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The importance of treating insomnia in psychiatric illness
Data suggests this symptom, defined as chronic sleep onset and/or sleep continuity problems associated with impaired daytime functioning, is common in psychiatric illnesses, and can worsen their course.2
The incidence of psychiatric illness in patients with insomnia is estimated at near 50%, with the highest rates found in mood disorders such as depression and bipolar disorder, as well as anxiety disorders.3 In patients with diagnosed major depressive disorder, insomnia rates can approach 90%.4-6
Insomnia has been identified as a risk factor for development of mental illness, including doubling the risk of major depressive disorder and tripling the risk of any depressive or anxiety disorder.7,8 It can also significantly increase the risk of alcohol abuse and psychosis.8
Sleep disturbances can worsen symptoms of diagnosed mental illness, including substance abuse, mood and psychotic disorders.9-10 In one study, nearly 75% of patients with a diagnosis of schizophrenia or bipolar spectrum disorder had at least one type of sleep disturbance (insomnia, hypersomnia, or delayed sleep phase).10 This was almost twice the rate in healthy controls. Importantly, compared with well-rested subjects with mental illness in this study, sleep-disordered participants had higher rates of negative and depressive symptoms on the Positive and Negative Syndrome Scale, as well as significantly lower function via the global assessment of functioning.11,12
Additional data suggests simply being awake during the night (00:00-05:59) elevates risk of suicide. The mean incident rate of completed suicide in one study was a striking four times the rate noted during daytime hours (06:00-23:59 ) (P < .001).13
Although insomnia symptoms can resolve after relief from a particular life stressor, as many as half of patients with more severe symptoms develop a chronic course.14 This then leads to an extended use of many types of sedative-hypnotics designed and studied primarily for short-term use.15 In a survey reviewing national use of prescription drugs for insomnia, as many as 20% of individuals use a medication to target insomnia in a given month.16
Fortunately, despite the many challenges posed by COVID-19, particularly for those with psychiatric illness and limited access to care, telehealth has become more readily available. Additionally, digital versions of evidence-based treatments specifically for sleep problems, such as cognitive-behavioral therapy for insomnia (CBT-I), are regularly being developed.
The benefits of CBT-I have been demonstrated repeatedly and it is recommended as the first line treatment for insomnia by the Clinical Guidelines of the American Academy of Sleep Medicine, the Centers for Disease Control and Prevention, and the National Institutes of Health.17-21 Studies suggest benefits persist long-term, even after completing the therapy sessions, which differ in durability from medication choices.18
One group that may be particularly suited for treatment with CBT-I is women with insomnia during pregnancy or the postpartum period. In these women, options for treatment may be limited by risk of medication during breastfeeding, as well as difficulty traveling to a physician’s or therapist’s office to receive psychotherapy. However, two recent studies evaluated the use of digital CBT-I to treat insomnia during pregnancy and in the postpartum period, respectively.22-23
In both studies,the same group of women with insomnia diagnosed during pregnancy were given six weekly 20-minute sessions of digital CBT-I or standard treatment for insomnia, including medication and psychotherapy per their usual provider.
By study end, the pregnant women receiving the CBT-I intervention not only had significantly improved severity of insomnia, they also experienced improved depression and anxiety symptoms, and a decrease in the use of prescription or over-the-counter sleep aides, compared with the standard treatment group, lowering the fetal exposure to medication during pregnancy.22
In the more recent study, the same group was followed for 6 months post partum.23 Results were again notable, with the women who received CBT-I reporting significantly less insomnia, as well as significantly lower rates of probable major depression at 3 and 6 months (18% vs. 4%, 10% vs. 0%, respectively.) They also exhibited lower rates of moderate to severe anxiety (17% vs. 4%) at 3 months, compared with those receiving standard care. With as many as one in seven women suffering from postpartum depression, these findings represent a substantial public health benefit.
In summary, insomnia is a critical area of focus for any provider diagnosing and treating psychiatric illness. Attempts to optimize sleep, whether through CBT-I or other psychotherapy approaches, or evidence-based medications dosed for appropriate lengths and at safe doses, should be a part of most, if not all, clinical encounters.
Dr. Reid is a board-certified psychiatrist and award-winning medical educator with a private practice in Philadelphia, as well as a clinical faculty role at the University of Pennsylvania, also in Philadelphia. She attended medical school at Columbia University, New York, and completed her psychiatry residency at the University of California, Los Angeles. Dr. Reid is a regular contributor to Psychology Today with her blog, “Think Like a Shrink,” and writes and podcasts as The Reflective Doc.
References
1. Voitsidis P et al. Psychiatry Res. 2020 Jul;289:113076. doi: 10.1016/j.psychres.2020.113076.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, Va.: American Psychiatric Publishing, 2013.
