associated with use of pimecrolimus (Elidel) and with tacrolimus (Protopic), because of an increased risk of KCs associated with oral calcineurin inhibitors and reports of skin cancer in patients on TCIs.

“Controversy has surrounded the association between TCI exposure and KC risk since the black-box warning was issued by the FDA. A hypothesized mechanism of action for TCIs increasing KC risk includes a direct effect of calcineurin inhibition on DNA repair and apoptosis, which could influence keratinocyte carcinogenesis,” the authors of the study wrote in JAMA Dermatology. But, they added, there have been “conflicting results” in research exploring this association.

In the retrospective cohort study, Dr. Asgari and coauthors evaluated 93,746 adult patients with AD at Kaiser Permanente Northern California, diagnosed between January 2002 and December 2013, comparing skin cancer risk among 7,033 patients exposed to TCIs, 73,674 patients taking topical corticosteroids, and 46,141 patients who had not been exposed to TCIs or topical corticosteroids. Results were adjusted in a multivariate Cox regression analysis for age, gender, race/ethnicity, calendar year, number of dermatology visits per year, history of KCs, immunosuppression, prior systemic AD treatment, autoimmune disease, treatment with ultraviolet therapy, chemotherapy, and radiotherapy.

The researchers also examined how TCI dose, frequency and exposure duration impacted skin cancer risk. Patients were grouped by high-dose (0.1%) and low-dose (0.03%) formulations of tacrolimus; and the 1% formulation of pimecrolimus. Frequency of use was defined as low (once daily or less) or high (twice daily or more), and exposure duration was based on short- (less than 2 years), moderate- (2-4 years), and long-term (4 years or more) use. Patients were at least 40 years old (mean age, 58.5 years), 58.7% were women, 50.5% were White, 20.6% were Asian, 12.2% were Hispanic, and 7.9% were Black. They were followed for a mean of 7.70 years.

Compared with patients who were exposed to topical corticosteroids, there was no association between risk of KCs and exposure to TCIs in patients with AD (adjusted hazard ratio, 1.02; 95% confidence interval, 0.93-1.13). There were also no significant differences in risk of BCCs and TCI exposure (aHR, 1.01; 95% CI, 0.90-1.14) and risk of SCCs and TCI exposure (aHR, 0.94; 95% CI, 0.82-1.08), compared with patients exposed to topical corticosteroids.

Results were similar for risk of KCs (aHR, 1.03; 95% CI, 0.92-1.14), BCCs (aHR, 1.04; 95% CI, 0.91-1.19), and SCCs (aHR, 0.91; 95% CI, 0.78-1.06) when patients exposed to TCIs were compared with those with AD who were unexposed to any medication. In secondary analyses, Dr. Asgari and coauthors found no association with overall risk of KCs, or risk of BCCs or SCCs, and the dose, frequency, or exposure duration to TCIs.

“Our findings appear to support those of smaller postmarketing surveillance studies of TCI and KC risk and may provide some reassurance about the safety profile of this class of topical agents in the treatment of AD,” they concluded.

In an interview, Jonathan Silverberg, MD, PhD, MPH, associate professor of dermatology, George Washington University, Washington, said initial concerns surrounding TCIs were based on high doses potentially increasing the risk of malignancy, and off-label use of TCIs for inflammatory skin diseases other than AD.

“However, the FDA’s concerns may not have been justified,” he said. The manufacturers of pimecrolimus and tacrolimus have published results of 10-year observational registries that assess cancer risk, which “found no evidence of any associations between TCIs and malignancy,” noted Dr. Silverberg, who is also director of clinical research and contact dermatitis at George Washington University.

Elizabeth Hughes, MD, a dermatologist in private practice in San Antonio, said in an interview that initial enthusiasm was “huge” for use of TCIs like tacrolimus in patients with AD when they first became available, especially in the pediatric population, for whom clinicians are hesitant to use long-term strong topical steroids. However, parents of children taking the medication soon became concerned about potential side effects.

“The TCIs can be absorbed to a small extent through body surface area, so it was not a big leap to become concerned that infants and small children could absorb enough ... into the bloodstream to give a similar side effect profile as oral tacrolimus,” she said.

The addition of the boxed warning in 2006 was frustrating for dermatologists “because a medication we needed very much for a young population now was ‘labeled’ and parents were scared to use it,” Dr. Hughes explained.

Dr. Silverberg noted that, while the results of the new study are unlikely to change clinical practice, they are reassuring, and provide real-world data and “further confirmation of previous studies showing no associations between AD and malignancy.”

“Since AD and skin cancer are both commonly managed by dermatologists, there is potential for increased surveillance and detection of skin cancers in AD patients. So, the greatest chance of seeing a false-positive signal for malignancy would likely occur with skin cancers,” he pointed out. “Yet, even in the case of skin cancers, there were no demonstrable signals.”

Based on the results, “I think it is definitely reasonable to reconsider” the TCI boxed warning, but there isn’t much precedent for boxed warnings to be removed from labeling, Dr. Silverberg commented. “Unfortunately, the black-box warning may persist despite a lot of reassuring data.”

In a related editorial, Aaron M. Drucker, MD, ScM, and Mina Tadrous, PharmD, PhD, of the University of Toronto, said the boxed warning “had the intent of helping patients and clinicians understand possible risks,” but also carried the “potential for harm” if patients discontinued or did not adhere to treatment. “Safety warnings on topical medications could lead to undertreatment of atopic dermatitis, reduced quality of life and, potentially, increased use of more toxic systemic medications.”

Long-term studies of medications and cancer risk are challenging to perform, having to account for dose-response relationships, confounding by indication, and time bias, among other factors, and this study “recognizes and attempts to address many of these challenges,” Dr. Drucker and Dr. Tadrous wrote.

These results are similar to previous studies that have “consistently reported no or minimal association between TCI use and skin cancer,” they noted, adding that, “if an association exists, it is likely very small, meaning that skin cancer attributable to TCI use is rare. Clinicians can use this evidence to counsel and reassure patients for whom the benefits of ongoing treatment with TCIs may outweigh the harms.”

This study was funded by a grant from Valeant Pharmaceuticals. Dr. Asgari reported receiving grants from Valeant during the study, and from Pfizer not related to the study. The other authors reported no relevant conflicts of interest. Dr. Drucker reported relationships with the Canadian Agency for Drugs and Technology in Health, CME Outfitters, Eczema Society of Canada, Sanofi, Regeneron, and RTI Health Solutions in the form of paid fees, consultancies, honoraria, educational grants, and other compensation paid to him and/or his institution. Dr. Tadrous reported no relevant disclosures. Dr. Silverberg reported receiving honoraria for advisory board, speaker, and consultant services from numerous pharmaceutical manufacturers, and research grants for investigator services from GlaxoSmithKline and Galderma. Dr. Hughes Tichy reported no relevant financial disclosures. Dr. Silverberg is a member of the Dermatology News editorial advisory board.

SOURCE: Asgari MM et al. JAMA Dermatol. 2020 Aug 12. doi: 10.1001/jamadermatol.2020.2240.

COVID-19 has forced health care organizations (HCOs) and medical practices to vastly speed up their adoption of technology for patient care. Patient portals and other tools enable visits for patients who have problems seeing physicians because of the pandemic or who prefer not to come to physician offices.

However, some patients find it significantly challenging to use this technology. Many patients are unfamiliar with a portal, a remote patient monitoring system, or a Bluetooth-enabled pulse oximeter – in addition to being uncertain about the medical aspects of an exam or treatment.

When ordering groceries or sending a check drawn on the bank, using an app is simple, because the user fully understands the objective. But health care has several complicating factors, including changes to patient health status, multipart treatment plans, drug interactions, coordination with providers, and dealing with insurance coverage.

It can get even more complicated when you’re coordinating care with family members, caretakers, and other health care professionals. If technology is going to help you treat patients, the patient needs a clear and simple presentation of what he or she needs to do and know.
 

Can your patient actually use your tools and technology?

The design of your patient portal, your website, and a phone app will play a huge role in how easily your patient can interact with your practice. A poorly designed portal will undermine your efforts to engage patients and could even create problems for patient safety.

For most tools, more is not necessarily better: A long list of wonderful features and options could make it too complex or confusing for many patients.

Cluttered screens, tiny buttons, and links that are hard to see within large blocks of text make it hard for your patients to use tools or portals. Patients also find it confusing and difficult to understand long written explanations of medical issues or treatment steps that don’t focus on the patient’s individual status, even though these explanations may include important information.

Take a close look at the tools or screens you want your patients to use. At the same time, you’ll want to make sure that the workflow within your practice supports the technology. For example, your portal may have a button to immediately access a staff person on a screen, but that feature is helpful only if you have staff available to interact with the patient.

Similarly, having to click through four screens to access a telehealth visit will confuse your patients and increase telehealth no-shows. If your staff doesn’t respond to patient questions or data gathered by the technology, you may wind up with more phone calls from patients or a missed opportunity to help a patient avoid a problem.

Here are ways you can help patients use your technology and prevent confusion:

Create short, targeted help tools and videos. These can show how to use the patient tools and technology, and they can be customized for different patient groups. Instead of a long video that covers many topics, it’s better to have separate videos for each remote patient-monitoring device (as short as 1-4 minutes). For your help tools and videos:

• Create a video that addresses the key steps of your patient’s medical visit, such as how to complete each health assessment questionnaire, how to send a message to your office, how to request a prescription, and how to view the treatment plan.
• Consider making videos that give instructions for specific diseases and care. For example, a video explaining the use of a spirometer would include a step-by-step demonstration that encourages the patient to follow along. Similarly, a video on blood pressure cuffs would have clear instructions on how to properly place the cuff and how to use it.
• Develop separate videos for each medical device, showing how each is used. For example, create separate videos for blood pressure cuffs on the wrist and the bicep.
• Make access to the videos easy and obvious. For example, have a link to the blood pressure cuff video on the blood pressure screen, or have a short video about tracking physical activities available on the treatment plan screen.
• Offer additional informational videos that give patients general information about their disease and condition.
• Present patient stories and testimonials (after getting signed permission from the patients). These can help patients better understand the practical aspects of their treatment and how technological tools and portals can help them.

Make buttons legible and write text that is easy to read. Many patients have smartphones and iPads with small screens. Larger displays are easier to see and may be less intimidating. Your technology should include a smartphone-friendly interface as well as a tablet- or iPad-friendly interface. Prominently display the key information.

Include only important and relevant information. The more information and clutter shown, the less likely patients are to focus on the really important issues. For example, some patient portals list items on the treatment plan without highlighting the important items in comparison to the informative or future orders. Don’t include older information that confuses them.

Use consumer terminology. When you’re giving treatment plans and care options, make sure to use words that the patient will understand and that are similar to the words you’d use when educating any patient or when you or your staff are giving verbal instructions.
 

Engaging patients

The more your patient uses your tools or technology during their care, the more familiar they’ll be with it and the more adept they’ll become at using it. Using a portal once a year will not create familiarity with your tools or create a good working relationship.

Continuing exchanges of information and telehealth visits with patients increase patient familiarity and comfort with your technology.

Here are some ways to help patients become more comfortable with and familiar with your technology:

Use remote patient monitoring. Remote patient monitoring (RPM) involves gathering physiologic information, such as blood pressure, pulse oximetry measurements, and glucose levels, from patients on a periodic, even daily basis. Insurance companies pay for this service because it helps spot potential problems before they become more serious and more costly to treat.

Look into conditions you treat in which RPM would be helpful. Through RPM, patients could be sending information daily, and your health care organization (HCO) could be coordinating refinements to the patient’s treatment plan based on daily information and trends over time. For example, a decrease in pulse oximetry levels could trigger a telehealth visit with a patient.

Use a health assessment questionnaire to engage your patients and reinforce important patient activities. A sample health assessment questionnaire can be found at ARHQ.gov. You may have several different questionnaires based on patient problems and treatment strategies. The questionnaire should be as concise as possible and target issues that would help your HCO understand the current health status of the patient and frame the next steps in patient service.

The data you receive can be used to provide follow-up services or even provision supplies, durable medical equipment, and prescriptions. Many patients face challenges in getting prescriptions and supplies in addition to presenting for planned check-ups and physicals.

Hold disease-specific group meetings. Group meeting technology, such as Zoom, can be used to conduct group meetings and provide information to at-risk patients. During online group patient meetings, you can give advice and guidance that can help offset the flood of rumors and false information about health care in general as well as COVID-19.

Offer general health information and conduct surveys. A medical organization or practice can present useful information on wearing a mask, social distancing, and other COVID-19 issues as well as disease-specific guidance to help patients more effectively interact with the practice. You might find it useful to periodically conduct a survey to assess and highlight mitigation strategies for at-risk populations.

Send email and text messages. Your practice should have the option of sending the patient an email or text message with a link to the relevant information or for a telehealth visit. For example, 15 minutes before a scheduled telehealth visit, your technology may send a message reminding the patient of the visit. Text links are particularly helpful – over 90% of text messages are read within 30 minutes of receipt.
 

How to help technology-challenged patients

Helping patients who have trouble with technology can be expensive and time consuming. Staff may spend a lot of time trying to train or support a patient who is struggling with technology.

Realistically, not every patient will be able to engage through your technology and tools. Some may not have a computer, laptop, or smartphone in their home or a reliable connection to the Internet. Other patients may have trouble affording devices such as tablets or services. Also important, not all smartphones, tablets, and computers may work with your technology base. (For patients who don’t have or can’t afford compatible technology, some state and local initiatives provide such tools to underserved and rural patients in response to the COVID-19 pandemic.)

You may need to assess whether some patients are good candidates for using technology, based on their education, finances, or ability to follow instructions. For those who are not, stick with more frequent office visits and phone-based consultations.

If a patient is unable to use the available tools, document it in your patient record so that you or other clinicians can structure the patient’s treatment plan in accordance with the patient’s abilities.

Going forward, patients may prefer using COVID-19–driven telehealth services in their homes over making a trip to the clinic. If you can put in the effort to ensure that your technologies are relevant and are targeted to the appropriate patients, you’ll be able to provide better care during the COVID-19 pandemic, and the COVID-19–driven changes may become permanent.

Dr. Sterling has disclosed no relevant financial relationships.

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

COVID-19 has forced health care organizations (HCOs) and medical practices to vastly speed up their adoption of technology for patient care. Patient portals and other tools enable visits for patients who have problems seeing physicians because of the pandemic or who prefer not to come to physician offices.

However, some patients find it significantly challenging to use this technology. Many patients are unfamiliar with a portal, a remote patient monitoring system, or a Bluetooth-enabled pulse oximeter – in addition to being uncertain about the medical aspects of an exam or treatment.