3. Ford DE and Kamerow DB. JAMA. 1989;262(11):1479-84. doi: 10.1001/jama.1989.03430110069030.
4. Ohayon MM and Roth T. J Psychiatr Res. Jan-Feb 2003;37(1):9-15. doi: 10.1016/s0022-3956(02)00052-3.
5. Seow LSE et al. J Ment Health. 2016 Dec;25(6):492-9. doi: 10.3109/09638237.2015.1124390.
6. Thase ME. J Clin Psychiatry. 1999;60 Suppl 17:28-31; discussion 46-8.
7. Baglioni C et al. J Affect Disord. 2011 Dec;135(1-3):10-9. doi: 10.1016/j.jad.2011.01.011.
8. Hertenstein E et al. Sleep Med Rev. 2019 Feb;43:96-105. doi: 10.1016/j.smrv.2018.10.006.
9. Brower KJ et al. Medical Hypotheses. 2010;74(5):928-33. doi: 10.1016/j.mehy.2009.10.020.
10. Laskemoen JF et al. Compr Psychiatry. 2019 May;91:6-12. doi: 10.1016/j.comppsych.2019.02.006.
11. Kay SR et al. Schizophr Bull. 1987;13(2):261-76. doi: 10.1093/schbul/13.2.261.
12. Hall R. Psychosomatics. May-Jun 1995;36(3):267-75. doi: 10.1016/S0033-3182(95)71666-8.
13. Perlis ML et al. J Clin Psychiatry. 2016 Jun;77(6):e726-33. doi: 10.4088/JCP.15m10131.
14. Morin CM et al. Arch Intern Med. 2009 Mar 9. doi: 10.1001/archinternmed.2008.610.
15. Cheung J et al. Sleep Med Clin. 2019 Jun;14(2):253-65. doi: 10.1016/j.jsmc.2019.01.006.
16. Bertisch SM et al. Sleep. 2014 Feb 1. doi: 10.5665/sleep.3410.
17. Okajima I et al. Sleep Biol Rhythms. 2010 Nov 28. doi: 10.1111/j.1479-8425.2010.00481.x.
18. Trauer JM et al. Ann Intern Med. 2015 Aug 4. doi: 10.7326/M14-2841.
19. Edinger J et al. J Clin Sleep Med. 2021 Feb 1. doi: 10.5664/jcsm.8986.
20. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/sleep/for-clinicians.html.
21. National Institutes of Health. Sleep Health. https://www.nhlbi.nih.gov/health-topics/education-and-awareness/sleep-health.
22. Felder JN et al. JAMA Psychiatry. 2020;77(5):484-92. doi:10.1001/jamapsychiatry.2019.4491.
23. Felder JN et al. Sleep. 2022 Feb 14. doi: 10.1093/sleep/zsab280.
Data suggests this symptom, defined as chronic sleep onset and/or sleep continuity problems associated with impaired daytime functioning, is common in psychiatric illnesses, and can worsen their course.2
The incidence of psychiatric illness in patients with insomnia is estimated at near 50%, with the highest rates found in mood disorders such as depression and bipolar disorder, as well as anxiety disorders.3 In patients with diagnosed major depressive disorder, insomnia rates can approach 90%.4-6
Insomnia has been identified as a risk factor for development of mental illness, including doubling the risk of major depressive disorder and tripling the risk of any depressive or anxiety disorder.7,8 It can also significantly increase the risk of alcohol abuse and psychosis.8
Sleep disturbances can worsen symptoms of diagnosed mental illness, including substance abuse, mood and psychotic disorders.9-10 In one study, nearly 75% of patients with a diagnosis of schizophrenia or bipolar spectrum disorder had at least one type of sleep disturbance (insomnia, hypersomnia, or delayed sleep phase).10 This was almost twice the rate in healthy controls. Importantly, compared with well-rested subjects with mental illness in this study, sleep-disordered participants had higher rates of negative and depressive symptoms on the Positive and Negative Syndrome Scale, as well as significantly lower function via the global assessment of functioning.11,12
Additional data suggests simply being awake during the night (00:00-05:59) elevates risk of suicide. The mean incident rate of completed suicide in one study was a striking four times the rate noted during daytime hours (06:00-23:59 ) (P < .001).13
Although insomnia symptoms can resolve after relief from a particular life stressor, as many as half of patients with more severe symptoms develop a chronic course.14 This then leads to an extended use of many types of sedative-hypnotics designed and studied primarily for short-term use.15 In a survey reviewing national use of prescription drugs for insomnia, as many as 20% of individuals use a medication to target insomnia in a given month.16
Fortunately, despite the many challenges posed by COVID-19, particularly for those with psychiatric illness and limited access to care, telehealth has become more readily available. Additionally, digital versions of evidence-based treatments specifically for sleep problems, such as cognitive-behavioral therapy for insomnia (CBT-I), are regularly being developed.
The benefits of CBT-I have been demonstrated repeatedly and it is recommended as the first line treatment for insomnia by the Clinical Guidelines of the American Academy of Sleep Medicine, the Centers for Disease Control and Prevention, and the National Institutes of Health.17-21 Studies suggest benefits persist long-term, even after completing the therapy sessions, which differ in durability from medication choices.18
One group that may be particularly suited for treatment with CBT-I is women with insomnia during pregnancy or the postpartum period. In these women, options for treatment may be limited by risk of medication during breastfeeding, as well as difficulty traveling to a physician’s or therapist’s office to receive psychotherapy. However, two recent studies evaluated the use of digital CBT-I to treat insomnia during pregnancy and in the postpartum period, respectively.22-23
In both studies,the same group of women with insomnia diagnosed during pregnancy were given six weekly 20-minute sessions of digital CBT-I or standard treatment for insomnia, including medication and psychotherapy per their usual provider.
By study end, the pregnant women receiving the CBT-I intervention not only had significantly improved severity of insomnia, they also experienced improved depression and anxiety symptoms, and a decrease in the use of prescription or over-the-counter sleep aides, compared with the standard treatment group, lowering the fetal exposure to medication during pregnancy.22
In the more recent study, the same group was followed for 6 months post partum.23 Results were again notable, with the women who received CBT-I reporting significantly less insomnia, as well as significantly lower rates of probable major depression at 3 and 6 months (18% vs. 4%, 10% vs. 0%, respectively.) They also exhibited lower rates of moderate to severe anxiety (17% vs. 4%) at 3 months, compared with those receiving standard care. With as many as one in seven women suffering from postpartum depression, these findings represent a substantial public health benefit.
In summary, insomnia is a critical area of focus for any provider diagnosing and treating psychiatric illness. Attempts to optimize sleep, whether through CBT-I or other psychotherapy approaches, or evidence-based medications dosed for appropriate lengths and at safe doses, should be a part of most, if not all, clinical encounters.
Dr. Reid is a board-certified psychiatrist and award-winning medical educator with a private practice in Philadelphia, as well as a clinical faculty role at the University of Pennsylvania, also in Philadelphia. She attended medical school at Columbia University, New York, and completed her psychiatry residency at the University of California, Los Angeles. Dr. Reid is a regular contributor to Psychology Today with her blog, “Think Like a Shrink,” and writes and podcasts as The Reflective Doc.
References
1. Voitsidis P et al. Psychiatry Res. 2020 Jul;289:113076. doi: 10.1016/j.psychres.2020.113076.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, Va.: American Psychiatric Publishing, 2013.
3. Ford DE and Kamerow DB. JAMA. 1989;262(11):1479-84. doi: 10.1001/jama.1989.03430110069030.
4. Ohayon MM and Roth T. J Psychiatr Res. Jan-Feb 2003;37(1):9-15. doi: 10.1016/s0022-3956(02)00052-3.
5. Seow LSE et al. J Ment Health. 2016 Dec;25(6):492-9. doi: 10.3109/09638237.2015.1124390.
6. Thase ME. J Clin Psychiatry. 1999;60 Suppl 17:28-31; discussion 46-8.
7. Baglioni C et al. J Affect Disord. 2011 Dec;135(1-3):10-9. doi: 10.1016/j.jad.2011.01.011.
8. Hertenstein E et al. Sleep Med Rev. 2019 Feb;43:96-105. doi: 10.1016/j.smrv.2018.10.006.
9. Brower KJ et al. Medical Hypotheses. 2010;74(5):928-33. doi: 10.1016/j.mehy.2009.10.020.
10. Laskemoen JF et al. Compr Psychiatry. 2019 May;91:6-12. doi: 10.1016/j.comppsych.2019.02.006.
11. Kay SR et al. Schizophr Bull. 1987;13(2):261-76. doi: 10.1093/schbul/13.2.261.
12. Hall R. Psychosomatics. May-Jun 1995;36(3):267-75. doi: 10.1016/S0033-3182(95)71666-8.
13. Perlis ML et al. J Clin Psychiatry. 2016 Jun;77(6):e726-33. doi: 10.4088/JCP.15m10131.
14. Morin CM et al. Arch Intern Med. 2009 Mar 9. doi: 10.1001/archinternmed.2008.610.
15. Cheung J et al. Sleep Med Clin. 2019 Jun;14(2):253-65. doi: 10.1016/j.jsmc.2019.01.006.
16. Bertisch SM et al. Sleep. 2014 Feb 1. doi: 10.5665/sleep.3410.
17. Okajima I et al. Sleep Biol Rhythms. 2010 Nov 28. doi: 10.1111/j.1479-8425.2010.00481.x.
18. Trauer JM et al. Ann Intern Med. 2015 Aug 4. doi: 10.7326/M14-2841.
19. Edinger J et al. J Clin Sleep Med. 2021 Feb 1. doi: 10.5664/jcsm.8986.
20. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/sleep/for-clinicians.html.
21. National Institutes of Health. Sleep Health. https://www.nhlbi.nih.gov/health-topics/education-and-awareness/sleep-health.
22. Felder JN et al. JAMA Psychiatry. 2020;77(5):484-92. doi:10.1001/jamapsychiatry.2019.4491.
23. Felder JN et al. Sleep. 2022 Feb 14. doi: 10.1093/sleep/zsab280.
Data suggests this symptom, defined as chronic sleep onset and/or sleep continuity problems associated with impaired daytime functioning, is common in psychiatric illnesses, and can worsen their course.2
The incidence of psychiatric illness in patients with insomnia is estimated at near 50%, with the highest rates found in mood disorders such as depression and bipolar disorder, as well as anxiety disorders.3 In patients with diagnosed major depressive disorder, insomnia rates can approach 90%.4-6
Insomnia has been identified as a risk factor for development of mental illness, including doubling the risk of major depressive disorder and tripling the risk of any depressive or anxiety disorder.7,8 It can also significantly increase the risk of alcohol abuse and psychosis.8
Sleep disturbances can worsen symptoms of diagnosed mental illness, including substance abuse, mood and psychotic disorders.9-10 In one study, nearly 75% of patients with a diagnosis of schizophrenia or bipolar spectrum disorder had at least one type of sleep disturbance (insomnia, hypersomnia, or delayed sleep phase).10 This was almost twice the rate in healthy controls. Importantly, compared with well-rested subjects with mental illness in this study, sleep-disordered participants had higher rates of negative and depressive symptoms on the Positive and Negative Syndrome Scale, as well as significantly lower function via the global assessment of functioning.11,12
Additional data suggests simply being awake during the night (00:00-05:59) elevates risk of suicide. The mean incident rate of completed suicide in one study was a striking four times the rate noted during daytime hours (06:00-23:59 ) (P < .001).13
Although insomnia symptoms can resolve after relief from a particular life stressor, as many as half of patients with more severe symptoms develop a chronic course.14 This then leads to an extended use of many types of sedative-hypnotics designed and studied primarily for short-term use.15 In a survey reviewing national use of prescription drugs for insomnia, as many as 20% of individuals use a medication to target insomnia in a given month.16
Fortunately, despite the many challenges posed by COVID-19, particularly for those with psychiatric illness and limited access to care, telehealth has become more readily available. Additionally, digital versions of evidence-based treatments specifically for sleep problems, such as cognitive-behavioral therapy for insomnia (CBT-I), are regularly being developed.
The benefits of CBT-I have been demonstrated repeatedly and it is recommended as the first line treatment for insomnia by the Clinical Guidelines of the American Academy of Sleep Medicine, the Centers for Disease Control and Prevention, and the National Institutes of Health.17-21 Studies suggest benefits persist long-term, even after completing the therapy sessions, which differ in durability from medication choices.18
One group that may be particularly suited for treatment with CBT-I is women with insomnia during pregnancy or the postpartum period. In these women, options for treatment may be limited by risk of medication during breastfeeding, as well as difficulty traveling to a physician’s or therapist’s office to receive psychotherapy. However, two recent studies evaluated the use of digital CBT-I to treat insomnia during pregnancy and in the postpartum period, respectively.22-23
In both studies,the same group of women with insomnia diagnosed during pregnancy were given six weekly 20-minute sessions of digital CBT-I or standard treatment for insomnia, including medication and psychotherapy per their usual provider.