When ordering groceries or sending a check drawn on the bank, using an app is simple, because the user fully understands the objective. But health care has several complicating factors, including changes to patient health status, multipart treatment plans, drug interactions, coordination with providers, and dealing with insurance coverage.

It can get even more complicated when you’re coordinating care with family members, caretakers, and other health care professionals. If technology is going to help you treat patients, the patient needs a clear and simple presentation of what he or she needs to do and know.
 

Can your patient actually use your tools and technology?

The design of your patient portal, your website, and a phone app will play a huge role in how easily your patient can interact with your practice. A poorly designed portal will undermine your efforts to engage patients and could even create problems for patient safety.

For most tools, more is not necessarily better: A long list of wonderful features and options could make it too complex or confusing for many patients.

Cluttered screens, tiny buttons, and links that are hard to see within large blocks of text make it hard for your patients to use tools or portals. Patients also find it confusing and difficult to understand long written explanations of medical issues or treatment steps that don’t focus on the patient’s individual status, even though these explanations may include important information.

Take a close look at the tools or screens you want your patients to use. At the same time, you’ll want to make sure that the workflow within your practice supports the technology. For example, your portal may have a button to immediately access a staff person on a screen, but that feature is helpful only if you have staff available to interact with the patient.

Similarly, having to click through four screens to access a telehealth visit will confuse your patients and increase telehealth no-shows. If your staff doesn’t respond to patient questions or data gathered by the technology, you may wind up with more phone calls from patients or a missed opportunity to help a patient avoid a problem.

Here are ways you can help patients use your technology and prevent confusion:

Create short, targeted help tools and videos. These can show how to use the patient tools and technology, and they can be customized for different patient groups. Instead of a long video that covers many topics, it’s better to have separate videos for each remote patient-monitoring device (as short as 1-4 minutes). For your help tools and videos:

• Create a video that addresses the key steps of your patient’s medical visit, such as how to complete each health assessment questionnaire, how to send a message to your office, how to request a prescription, and how to view the treatment plan.
• Consider making videos that give instructions for specific diseases and care. For example, a video explaining the use of a spirometer would include a step-by-step demonstration that encourages the patient to follow along. Similarly, a video on blood pressure cuffs would have clear instructions on how to properly place the cuff and how to use it.
• Develop separate videos for each medical device, showing how each is used. For example, create separate videos for blood pressure cuffs on the wrist and the bicep.
• Make access to the videos easy and obvious. For example, have a link to the blood pressure cuff video on the blood pressure screen, or have a short video about tracking physical activities available on the treatment plan screen.
• Offer additional informational videos that give patients general information about their disease and condition.
• Present patient stories and testimonials (after getting signed permission from the patients). These can help patients better understand the practical aspects of their treatment and how technological tools and portals can help them.

Make buttons legible and write text that is easy to read. Many patients have smartphones and iPads with small screens. Larger displays are easier to see and may be less intimidating. Your technology should include a smartphone-friendly interface as well as a tablet- or iPad-friendly interface. Prominently display the key information.

Include only important and relevant information. The more information and clutter shown, the less likely patients are to focus on the really important issues. For example, some patient portals list items on the treatment plan without highlighting the important items in comparison to the informative or future orders. Don’t include older information that confuses them.

Use consumer terminology. When you’re giving treatment plans and care options, make sure to use words that the patient will understand and that are similar to the words you’d use when educating any patient or when you or your staff are giving verbal instructions.
 

Engaging patients

The more your patient uses your tools or technology during their care, the more familiar they’ll be with it and the more adept they’ll become at using it. Using a portal once a year will not create familiarity with your tools or create a good working relationship.

Continuing exchanges of information and telehealth visits with patients increase patient familiarity and comfort with your technology.

Here are some ways to help patients become more comfortable with and familiar with your technology:

Use remote patient monitoring. Remote patient monitoring (RPM) involves gathering physiologic information, such as blood pressure, pulse oximetry measurements, and glucose levels, from patients on a periodic, even daily basis. Insurance companies pay for this service because it helps spot potential problems before they become more serious and more costly to treat.

Look into conditions you treat in which RPM would be helpful. Through RPM, patients could be sending information daily, and your health care organization (HCO) could be coordinating refinements to the patient’s treatment plan based on daily information and trends over time. For example, a decrease in pulse oximetry levels could trigger a telehealth visit with a patient.

Use a health assessment questionnaire to engage your patients and reinforce important patient activities. A sample health assessment questionnaire can be found at ARHQ.gov. You may have several different questionnaires based on patient problems and treatment strategies. The questionnaire should be as concise as possible and target issues that would help your HCO understand the current health status of the patient and frame the next steps in patient service.

The data you receive can be used to provide follow-up services or even provision supplies, durable medical equipment, and prescriptions. Many patients face challenges in getting prescriptions and supplies in addition to presenting for planned check-ups and physicals.

Hold disease-specific group meetings. Group meeting technology, such as Zoom, can be used to conduct group meetings and provide information to at-risk patients. During online group patient meetings, you can give advice and guidance that can help offset the flood of rumors and false information about health care in general as well as COVID-19.

Offer general health information and conduct surveys. A medical organization or practice can present useful information on wearing a mask, social distancing, and other COVID-19 issues as well as disease-specific guidance to help patients more effectively interact with the practice. You might find it useful to periodically conduct a survey to assess and highlight mitigation strategies for at-risk populations.

Send email and text messages. Your practice should have the option of sending the patient an email or text message with a link to the relevant information or for a telehealth visit. For example, 15 minutes before a scheduled telehealth visit, your technology may send a message reminding the patient of the visit. Text links are particularly helpful – over 90% of text messages are read within 30 minutes of receipt.
 

How to help technology-challenged patients

Helping patients who have trouble with technology can be expensive and time consuming. Staff may spend a lot of time trying to train or support a patient who is struggling with technology.

Realistically, not every patient will be able to engage through your technology and tools. Some may not have a computer, laptop, or smartphone in their home or a reliable connection to the Internet. Other patients may have trouble affording devices such as tablets or services. Also important, not all smartphones, tablets, and computers may work with your technology base. (For patients who don’t have or can’t afford compatible technology, some state and local initiatives provide such tools to underserved and rural patients in response to the COVID-19 pandemic.)

You may need to assess whether some patients are good candidates for using technology, based on their education, finances, or ability to follow instructions. For those who are not, stick with more frequent office visits and phone-based consultations.

If a patient is unable to use the available tools, document it in your patient record so that you or other clinicians can structure the patient’s treatment plan in accordance with the patient’s abilities.

Going forward, patients may prefer using COVID-19–driven telehealth services in their homes over making a trip to the clinic. If you can put in the effort to ensure that your technologies are relevant and are targeted to the appropriate patients, you’ll be able to provide better care during the COVID-19 pandemic, and the COVID-19–driven changes may become permanent.

Dr. Sterling has disclosed no relevant financial relationships.

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

COVID-19 has forced health care organizations (HCOs) and medical practices to vastly speed up their adoption of technology for patient care. Patient portals and other tools enable visits for patients who have problems seeing physicians because of the pandemic or who prefer not to come to physician offices.

However, some patients find it significantly challenging to use this technology. Many patients are unfamiliar with a portal, a remote patient monitoring system, or a Bluetooth-enabled pulse oximeter – in addition to being uncertain about the medical aspects of an exam or treatment.

When ordering groceries or sending a check drawn on the bank, using an app is simple, because the user fully understands the objective. But health care has several complicating factors, including changes to patient health status, multipart treatment plans, drug interactions, coordination with providers, and dealing with insurance coverage.

It can get even more complicated when you’re coordinating care with family members, caretakers, and other health care professionals. If technology is going to help you treat patients, the patient needs a clear and simple presentation of what he or she needs to do and know.
 

Can your patient actually use your tools and technology?

The design of your patient portal, your website, and a phone app will play a huge role in how easily your patient can interact with your practice. A poorly designed portal will undermine your efforts to engage patients and could even create problems for patient safety.

For most tools, more is not necessarily better: A long list of wonderful features and options could make it too complex or confusing for many patients.

Cluttered screens, tiny buttons, and links that are hard to see within large blocks of text make it hard for your patients to use tools or portals. Patients also find it confusing and difficult to understand long written explanations of medical issues or treatment steps that don’t focus on the patient’s individual status, even though these explanations may include important information.

Take a close look at the tools or screens you want your patients to use. At the same time, you’ll want to make sure that the workflow within your practice supports the technology. For example, your portal may have a button to immediately access a staff person on a screen, but that feature is helpful only if you have staff available to interact with the patient.

Similarly, having to click through four screens to access a telehealth visit will confuse your patients and increase telehealth no-shows. If your staff doesn’t respond to patient questions or data gathered by the technology, you may wind up with more phone calls from patients or a missed opportunity to help a patient avoid a problem.

Here are ways you can help patients use your technology and prevent confusion:

Create short, targeted help tools and videos. These can show how to use the patient tools and technology, and they can be customized for different patient groups. Instead of a long video that covers many topics, it’s better to have separate videos for each remote patient-monitoring device (as short as 1-4 minutes). For your help tools and videos:

• Create a video that addresses the key steps of your patient’s medical visit, such as how to complete each health assessment questionnaire, how to send a message to your office, how to request a prescription, and how to view the treatment plan.
• Consider making videos that give instructions for specific diseases and care. For example, a video explaining the use of a spirometer would include a step-by-step demonstration that encourages the patient to follow along. Similarly, a video on blood pressure cuffs would have clear instructions on how to properly place the cuff and how to use it.
• Develop separate videos for each medical device, showing how each is used. For example, create separate videos for blood pressure cuffs on the wrist and the bicep.
• Make access to the videos easy and obvious. For example, have a link to the blood pressure cuff video on the blood pressure screen, or have a short video about tracking physical activities available on the treatment plan screen.
• Offer additional informational videos that give patients general information about their disease and condition.
• Present patient stories and testimonials (after getting signed permission from the patients). These can help patients better understand the practical aspects of their treatment and how technological tools and portals can help them.

Make buttons legible and write text that is easy to read. Many patients have smartphones and iPads with small screens. Larger displays are easier to see and may be less intimidating. Your technology should include a smartphone-friendly interface as well as a tablet- or iPad-friendly interface. Prominently display the key information.

Include only important and relevant information. The more information and clutter shown, the less likely patients are to focus on the really important issues. For example, some patient portals list items on the treatment plan without highlighting the important items in comparison to the informative or future orders. Don’t include older information that confuses them.

Use consumer terminology. When you’re giving treatment plans and care options, make sure to use words that the patient will understand and that are similar to the words you’d use when educating any patient or when you or your staff are giving verbal instructions.
 

Engaging patients

The more your patient uses your tools or technology during their care, the more familiar they’ll be with it and the more adept they’ll become at using it. Using a portal once a year will not create familiarity with your tools or create a good working relationship.

Continuing exchanges of information and telehealth visits with patients increase patient familiarity and comfort with your technology.

Here are some ways to help patients become more comfortable with and familiar with your technology:

Use remote patient monitoring. Remote patient monitoring (RPM) involves gathering physiologic information, such as blood pressure, pulse oximetry measurements, and glucose levels, from patients on a periodic, even daily basis. Insurance companies pay for this service because it helps spot potential problems before they become more serious and more costly to treat.

Look into conditions you treat in which RPM would be helpful. Through RPM, patients could be sending information daily, and your health care organization (HCO) could be coordinating refinements to the patient’s treatment plan based on daily information and trends over time. For example, a decrease in pulse oximetry levels could trigger a telehealth visit with a patient.

Use a health assessment questionnaire to engage your patients and reinforce important patient activities. A sample health assessment questionnaire can be found at ARHQ.gov. You may have several different questionnaires based on patient problems and treatment strategies. The questionnaire should be as concise as possible and target issues that would help your HCO understand the current health status of the patient and frame the next steps in patient service.

The data you receive can be used to provide follow-up services or even provision supplies, durable medical equipment, and prescriptions. Many patients face challenges in getting prescriptions and supplies in addition to presenting for planned check-ups and physicals.

Hold disease-specific group meetings. Group meeting technology, such as Zoom, can be used to conduct group meetings and provide information to at-risk patients. During online group patient meetings, you can give advice and guidance that can help offset the flood of rumors and false information about health care in general as well as COVID-19.

Offer general health information and conduct surveys. A medical organization or practice can present useful information on wearing a mask, social distancing, and other COVID-19 issues as well as disease-specific guidance to help patients more effectively interact with the practice. You might find it useful to periodically conduct a survey to assess and highlight mitigation strategies for at-risk populations.

Send email and text messages. Your practice should have the option of sending the patient an email or text message with a link to the relevant information or for a telehealth visit. For example, 15 minutes before a scheduled telehealth visit, your technology may send a message reminding the patient of the visit. Text links are particularly helpful – over 90% of text messages are read within 30 minutes of receipt.
 

How to help technology-challenged patients

Helping patients who have trouble with technology can be expensive and time consuming. Staff may spend a lot of time trying to train or support a patient who is struggling with technology.

Realistically, not every patient will be able to engage through your technology and tools. Some may not have a computer, laptop, or smartphone in their home or a reliable connection to the Internet. Other patients may have trouble affording devices such as tablets or services. Also important, not all smartphones, tablets, and computers may work with your technology base. (For patients who don’t have or can’t afford compatible technology, some state and local initiatives provide such tools to underserved and rural patients in response to the COVID-19 pandemic.)

You may need to assess whether some patients are good candidates for using technology, based on their education, finances, or ability to follow instructions. For those who are not, stick with more frequent office visits and phone-based consultations.

If a patient is unable to use the available tools, document it in your patient record so that you or other clinicians can structure the patient’s treatment plan in accordance with the patient’s abilities.

Going forward, patients may prefer using COVID-19–driven telehealth services in their homes over making a trip to the clinic. If you can put in the effort to ensure that your technologies are relevant and are targeted to the appropriate patients, you’ll be able to provide better care during the COVID-19 pandemic, and the COVID-19–driven changes may become permanent.

Dr. Sterling has disclosed no relevant financial relationships.

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

Two new studies highlight the importance of early intervention in first-episode psychosis (FEP).

In the first study, Australian investigators conclude that, for some FEP patients, early psychosocial interventions may fend off the need for immediate treatment with antipsychotic medications.

In the second study, UK researchers show that long duration of untreated psychosis (DUP) is linked to a significantly reduced treatment response.

For both studies, the findings highlight the importance of rapid access to a comprehensive range of treatments in the first weeks after FEP onset.