By study end, the pregnant women receiving the CBT-I intervention not only had significantly improved severity of insomnia, they also experienced improved depression and anxiety symptoms, and a decrease in the use of prescription or over-the-counter sleep aides, compared with the standard treatment group, lowering the fetal exposure to medication during pregnancy.22
In the more recent study, the same group was followed for 6 months post partum.23 Results were again notable, with the women who received CBT-I reporting significantly less insomnia, as well as significantly lower rates of probable major depression at 3 and 6 months (18% vs. 4%, 10% vs. 0%, respectively.) They also exhibited lower rates of moderate to severe anxiety (17% vs. 4%) at 3 months, compared with those receiving standard care. With as many as one in seven women suffering from postpartum depression, these findings represent a substantial public health benefit.
In summary, insomnia is a critical area of focus for any provider diagnosing and treating psychiatric illness. Attempts to optimize sleep, whether through CBT-I or other psychotherapy approaches, or evidence-based medications dosed for appropriate lengths and at safe doses, should be a part of most, if not all, clinical encounters.
Dr. Reid is a board-certified psychiatrist and award-winning medical educator with a private practice in Philadelphia, as well as a clinical faculty role at the University of Pennsylvania, also in Philadelphia. She attended medical school at Columbia University, New York, and completed her psychiatry residency at the University of California, Los Angeles. Dr. Reid is a regular contributor to Psychology Today with her blog, “Think Like a Shrink,” and writes and podcasts as The Reflective Doc.
References
1. Voitsidis P et al. Psychiatry Res. 2020 Jul;289:113076. doi: 10.1016/j.psychres.2020.113076.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, Va.: American Psychiatric Publishing, 2013.
3. Ford DE and Kamerow DB. JAMA. 1989;262(11):1479-84. doi: 10.1001/jama.1989.03430110069030.
4. Ohayon MM and Roth T. J Psychiatr Res. Jan-Feb 2003;37(1):9-15. doi: 10.1016/s0022-3956(02)00052-3.
5. Seow LSE et al. J Ment Health. 2016 Dec;25(6):492-9. doi: 10.3109/09638237.2015.1124390.
6. Thase ME. J Clin Psychiatry. 1999;60 Suppl 17:28-31; discussion 46-8.
7. Baglioni C et al. J Affect Disord. 2011 Dec;135(1-3):10-9. doi: 10.1016/j.jad.2011.01.011.
8. Hertenstein E et al. Sleep Med Rev. 2019 Feb;43:96-105. doi: 10.1016/j.smrv.2018.10.006.
9. Brower KJ et al. Medical Hypotheses. 2010;74(5):928-33. doi: 10.1016/j.mehy.2009.10.020.
10. Laskemoen JF et al. Compr Psychiatry. 2019 May;91:6-12. doi: 10.1016/j.comppsych.2019.02.006.
11. Kay SR et al. Schizophr Bull. 1987;13(2):261-76. doi: 10.1093/schbul/13.2.261.
12. Hall R. Psychosomatics. May-Jun 1995;36(3):267-75. doi: 10.1016/S0033-3182(95)71666-8.
13. Perlis ML et al. J Clin Psychiatry. 2016 Jun;77(6):e726-33. doi: 10.4088/JCP.15m10131.
14. Morin CM et al. Arch Intern Med. 2009 Mar 9. doi: 10.1001/archinternmed.2008.610.
15. Cheung J et al. Sleep Med Clin. 2019 Jun;14(2):253-65. doi: 10.1016/j.jsmc.2019.01.006.
16. Bertisch SM et al. Sleep. 2014 Feb 1. doi: 10.5665/sleep.3410.
17. Okajima I et al. Sleep Biol Rhythms. 2010 Nov 28. doi: 10.1111/j.1479-8425.2010.00481.x.
18. Trauer JM et al. Ann Intern Med. 2015 Aug 4. doi: 10.7326/M14-2841.
19. Edinger J et al. J Clin Sleep Med. 2021 Feb 1. doi: 10.5664/jcsm.8986.
20. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/sleep/for-clinicians.html.
21. National Institutes of Health. Sleep Health. https://www.nhlbi.nih.gov/health-topics/education-and-awareness/sleep-health.
22. Felder JN et al. JAMA Psychiatry. 2020;77(5):484-92. doi:10.1001/jamapsychiatry.2019.4491.
23. Felder JN et al. Sleep. 2022 Feb 14. doi: 10.1093/sleep/zsab280.
Give patients can’ts but also can do’s
On his last shift in the last hockey game of the regular season, our 14-year-old grandson broke his arm. Although this was his first fracture, the rest of the nuclear family has had ample experience with orthopedic trauma over the last year, both planned and unplanned.
As I drove Peter and my daughter-in-law to his first postsetting and casting appointment I told him how sorry I was that he had been told “no contact sports for the next 3 months.” This was a tough pill for a kid eager to begin his first high school lacrosse season. Then I asked him what the doctor had told him he could do in the way of activity.
Based on personal and professional experience I was not surprised when he told me that no one had suggested things he could be doing. In fact, being a cautious and thoughtful kid, he was concerned about what he should be doing around the house let alone any athletic activities. It turns out he wasn’t even lifting his laptop computer with two hands because some nurse had told him not to lift anything over 2 pounds.
I told him “Peter, even some of the most experienced doctors focus on the ‘can’ts’ and forget to tell you the ‘cans’ and ‘shoulds.’ While you’re in the waiting room make up a mental list of what you would like to be doing that you aren’t.”
As he climbed back in the car for the ride home I asked how the visit went. The x-ray showed good alignment and the doctor was pleased. But, as I predicted, they were already on the launch pad to the receptionist to make a follow-up appointment without the physician uttering a single word about what activities he could resume. Always a very coachable kid, Peter piped up with the list he had created in the waiting room and was relieved to hear that he could do anything as long as it didn’t hurt. In fact, the doctor encouraged him to use his fingers because it might speed the healing.
Not every patient, regardless of age, is as cautious as my grandson and in some circumstances the physician must err on the side of emphasizing the “don’ts.” However, in my experience, too many physicians forget to include a generous list of “can do’s” in their visit closing discussions. This oversight is a mistake for several reasons.
First, and maybe most importantly, even a brief discussion of “can do’s” can soften the depressing message that the patient will not be able to do things he or she enjoys. I can’t quote the references but I am sure there is plenty of evidence that depression slows the healing process.