“In a select group of people with first-episode psychosis, we found there was no difference in symptoms and functioning between those who had antipsychotic medication and those who didn’t,” lead author Shona M. Francey, PhD, clinical psychologist at Orygen, the National Center of Excellence in Youth Mental Health, Parkville, Australia, told Medscape Medical News.

“These findings supported our idea that, in the early phases of psychosis, with close monitoring and good psychosocial intervention, antipsychotic medication can be delayed,” Francey said.

The Australian study was published in Schizophrenia Bulletin Open. The British study was published in Lancet Psychiatry.
 

Adverse effects

Francey and colleagues note that, in comparison with standard treatment, early interventions produce superior outcomes for patients with psychosis. Although there are a variety of treatment options, low-dose second-generation antipsychotics typically play a central role.

However, atypical antipsychotics have rapid metabolic side effects, including weight gain and altered glucose metabolism, that increase the risk for cardiovascular disease and premature mortality. Importantly, such adverse effects are amplified among patients with FEP, who tend to be younger and treatment naive.

On the other hand, a growing body of evidence shows the benefit of nonpharmacologic interventions for patients with FEP, the investigators note. In addition, clinical staging models appear to support the use of less aggressive treatment early in the disease course.

“We have been working in early intervention for psychosis for a number of years and have found it’s possible to intervene early with young people and either prevent the onset of psychosis or ameliorate its impact,” said Francey.

“Since we can see some improvement in people in the prepsychotic phase, we wanted to know if we can also see some benefit without medication after the onset of what we would call full-threshold psychosis,” she added.

Staged Treatment and Acceptability Guidelines in Early Psychosis (STAGES) was a 6-month, triple-blind, randomized controlled noninferiority study that included 90 participants between the ages of 15 and 25 years who had FEP.

To maximize safety, patients were required to have low levels of suicidality and aggression, a DUP of less than 6 months, and to be living in stable accommodation with social support.

Participants were randomly assigned to two groups – one in which patients underwent intensive psychosocial therapy and received low-dose antipsychotic medication (n = 44), and one in which patients underwent intensive psychosocial therapy and were given placebo (n = 46).

Depending on the timing of study enrollment, those in the medication group received risperidone 1 mg or paliperidone 3 mg.

The psychosocial intervention consisted of cognitive-behavioral case management (CBCM), an intervention developed specifically for patients with early psychosis that is strongly focused on therapeutic engagement.

CBCM delivers formulation-driven cognitive-behavioral therapy and psychoeducation within a therapeutic case management framework, Francey said.

The primary outcome was level of functioning at 6, 12, and 24 months, as measured by the Social and Occupational Functioning Scale (SOFAS). The primary prespecified endpoint was outcome at 6 months. A noninferiority margin of 10.5 on the SOFAS was used as the smallest value representing a clinically important effect.

Other assessment tools included the BPRS-4 to test for positive psychotic symptoms, the Scale for the Assessment of Negative Symptoms (SANS), the Hamilton Rating Scale for Depression, and the Hamilton Rating Scale for Anxiety.

At baseline, the two treatment groups were comparable with respect to all measures of functioning and psychopathology.

The study’s discontinuation rate was high. At 6 months, only 16 patients in the psychosocial group had completed therapy, compared with 11 in the antipsychotic group.

At this point, the two groups were comparable in terms of psychopathology and functioning ratings. Both groups had lower symptoms, higher functioning scores, and higher Quality of Life Scale (QLS) scores than at baseline.

SOFAS scores were not significantly different between the groups at this time point. The mean score was 61.7 ± 16.8 in the psychosocial group and 61.5 ± 13.4 in the medication group.

The researchers note that, because the upper limit of the confidence interval (CI) was less than the study’s a priori inferiority margin of 10.5, psychosocial therapy was not inferior to medication at the 6-month assessment point.
 

Antipsychotics: Use with caution

Although between-group differences in SOFAS scores were not significant at 12 and 24 months, noninferiority of psychosocial therapy alone could not be confirmed because the CIs included the inferiority margin at each time point.

The two groups were statistically comparable at 6 months with respect to all other measures of psychopathology and the QLS. Similar results were found at 12 and 24 months.

The lone exception was with SANS at 12 months, on which patients in the placebo group had significantly higher negative symptom scores than the patients in the medication group.

There were no significant differences between study groups with respect to the number of adverse events.

Francey noted that the findings are important because they suggest that some young people with early-stage FEP and short DUP may be able to achieve symptom remission and function better without antipsychotic medication, provided they receive psychological interventions and comprehensive case management.

This challenges conventional wisdom that antipsychotic medications should be used for all patients who experience psychosis, she added.

However, managing FEP with psychosocial interventions should only be considered when it is safe to do so, Francey noted. In addition, the benefits of psychosocial interventions in these patients are less clear at 12 and 24 months.

Given these caveats, she noted that antipsychotics still play an important role in the treatment of these patients.

“I think there is definitely a place for medications. But I think they should be used cautiously, and you need a good, strong relationship between your treating team and your [patient] to work out what is needed and when it’s needed,” said Francey.

In addition, “when we do use medications, we should use the smallest possible dose that we can and also incorporate psychological support. I think that’s a really important part of it as well,” she said.
 

Timing matters

In the Lancet Psychiatry study, the researchers note that prolonged DUP is associated with worse outcomes, including increased symptoms, diminished social functioning, and poorer quality of life. The mechanism by which delayed treatment causes more harm remains unclear.

It is possible that symptoms simply accumulate over time, thereby worsening presentation. Another possibility is that continued psychosis after an initial critical period may cause long-term harm, they write.

They hypothesize that untreated psychosis can cause general treatment resistance by exacerbating underlying disease processes and that such damage progresses faster in the early stages of illness and then slows over time.

In addition, socially disruptive symptoms that are evident prior to FEP presentation may have a confounding effect, thereby leading to earlier presentation.

The investigators used data from two longitudinal cohort studies – the National Evaluation of Development of Early Intervention Network (NEDEN) study and the Outlook study.

In the NEDEN trial, 290 of 901 FEP patients (32%) were assessed within 3 weeks of presentation. In Outlook, 69 of 332 patients (21%) were assessed within 3 weeks of presentation.

In both studies, patients were examined at baseline, 6 months, and 12 months using the Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia, the Mania Rating Scale, the Insight Scale, and SOFAS. The latter two measures were used only at baseline and 12-month follow-up. Logistic regression analyses were used to determine the association between DUP and outcomes.

In the NEDEN study, 751 patients were assessed at 6 months, and 719 were assessed at 12 months. In the Outlook study, 238 and 220 were assessed at the same two time points, respectively.

Results showed a curvilinear relationship between DUP and symptom severity. Longer DUP was predictive of reduced treatment response. However, patient response worsened more slowly as DUP lengthened.

For example, increasing DUP by ten times was predictive of less improvement in PANSS total score by 7.34 (95% CI, 5.76 – 8.92; P < .0001) in NEDEN and by 3.85 (95% CI, 1.69 – 600; P =. 0005) in Outlook. Nevertheless, longer DUP was not associated with worse presentation for any symptoms except depression in NEDEN.

The findings seem to support that the potential harm incurred by delaying treatment among patients with FEP is greatest in the early weeks of psychosis and then levels off, the investigators note.

Given these insights, mental health professionals might consider focusing their efforts on the early detection and treatment of patients for whom DUP is short.

Similarly, because DUP was directly associated with all symptoms, early access to comprehensive treatment “might be preferable to early delivery of particular treatments with particular effects (eg, dopamine antagonists),” they write.
 

“A pragmatic call”

Commenting on the British study in an accompanying editorial, Lena K. Palaniyappan, MD, University of Western Ontario, London, Canada, and Rajeev Krishnadas, MD, University of Glasgow, Scotland, write that any illness left untreated can become more challenging to treat, including psychosis.

“This should make early intervention in psychosis a pragmatic call with no prima facie argument against it,” they write. A reduction in DUP “underpins the rationale behind early detection and intervention in psychosis.”

The editorialists note that the relationship between DUP and successful treatment in early psychosis “strengthens the argument for more proactive early assessment and intervention to shorten treatment delay.

“As we have learnt over the past two decades, even punctual treatment when symptoms first arise continues to be too late when it comes to psychosis,” they write.

Francey also recognizes the value of early intervention in FEP. However, she noted that comprehensive psychosocial therapy might well prove effective enough to stave off antipsychotic therapy in a certain subset of patients.

“For some people, antipsychotics may never need to be introduced,” she said. “Some people recover from their first episode of psychosis and don’t go on to have any more, while others have an episodic illness,” she said.

If another episode develops and the symptoms come back, further psychosocial interventions could then be tried “or you might want to move on” to psychotic medication “because trying to get people better and functioning as well as they can is our primary aim,” Francey said.

The STAGES study was supported by the Australian National Health and Medical Research Council. The British study was funded by the UK Department of Health, the National Institute of Health Research, and the Medical Research Council. Francey and Krishnadas have reported no relevant financial relationships. Palaniyappan has received grants and personal fees from Janssen Canada and Otsuka Canada, grants from Sunovion, and personal fees from SPMM Course UK and the Canadian Psychiatric Association.
 

This article first appeared on Medscape.com.

Two new studies highlight the importance of early intervention in first-episode psychosis (FEP).

In the first study, Australian investigators conclude that, for some FEP patients, early psychosocial interventions may fend off the need for immediate treatment with antipsychotic medications.

In the second study, UK researchers show that long duration of untreated psychosis (DUP) is linked to a significantly reduced treatment response.

For both studies, the findings highlight the importance of rapid access to a comprehensive range of treatments in the first weeks after FEP onset.

“In a select group of people with first-episode psychosis, we found there was no difference in symptoms and functioning between those who had antipsychotic medication and those who didn’t,” lead author Shona M. Francey, PhD, clinical psychologist at Orygen, the National Center of Excellence in Youth Mental Health, Parkville, Australia, told Medscape Medical News.

“These findings supported our idea that, in the early phases of psychosis, with close monitoring and good psychosocial intervention, antipsychotic medication can be delayed,” Francey said.

The Australian study was published in Schizophrenia Bulletin Open. The British study was published in Lancet Psychiatry.
 

Adverse effects

Francey and colleagues note that, in comparison with standard treatment, early interventions produce superior outcomes for patients with psychosis. Although there are a variety of treatment options, low-dose second-generation antipsychotics typically play a central role.

However, atypical antipsychotics have rapid metabolic side effects, including weight gain and altered glucose metabolism, that increase the risk for cardiovascular disease and premature mortality. Importantly, such adverse effects are amplified among patients with FEP, who tend to be younger and treatment naive.

On the other hand, a growing body of evidence shows the benefit of nonpharmacologic interventions for patients with FEP, the investigators note. In addition, clinical staging models appear to support the use of less aggressive treatment early in the disease course.

“We have been working in early intervention for psychosis for a number of years and have found it’s possible to intervene early with young people and either prevent the onset of psychosis or ameliorate its impact,” said Francey.

“Since we can see some improvement in people in the prepsychotic phase, we wanted to know if we can also see some benefit without medication after the onset of what we would call full-threshold psychosis,” she added.

Staged Treatment and Acceptability Guidelines in Early Psychosis (STAGES) was a 6-month, triple-blind, randomized controlled noninferiority study that included 90 participants between the ages of 15 and 25 years who had FEP.

To maximize safety, patients were required to have low levels of suicidality and aggression, a DUP of less than 6 months, and to be living in stable accommodation with social support.

Participants were randomly assigned to two groups – one in which patients underwent intensive psychosocial therapy and received low-dose antipsychotic medication (n = 44), and one in which patients underwent intensive psychosocial therapy and were given placebo (n = 46).

Depending on the timing of study enrollment, those in the medication group received risperidone 1 mg or paliperidone 3 mg.

The psychosocial intervention consisted of cognitive-behavioral case management (CBCM), an intervention developed specifically for patients with early psychosis that is strongly focused on therapeutic engagement.

CBCM delivers formulation-driven cognitive-behavioral therapy and psychoeducation within a therapeutic case management framework, Francey said.

The primary outcome was level of functioning at 6, 12, and 24 months, as measured by the Social and Occupational Functioning Scale (SOFAS). The primary prespecified endpoint was outcome at 6 months. A noninferiority margin of 10.5 on the SOFAS was used as the smallest value representing a clinically important effect.

Other assessment tools included the BPRS-4 to test for positive psychotic symptoms, the Scale for the Assessment of Negative Symptoms (SANS), the Hamilton Rating Scale for Depression, and the Hamilton Rating Scale for Anxiety.

At baseline, the two treatment groups were comparable with respect to all measures of functioning and psychopathology.

The study’s discontinuation rate was high. At 6 months, only 16 patients in the psychosocial group had completed therapy, compared with 11 in the antipsychotic group.

At this point, the two groups were comparable in terms of psychopathology and functioning ratings. Both groups had lower symptoms, higher functioning scores, and higher Quality of Life Scale (QLS) scores than at baseline.

SOFAS scores were not significantly different between the groups at this time point. The mean score was 61.7 ± 16.8 in the psychosocial group and 61.5 ± 13.4 in the medication group.

The researchers note that, because the upper limit of the confidence interval (CI) was less than the study’s a priori inferiority margin of 10.5, psychosocial therapy was not inferior to medication at the 6-month assessment point.
 

Antipsychotics: Use with caution

Although between-group differences in SOFAS scores were not significant at 12 and 24 months, noninferiority of psychosocial therapy alone could not be confirmed because the CIs included the inferiority margin at each time point.

The two groups were statistically comparable at 6 months with respect to all other measures of psychopathology and the QLS. Similar results were found at 12 and 24 months.

The lone exception was with SANS at 12 months, on which patients in the placebo group had significantly higher negative symptom scores than the patients in the medication group.

There were no significant differences between study groups with respect to the number of adverse events.

Francey noted that the findings are important because they suggest that some young people with early-stage FEP and short DUP may be able to achieve symptom remission and function better without antipsychotic medication, provided they receive psychological interventions and comprehensive case management.

This challenges conventional wisdom that antipsychotic medications should be used for all patients who experience psychosis, she added.

However, managing FEP with psychosocial interventions should only be considered when it is safe to do so, Francey noted. In addition, the benefits of psychosocial interventions in these patients are less clear at 12 and 24 months.

Given these caveats, she noted that antipsychotics still play an important role in the treatment of these patients.

“I think there is definitely a place for medications. But I think they should be used cautiously, and you need a good, strong relationship between your treating team and your [patient] to work out what is needed and when it’s needed,” said Francey.

In addition, “when we do use medications, we should use the smallest possible dose that we can and also incorporate psychological support. I think that’s a really important part of it as well,” she said.
 