Second, and this is particularly true in older patients with orthopedic problems – failure to include a plan for return to activity can hinder recovery. I can recall more than a few patients who were seen in the emergency department and diagnosed with sprains but not given even the simplest instructions on how to begin moving the injured joint. When they finally returned to see me we had to begin the painful and unnecessary project of thawing a frozen joint.
Fortunately, we have evolved past the era when best rest was near the top of the list of our recommended remedies. However, there still remains a bias against activity in some situations. The most recent example is the evolving strategies for the management of concussion. There is some evidence that involving the patient in a return to activity plan may shorten the time to recovery. The myth about brain rest has been slow to die.
Finally, providing the patient with a personalized list of “can do’s” makes good business sense because it can head off those time-gobbling call backs that tie up you and your office staff. As an experienced physician, you have probably learned the most frequently asked “Can Jason do ... ?” questions. Make your own list and give the patient your answers. An ounce of anticipatory guidance is worth hours on the telephone or sorting through the email inbox.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
On his last shift in the last hockey game of the regular season, our 14-year-old grandson broke his arm. Although this was his first fracture, the rest of the nuclear family has had ample experience with orthopedic trauma over the last year, both planned and unplanned.
As I drove Peter and my daughter-in-law to his first postsetting and casting appointment I told him how sorry I was that he had been told “no contact sports for the next 3 months.” This was a tough pill for a kid eager to begin his first high school lacrosse season. Then I asked him what the doctor had told him he could do in the way of activity.
Based on personal and professional experience I was not surprised when he told me that no one had suggested things he could be doing. In fact, being a cautious and thoughtful kid, he was concerned about what he should be doing around the house let alone any athletic activities. It turns out he wasn’t even lifting his laptop computer with two hands because some nurse had told him not to lift anything over 2 pounds.
I told him “Peter, even some of the most experienced doctors focus on the ‘can’ts’ and forget to tell you the ‘cans’ and ‘shoulds.’ While you’re in the waiting room make up a mental list of what you would like to be doing that you aren’t.”
As he climbed back in the car for the ride home I asked how the visit went. The x-ray showed good alignment and the doctor was pleased. But, as I predicted, they were already on the launch pad to the receptionist to make a follow-up appointment without the physician uttering a single word about what activities he could resume. Always a very coachable kid, Peter piped up with the list he had created in the waiting room and was relieved to hear that he could do anything as long as it didn’t hurt. In fact, the doctor encouraged him to use his fingers because it might speed the healing.
Not every patient, regardless of age, is as cautious as my grandson and in some circumstances the physician must err on the side of emphasizing the “don’ts.” However, in my experience, too many physicians forget to include a generous list of “can do’s” in their visit closing discussions. This oversight is a mistake for several reasons.
First, and maybe most importantly, even a brief discussion of “can do’s” can soften the depressing message that the patient will not be able to do things he or she enjoys. I can’t quote the references but I am sure there is plenty of evidence that depression slows the healing process.
Second, and this is particularly true in older patients with orthopedic problems – failure to include a plan for return to activity can hinder recovery. I can recall more than a few patients who were seen in the emergency department and diagnosed with sprains but not given even the simplest instructions on how to begin moving the injured joint. When they finally returned to see me we had to begin the painful and unnecessary project of thawing a frozen joint.
Fortunately, we have evolved past the era when best rest was near the top of the list of our recommended remedies. However, there still remains a bias against activity in some situations. The most recent example is the evolving strategies for the management of concussion. There is some evidence that involving the patient in a return to activity plan may shorten the time to recovery. The myth about brain rest has been slow to die.
Finally, providing the patient with a personalized list of “can do’s” makes good business sense because it can head off those time-gobbling call backs that tie up you and your office staff. As an experienced physician, you have probably learned the most frequently asked “Can Jason do ... ?” questions. Make your own list and give the patient your answers. An ounce of anticipatory guidance is worth hours on the telephone or sorting through the email inbox.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
On his last shift in the last hockey game of the regular season, our 14-year-old grandson broke his arm. Although this was his first fracture, the rest of the nuclear family has had ample experience with orthopedic trauma over the last year, both planned and unplanned.
As I drove Peter and my daughter-in-law to his first postsetting and casting appointment I told him how sorry I was that he had been told “no contact sports for the next 3 months.” This was a tough pill for a kid eager to begin his first high school lacrosse season. Then I asked him what the doctor had told him he could do in the way of activity.
Based on personal and professional experience I was not surprised when he told me that no one had suggested things he could be doing. In fact, being a cautious and thoughtful kid, he was concerned about what he should be doing around the house let alone any athletic activities. It turns out he wasn’t even lifting his laptop computer with two hands because some nurse had told him not to lift anything over 2 pounds.
I told him “Peter, even some of the most experienced doctors focus on the ‘can’ts’ and forget to tell you the ‘cans’ and ‘shoulds.’ While you’re in the waiting room make up a mental list of what you would like to be doing that you aren’t.”
As he climbed back in the car for the ride home I asked how the visit went. The x-ray showed good alignment and the doctor was pleased. But, as I predicted, they were already on the launch pad to the receptionist to make a follow-up appointment without the physician uttering a single word about what activities he could resume. Always a very coachable kid, Peter piped up with the list he had created in the waiting room and was relieved to hear that he could do anything as long as it didn’t hurt. In fact, the doctor encouraged him to use his fingers because it might speed the healing.
Not every patient, regardless of age, is as cautious as my grandson and in some circumstances the physician must err on the side of emphasizing the “don’ts.” However, in my experience, too many physicians forget to include a generous list of “can do’s” in their visit closing discussions. This oversight is a mistake for several reasons.
First, and maybe most importantly, even a brief discussion of “can do’s” can soften the depressing message that the patient will not be able to do things he or she enjoys. I can’t quote the references but I am sure there is plenty of evidence that depression slows the healing process.
Second, and this is particularly true in older patients with orthopedic problems – failure to include a plan for return to activity can hinder recovery. I can recall more than a few patients who were seen in the emergency department and diagnosed with sprains but not given even the simplest instructions on how to begin moving the injured joint. When they finally returned to see me we had to begin the painful and unnecessary project of thawing a frozen joint.
Fortunately, we have evolved past the era when best rest was near the top of the list of our recommended remedies. However, there still remains a bias against activity in some situations. The most recent example is the evolving strategies for the management of concussion. There is some evidence that involving the patient in a return to activity plan may shorten the time to recovery. The myth about brain rest has been slow to die.
Finally, providing the patient with a personalized list of “can do’s” makes good business sense because it can head off those time-gobbling call backs that tie up you and your office staff. As an experienced physician, you have probably learned the most frequently asked “Can Jason do ... ?” questions. Make your own list and give the patient your answers. An ounce of anticipatory guidance is worth hours on the telephone or sorting through the email inbox.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Microdosing psychedelics: Untapped potential in psychiatry?
In her month-long memoir, A Really Good Day: How Microdosing Made a Mega Difference in My Mood, My Marriage, and My Life (Knopf, 2017), author Ayelet Waldman turns herself into a one-woman experiment.
Over a single month she takes one-tenth of a recreational dose of LSD every third day. She plots her emotions, her productivity, and her pain along the way. Ms. Waldman obtains the LSD in a single vial, enough for 10 doses, from a researcher, who is retiring. What she’s looking for, she tells the reader, is a really good day – something that has been elusive in her turbulent life.
Although psychedelics remain illegal for both recreational and therapeutic use, they are increasingly being studied at academic centers, and there is hope that they will offer something that our traditional medications might not. However, these are not “micro” doses, but full doses of psychedelic agents that induce clinically-monitored “trips” in order to treat conditions such as depression, anorexia nervosa, or for smoking cessation, to name just a few.
Yet
Because these drugs are illegal under most circumstances, many of the studies involve surveys of users in their natural environments who are already microdosing in an uncontrolled manner. In a 2019 study published in PLOS One, Vince Polito and Richard Stevenson, from Macquarie University, Sydney, gave daily surveys of psychological functioning to 98 microdosers over 6 weeks. Several participants were excluded for using doses that were too high or for concurrent use of other illicit substances.
Whereas the authors found that many people claimed to have positive experiences, there was an increase in neuroticism in some of the subjects. There was no control group and no uniformity to what the subject claimed to be ingesting with regard to dose, frequency, substance, or verification of the chemical content.
University of Chicago neuroscientist Harriet De Wit, PhD, leads one of the few laboratories that conducts controlled, double-blind studies looking at microdosing LSD.
“With microdosing there are expectations, and we don’t know if it’s the expectation or the agent that is making a difference,” she explained. And when asked who in her experience is experimenting with microdosing psychedelics, she expounded “Everybody under the sun!”
Dr. De Wit notes that people microdose to increase their creativity, productivity, focus, and energy, to heighten their spiritual awareness, improve empathy and social relational skills, and to improve their mood – all purported benefits of low-dose psychedelics.
Her group published a study in Addiction Biology, in which 39 subjects were administered low doses of LSD four times over 2 weeks. To address the issues of expectation, the subjects were not told they were participating in a study of hallucinogens specifically but were instead given a list of pharmaceuticals in different classes that they might be given. Microdoses of LSD did not improve either mood or performance, but they did appear to be safe, and they produced no adverse effects.
To date, studies on microdosing have looked at their effects on healthy populations, and the practice has been associated with “Silicon Valley techies” looking for performance enhancement. Ms. Waldman, however, is different.
She is open about her diagnosis of bipolar disorder, and her long history with therapy and medications. As she describes herself in the beginning of her book, she is emotionally uncomfortable, and both irritable and reactive to the point that her life is propelled by interpersonal chaos. In her uncontrolled ‘study,’ she is an N of 1, and she is pleased with the results. Microdosing, she believes, helped her become less irritable, more resilient, and in fact, have some very good days.
By the end of her memoir, she was looking for a way to continue microdosing but was unsure how to safely obtain more LSD and be certain of its purity. Her experience does raise the possibility that microdoses may have therapeutic benefits in people with certain psychiatric conditions, but this has yet to be studied.
J. Raymond DePaulo Jr., MD, is the chair of the National Network of Depression Centers and a distinguished service professor at Johns Hopkins Hospital, Baltimore. “Microdosing of psychedelics is very problematic for two equally serious reasons,” he cautioned. “There is no control over what it is that people are actually taking, it is completely unstudied scientifically, and there is no agreement on what a ‘micro’ dose is.”
He noted that one of his patients thought he was taking psilocybin. A chemical analysis was done that revealed the agent to contain a combination of THC, a stimulant, morphine, and fluoxetine. There wasn’t a trace of psilocybin. “Mislabeling is the rule, not the exception,” Dr. DePaulo has concluded.
He also believes the placebo effect has a powerful role with microdosing. “It’s not working because of what is in the pill, more likely it is working because of what is advertised to be in it.”
Ms. De Wit noted that when she started her study, she tried to find people who were elevated on measures of depression or anxiety, but she was not looking for a specific clinical population of patients with these clinical diagnoses. “We found a handful of people, and they improved, but so did those in the placebo group; they all got better.”
Psychedelic agents interact with antidepressants, so subjects in controlled studies need to go off their medications before enrolling – this is a limiting factor in studies of both macro- and microdosing. Ms. De Wit also notes that there are logistical and practical obstacles – it is difficult to get approval to use these agents, and the patients have to remain in the lab and be observed for several hours after they are administered, just as with standard doses.
As might be expected, data collection and anecdotal microdosing experiences are rampant on the internet. The social media forum Reddit alone boasts 192,000 members in its microdosing group, while Imperial College London invites microdosers to take part in surveys intended to add to the body of knowledge. But despite its popularity, there is little in the way of prospective, agent-verified, placebo-controlled research exploring whether or not microdosing is truly beneficial beyond just anecdotal evidence.