Timing matters

In the Lancet Psychiatry study, the researchers note that prolonged DUP is associated with worse outcomes, including increased symptoms, diminished social functioning, and poorer quality of life. The mechanism by which delayed treatment causes more harm remains unclear.

It is possible that symptoms simply accumulate over time, thereby worsening presentation. Another possibility is that continued psychosis after an initial critical period may cause long-term harm, they write.

They hypothesize that untreated psychosis can cause general treatment resistance by exacerbating underlying disease processes and that such damage progresses faster in the early stages of illness and then slows over time.

In addition, socially disruptive symptoms that are evident prior to FEP presentation may have a confounding effect, thereby leading to earlier presentation.

The investigators used data from two longitudinal cohort studies – the National Evaluation of Development of Early Intervention Network (NEDEN) study and the Outlook study.

In the NEDEN trial, 290 of 901 FEP patients (32%) were assessed within 3 weeks of presentation. In Outlook, 69 of 332 patients (21%) were assessed within 3 weeks of presentation.

In both studies, patients were examined at baseline, 6 months, and 12 months using the Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia, the Mania Rating Scale, the Insight Scale, and SOFAS. The latter two measures were used only at baseline and 12-month follow-up. Logistic regression analyses were used to determine the association between DUP and outcomes.

In the NEDEN study, 751 patients were assessed at 6 months, and 719 were assessed at 12 months. In the Outlook study, 238 and 220 were assessed at the same two time points, respectively.

Results showed a curvilinear relationship between DUP and symptom severity. Longer DUP was predictive of reduced treatment response. However, patient response worsened more slowly as DUP lengthened.

For example, increasing DUP by ten times was predictive of less improvement in PANSS total score by 7.34 (95% CI, 5.76 – 8.92; P < .0001) in NEDEN and by 3.85 (95% CI, 1.69 – 600; P =. 0005) in Outlook. Nevertheless, longer DUP was not associated with worse presentation for any symptoms except depression in NEDEN.

The findings seem to support that the potential harm incurred by delaying treatment among patients with FEP is greatest in the early weeks of psychosis and then levels off, the investigators note.

Given these insights, mental health professionals might consider focusing their efforts on the early detection and treatment of patients for whom DUP is short.

Similarly, because DUP was directly associated with all symptoms, early access to comprehensive treatment “might be preferable to early delivery of particular treatments with particular effects (eg, dopamine antagonists),” they write.
 

“A pragmatic call”

Commenting on the British study in an accompanying editorial, Lena K. Palaniyappan, MD, University of Western Ontario, London, Canada, and Rajeev Krishnadas, MD, University of Glasgow, Scotland, write that any illness left untreated can become more challenging to treat, including psychosis.

“This should make early intervention in psychosis a pragmatic call with no prima facie argument against it,” they write. A reduction in DUP “underpins the rationale behind early detection and intervention in psychosis.”

The editorialists note that the relationship between DUP and successful treatment in early psychosis “strengthens the argument for more proactive early assessment and intervention to shorten treatment delay.

“As we have learnt over the past two decades, even punctual treatment when symptoms first arise continues to be too late when it comes to psychosis,” they write.

Francey also recognizes the value of early intervention in FEP. However, she noted that comprehensive psychosocial therapy might well prove effective enough to stave off antipsychotic therapy in a certain subset of patients.

“For some people, antipsychotics may never need to be introduced,” she said. “Some people recover from their first episode of psychosis and don’t go on to have any more, while others have an episodic illness,” she said.

If another episode develops and the symptoms come back, further psychosocial interventions could then be tried “or you might want to move on” to psychotic medication “because trying to get people better and functioning as well as they can is our primary aim,” Francey said.

The STAGES study was supported by the Australian National Health and Medical Research Council. The British study was funded by the UK Department of Health, the National Institute of Health Research, and the Medical Research Council. Francey and Krishnadas have reported no relevant financial relationships. Palaniyappan has received grants and personal fees from Janssen Canada and Otsuka Canada, grants from Sunovion, and personal fees from SPMM Course UK and the Canadian Psychiatric Association.
 

This article first appeared on Medscape.com.

Two new studies highlight the importance of early intervention in first-episode psychosis (FEP).

In the first study, Australian investigators conclude that, for some FEP patients, early psychosocial interventions may fend off the need for immediate treatment with antipsychotic medications.

In the second study, UK researchers show that long duration of untreated psychosis (DUP) is linked to a significantly reduced treatment response.

For both studies, the findings highlight the importance of rapid access to a comprehensive range of treatments in the first weeks after FEP onset.

“In a select group of people with first-episode psychosis, we found there was no difference in symptoms and functioning between those who had antipsychotic medication and those who didn’t,” lead author Shona M. Francey, PhD, clinical psychologist at Orygen, the National Center of Excellence in Youth Mental Health, Parkville, Australia, told Medscape Medical News.

“These findings supported our idea that, in the early phases of psychosis, with close monitoring and good psychosocial intervention, antipsychotic medication can be delayed,” Francey said.

The Australian study was published in Schizophrenia Bulletin Open. The British study was published in Lancet Psychiatry.
 

Adverse effects

Francey and colleagues note that, in comparison with standard treatment, early interventions produce superior outcomes for patients with psychosis. Although there are a variety of treatment options, low-dose second-generation antipsychotics typically play a central role.

However, atypical antipsychotics have rapid metabolic side effects, including weight gain and altered glucose metabolism, that increase the risk for cardiovascular disease and premature mortality. Importantly, such adverse effects are amplified among patients with FEP, who tend to be younger and treatment naive.

On the other hand, a growing body of evidence shows the benefit of nonpharmacologic interventions for patients with FEP, the investigators note. In addition, clinical staging models appear to support the use of less aggressive treatment early in the disease course.

“We have been working in early intervention for psychosis for a number of years and have found it’s possible to intervene early with young people and either prevent the onset of psychosis or ameliorate its impact,” said Francey.

“Since we can see some improvement in people in the prepsychotic phase, we wanted to know if we can also see some benefit without medication after the onset of what we would call full-threshold psychosis,” she added.

Staged Treatment and Acceptability Guidelines in Early Psychosis (STAGES) was a 6-month, triple-blind, randomized controlled noninferiority study that included 90 participants between the ages of 15 and 25 years who had FEP.

To maximize safety, patients were required to have low levels of suicidality and aggression, a DUP of less than 6 months, and to be living in stable accommodation with social support.

Participants were randomly assigned to two groups – one in which patients underwent intensive psychosocial therapy and received low-dose antipsychotic medication (n = 44), and one in which patients underwent intensive psychosocial therapy and were given placebo (n = 46).

Depending on the timing of study enrollment, those in the medication group received risperidone 1 mg or paliperidone 3 mg.

The psychosocial intervention consisted of cognitive-behavioral case management (CBCM), an intervention developed specifically for patients with early psychosis that is strongly focused on therapeutic engagement.

CBCM delivers formulation-driven cognitive-behavioral therapy and psychoeducation within a therapeutic case management framework, Francey said.

The primary outcome was level of functioning at 6, 12, and 24 months, as measured by the Social and Occupational Functioning Scale (SOFAS). The primary prespecified endpoint was outcome at 6 months. A noninferiority margin of 10.5 on the SOFAS was used as the smallest value representing a clinically important effect.

Other assessment tools included the BPRS-4 to test for positive psychotic symptoms, the Scale for the Assessment of Negative Symptoms (SANS), the Hamilton Rating Scale for Depression, and the Hamilton Rating Scale for Anxiety.