Perhaps microdosing is a fad, or perhaps it offers some benefits to some people. Given the current interest in the therapeutic uses of psychedelics, it would be useful to have controlled studies of lower doses that don’t carry the risk of “bad trips.”
Certainly, psychiatry could use more agents to address mental health issues, and society might benefit from the use of agents that are proven to be evidence-based options for improving creativity and productivity. Anything that has potential to reduce psychiatric suffering seems worthy of further study to delineate which populations could be helped or harmed.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. Dr. Miller has no conflicts of interest.
A version of this article first appeared on Medscape.com.
In her month-long memoir, A Really Good Day: How Microdosing Made a Mega Difference in My Mood, My Marriage, and My Life (Knopf, 2017), author Ayelet Waldman turns herself into a one-woman experiment.
Over a single month she takes one-tenth of a recreational dose of LSD every third day. She plots her emotions, her productivity, and her pain along the way. Ms. Waldman obtains the LSD in a single vial, enough for 10 doses, from a researcher, who is retiring. What she’s looking for, she tells the reader, is a really good day – something that has been elusive in her turbulent life.
Although psychedelics remain illegal for both recreational and therapeutic use, they are increasingly being studied at academic centers, and there is hope that they will offer something that our traditional medications might not. However, these are not “micro” doses, but full doses of psychedelic agents that induce clinically-monitored “trips” in order to treat conditions such as depression, anorexia nervosa, or for smoking cessation, to name just a few.
Yet
Because these drugs are illegal under most circumstances, many of the studies involve surveys of users in their natural environments who are already microdosing in an uncontrolled manner. In a 2019 study published in PLOS One, Vince Polito and Richard Stevenson, from Macquarie University, Sydney, gave daily surveys of psychological functioning to 98 microdosers over 6 weeks. Several participants were excluded for using doses that were too high or for concurrent use of other illicit substances.
Whereas the authors found that many people claimed to have positive experiences, there was an increase in neuroticism in some of the subjects. There was no control group and no uniformity to what the subject claimed to be ingesting with regard to dose, frequency, substance, or verification of the chemical content.
University of Chicago neuroscientist Harriet De Wit, PhD, leads one of the few laboratories that conducts controlled, double-blind studies looking at microdosing LSD.
“With microdosing there are expectations, and we don’t know if it’s the expectation or the agent that is making a difference,” she explained. And when asked who in her experience is experimenting with microdosing psychedelics, she expounded “Everybody under the sun!”
Dr. De Wit notes that people microdose to increase their creativity, productivity, focus, and energy, to heighten their spiritual awareness, improve empathy and social relational skills, and to improve their mood – all purported benefits of low-dose psychedelics.
Her group published a study in Addiction Biology, in which 39 subjects were administered low doses of LSD four times over 2 weeks. To address the issues of expectation, the subjects were not told they were participating in a study of hallucinogens specifically but were instead given a list of pharmaceuticals in different classes that they might be given. Microdoses of LSD did not improve either mood or performance, but they did appear to be safe, and they produced no adverse effects.
To date, studies on microdosing have looked at their effects on healthy populations, and the practice has been associated with “Silicon Valley techies” looking for performance enhancement. Ms. Waldman, however, is different.
She is open about her diagnosis of bipolar disorder, and her long history with therapy and medications. As she describes herself in the beginning of her book, she is emotionally uncomfortable, and both irritable and reactive to the point that her life is propelled by interpersonal chaos. In her uncontrolled ‘study,’ she is an N of 1, and she is pleased with the results. Microdosing, she believes, helped her become less irritable, more resilient, and in fact, have some very good days.
By the end of her memoir, she was looking for a way to continue microdosing but was unsure how to safely obtain more LSD and be certain of its purity. Her experience does raise the possibility that microdoses may have therapeutic benefits in people with certain psychiatric conditions, but this has yet to be studied.
J. Raymond DePaulo Jr., MD, is the chair of the National Network of Depression Centers and a distinguished service professor at Johns Hopkins Hospital, Baltimore. “Microdosing of psychedelics is very problematic for two equally serious reasons,” he cautioned. “There is no control over what it is that people are actually taking, it is completely unstudied scientifically, and there is no agreement on what a ‘micro’ dose is.”
He noted that one of his patients thought he was taking psilocybin. A chemical analysis was done that revealed the agent to contain a combination of THC, a stimulant, morphine, and fluoxetine. There wasn’t a trace of psilocybin. “Mislabeling is the rule, not the exception,” Dr. DePaulo has concluded.
He also believes the placebo effect has a powerful role with microdosing. “It’s not working because of what is in the pill, more likely it is working because of what is advertised to be in it.”
Ms. De Wit noted that when she started her study, she tried to find people who were elevated on measures of depression or anxiety, but she was not looking for a specific clinical population of patients with these clinical diagnoses. “We found a handful of people, and they improved, but so did those in the placebo group; they all got better.”
Psychedelic agents interact with antidepressants, so subjects in controlled studies need to go off their medications before enrolling – this is a limiting factor in studies of both macro- and microdosing. Ms. De Wit also notes that there are logistical and practical obstacles – it is difficult to get approval to use these agents, and the patients have to remain in the lab and be observed for several hours after they are administered, just as with standard doses.
As might be expected, data collection and anecdotal microdosing experiences are rampant on the internet. The social media forum Reddit alone boasts 192,000 members in its microdosing group, while Imperial College London invites microdosers to take part in surveys intended to add to the body of knowledge. But despite its popularity, there is little in the way of prospective, agent-verified, placebo-controlled research exploring whether or not microdosing is truly beneficial beyond just anecdotal evidence.
Perhaps microdosing is a fad, or perhaps it offers some benefits to some people. Given the current interest in the therapeutic uses of psychedelics, it would be useful to have controlled studies of lower doses that don’t carry the risk of “bad trips.”
Certainly, psychiatry could use more agents to address mental health issues, and society might benefit from the use of agents that are proven to be evidence-based options for improving creativity and productivity. Anything that has potential to reduce psychiatric suffering seems worthy of further study to delineate which populations could be helped or harmed.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. Dr. Miller has no conflicts of interest.
A version of this article first appeared on Medscape.com.