At baseline, the two treatment groups were comparable with respect to all measures of functioning and psychopathology.

The study’s discontinuation rate was high. At 6 months, only 16 patients in the psychosocial group had completed therapy, compared with 11 in the antipsychotic group.

At this point, the two groups were comparable in terms of psychopathology and functioning ratings. Both groups had lower symptoms, higher functioning scores, and higher Quality of Life Scale (QLS) scores than at baseline.

SOFAS scores were not significantly different between the groups at this time point. The mean score was 61.7 ± 16.8 in the psychosocial group and 61.5 ± 13.4 in the medication group.

The researchers note that, because the upper limit of the confidence interval (CI) was less than the study’s a priori inferiority margin of 10.5, psychosocial therapy was not inferior to medication at the 6-month assessment point.
 

Antipsychotics: Use with caution

Although between-group differences in SOFAS scores were not significant at 12 and 24 months, noninferiority of psychosocial therapy alone could not be confirmed because the CIs included the inferiority margin at each time point.

The two groups were statistically comparable at 6 months with respect to all other measures of psychopathology and the QLS. Similar results were found at 12 and 24 months.

The lone exception was with SANS at 12 months, on which patients in the placebo group had significantly higher negative symptom scores than the patients in the medication group.

There were no significant differences between study groups with respect to the number of adverse events.

Francey noted that the findings are important because they suggest that some young people with early-stage FEP and short DUP may be able to achieve symptom remission and function better without antipsychotic medication, provided they receive psychological interventions and comprehensive case management.

This challenges conventional wisdom that antipsychotic medications should be used for all patients who experience psychosis, she added.

However, managing FEP with psychosocial interventions should only be considered when it is safe to do so, Francey noted. In addition, the benefits of psychosocial interventions in these patients are less clear at 12 and 24 months.

Given these caveats, she noted that antipsychotics still play an important role in the treatment of these patients.

“I think there is definitely a place for medications. But I think they should be used cautiously, and you need a good, strong relationship between your treating team and your [patient] to work out what is needed and when it’s needed,” said Francey.

In addition, “when we do use medications, we should use the smallest possible dose that we can and also incorporate psychological support. I think that’s a really important part of it as well,” she said.
 

Timing matters

In the Lancet Psychiatry study, the researchers note that prolonged DUP is associated with worse outcomes, including increased symptoms, diminished social functioning, and poorer quality of life. The mechanism by which delayed treatment causes more harm remains unclear.

It is possible that symptoms simply accumulate over time, thereby worsening presentation. Another possibility is that continued psychosis after an initial critical period may cause long-term harm, they write.

They hypothesize that untreated psychosis can cause general treatment resistance by exacerbating underlying disease processes and that such damage progresses faster in the early stages of illness and then slows over time.

In addition, socially disruptive symptoms that are evident prior to FEP presentation may have a confounding effect, thereby leading to earlier presentation.

The investigators used data from two longitudinal cohort studies – the National Evaluation of Development of Early Intervention Network (NEDEN) study and the Outlook study.

In the NEDEN trial, 290 of 901 FEP patients (32%) were assessed within 3 weeks of presentation. In Outlook, 69 of 332 patients (21%) were assessed within 3 weeks of presentation.

In both studies, patients were examined at baseline, 6 months, and 12 months using the Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia, the Mania Rating Scale, the Insight Scale, and SOFAS. The latter two measures were used only at baseline and 12-month follow-up. Logistic regression analyses were used to determine the association between DUP and outcomes.

In the NEDEN study, 751 patients were assessed at 6 months, and 719 were assessed at 12 months. In the Outlook study, 238 and 220 were assessed at the same two time points, respectively.

Results showed a curvilinear relationship between DUP and symptom severity. Longer DUP was predictive of reduced treatment response. However, patient response worsened more slowly as DUP lengthened.

For example, increasing DUP by ten times was predictive of less improvement in PANSS total score by 7.34 (95% CI, 5.76 – 8.92; P < .0001) in NEDEN and by 3.85 (95% CI, 1.69 – 600; P =. 0005) in Outlook. Nevertheless, longer DUP was not associated with worse presentation for any symptoms except depression in NEDEN.

The findings seem to support that the potential harm incurred by delaying treatment among patients with FEP is greatest in the early weeks of psychosis and then levels off, the investigators note.

Given these insights, mental health professionals might consider focusing their efforts on the early detection and treatment of patients for whom DUP is short.

Similarly, because DUP was directly associated with all symptoms, early access to comprehensive treatment “might be preferable to early delivery of particular treatments with particular effects (eg, dopamine antagonists),” they write.
 

“A pragmatic call”

Commenting on the British study in an accompanying editorial, Lena K. Palaniyappan, MD, University of Western Ontario, London, Canada, and Rajeev Krishnadas, MD, University of Glasgow, Scotland, write that any illness left untreated can become more challenging to treat, including psychosis.

“This should make early intervention in psychosis a pragmatic call with no prima facie argument against it,” they write. A reduction in DUP “underpins the rationale behind early detection and intervention in psychosis.”

The editorialists note that the relationship between DUP and successful treatment in early psychosis “strengthens the argument for more proactive early assessment and intervention to shorten treatment delay.

“As we have learnt over the past two decades, even punctual treatment when symptoms first arise continues to be too late when it comes to psychosis,” they write.

Francey also recognizes the value of early intervention in FEP. However, she noted that comprehensive psychosocial therapy might well prove effective enough to stave off antipsychotic therapy in a certain subset of patients.

“For some people, antipsychotics may never need to be introduced,” she said. “Some people recover from their first episode of psychosis and don’t go on to have any more, while others have an episodic illness,” she said.

If another episode develops and the symptoms come back, further psychosocial interventions could then be tried “or you might want to move on” to psychotic medication “because trying to get people better and functioning as well as they can is our primary aim,” Francey said.

The STAGES study was supported by the Australian National Health and Medical Research Council. The British study was funded by the UK Department of Health, the National Institute of Health Research, and the Medical Research Council. Francey and Krishnadas have reported no relevant financial relationships. Palaniyappan has received grants and personal fees from Janssen Canada and Otsuka Canada, grants from Sunovion, and personal fees from SPMM Course UK and the Canadian Psychiatric Association.
 

This article first appeared on Medscape.com.

The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.

Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.

And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.

CANCER CIFTCI/Getty Images

We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.

The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.

Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.

Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.

But another reason might be the lowered expectations. As one stable patient with schizophrenia said, “No one is hassling me now; no one is aggravating me to go to this group or that, to leave the house to volunteer, to get a job. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.

As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.

Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.

It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.

How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.

Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.

This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
 

Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.

Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.

And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.

CANCER CIFTCI/Getty Images

We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.

The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.

Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.

Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.

But another reason might be the lowered expectations. As one stable patient with schizophrenia said, “No one is hassling me now; no one is aggravating me to go to this group or that, to leave the house to volunteer, to get a job. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.

As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.

Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.

It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.

How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.

Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.

This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
 

Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.

The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.

Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.

And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.

CANCER CIFTCI/Getty Images

We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.

The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.

Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.

Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.

But another reason might be the lowered expectations. As one stable patient with schizophrenia said, “No one is hassling me now; no one is aggravating me to go to this group or that, to leave the house to volunteer, to get a job. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.

As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.

Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.

It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.

How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.

Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.

This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
 

Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.