In her month-long memoir, A Really Good Day: How Microdosing Made a Mega Difference in My Mood, My Marriage, and My Life (Knopf, 2017), author Ayelet Waldman turns herself into a one-woman experiment.
Over a single month she takes one-tenth of a recreational dose of LSD every third day. She plots her emotions, her productivity, and her pain along the way. Ms. Waldman obtains the LSD in a single vial, enough for 10 doses, from a researcher, who is retiring. What she’s looking for, she tells the reader, is a really good day – something that has been elusive in her turbulent life.
Although psychedelics remain illegal for both recreational and therapeutic use, they are increasingly being studied at academic centers, and there is hope that they will offer something that our traditional medications might not. However, these are not “micro” doses, but full doses of psychedelic agents that induce clinically-monitored “trips” in order to treat conditions such as depression, anorexia nervosa, or for smoking cessation, to name just a few.
Yet
Because these drugs are illegal under most circumstances, many of the studies involve surveys of users in their natural environments who are already microdosing in an uncontrolled manner. In a 2019 study published in PLOS One, Vince Polito and Richard Stevenson, from Macquarie University, Sydney, gave daily surveys of psychological functioning to 98 microdosers over 6 weeks. Several participants were excluded for using doses that were too high or for concurrent use of other illicit substances.
Whereas the authors found that many people claimed to have positive experiences, there was an increase in neuroticism in some of the subjects. There was no control group and no uniformity to what the subject claimed to be ingesting with regard to dose, frequency, substance, or verification of the chemical content.
University of Chicago neuroscientist Harriet De Wit, PhD, leads one of the few laboratories that conducts controlled, double-blind studies looking at microdosing LSD.
“With microdosing there are expectations, and we don’t know if it’s the expectation or the agent that is making a difference,” she explained. And when asked who in her experience is experimenting with microdosing psychedelics, she expounded “Everybody under the sun!”
Dr. De Wit notes that people microdose to increase their creativity, productivity, focus, and energy, to heighten their spiritual awareness, improve empathy and social relational skills, and to improve their mood – all purported benefits of low-dose psychedelics.
Her group published a study in Addiction Biology, in which 39 subjects were administered low doses of LSD four times over 2 weeks. To address the issues of expectation, the subjects were not told they were participating in a study of hallucinogens specifically but were instead given a list of pharmaceuticals in different classes that they might be given. Microdoses of LSD did not improve either mood or performance, but they did appear to be safe, and they produced no adverse effects.
To date, studies on microdosing have looked at their effects on healthy populations, and the practice has been associated with “Silicon Valley techies” looking for performance enhancement. Ms. Waldman, however, is different.
She is open about her diagnosis of bipolar disorder, and her long history with therapy and medications. As she describes herself in the beginning of her book, she is emotionally uncomfortable, and both irritable and reactive to the point that her life is propelled by interpersonal chaos. In her uncontrolled ‘study,’ she is an N of 1, and she is pleased with the results. Microdosing, she believes, helped her become less irritable, more resilient, and in fact, have some very good days.
By the end of her memoir, she was looking for a way to continue microdosing but was unsure how to safely obtain more LSD and be certain of its purity. Her experience does raise the possibility that microdoses may have therapeutic benefits in people with certain psychiatric conditions, but this has yet to be studied.
J. Raymond DePaulo Jr., MD, is the chair of the National Network of Depression Centers and a distinguished service professor at Johns Hopkins Hospital, Baltimore. “Microdosing of psychedelics is very problematic for two equally serious reasons,” he cautioned. “There is no control over what it is that people are actually taking, it is completely unstudied scientifically, and there is no agreement on what a ‘micro’ dose is.”
He noted that one of his patients thought he was taking psilocybin. A chemical analysis was done that revealed the agent to contain a combination of THC, a stimulant, morphine, and fluoxetine. There wasn’t a trace of psilocybin. “Mislabeling is the rule, not the exception,” Dr. DePaulo has concluded.
He also believes the placebo effect has a powerful role with microdosing. “It’s not working because of what is in the pill, more likely it is working because of what is advertised to be in it.”
Ms. De Wit noted that when she started her study, she tried to find people who were elevated on measures of depression or anxiety, but she was not looking for a specific clinical population of patients with these clinical diagnoses. “We found a handful of people, and they improved, but so did those in the placebo group; they all got better.”
Psychedelic agents interact with antidepressants, so subjects in controlled studies need to go off their medications before enrolling – this is a limiting factor in studies of both macro- and microdosing. Ms. De Wit also notes that there are logistical and practical obstacles – it is difficult to get approval to use these agents, and the patients have to remain in the lab and be observed for several hours after they are administered, just as with standard doses.
As might be expected, data collection and anecdotal microdosing experiences are rampant on the internet. The social media forum Reddit alone boasts 192,000 members in its microdosing group, while Imperial College London invites microdosers to take part in surveys intended to add to the body of knowledge. But despite its popularity, there is little in the way of prospective, agent-verified, placebo-controlled research exploring whether or not microdosing is truly beneficial beyond just anecdotal evidence.
Perhaps microdosing is a fad, or perhaps it offers some benefits to some people. Given the current interest in the therapeutic uses of psychedelics, it would be useful to have controlled studies of lower doses that don’t carry the risk of “bad trips.”
Certainly, psychiatry could use more agents to address mental health issues, and society might benefit from the use of agents that are proven to be evidence-based options for improving creativity and productivity. Anything that has potential to reduce psychiatric suffering seems worthy of further study to delineate which populations could be helped or harmed.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. Dr. Miller has no conflicts of interest.
A version of this article first appeared on Medscape.com.
Will we ever outgrow the Goldwater rule?
Since it appeared in the first edition of the American Psychiatric Association’s Principles of Medical Ethics in 1973, the “Goldwater rule” – often referred to in terms of where in the APA’s guideline it can be found, Section 7.3 – has placed a stringent prohibition on psychiatrists offering professional opinions about public figures “unless he or she has conducted an examination and has been granted proper authorization for such a statement.”1
Some psychiatrists experienced the restrictive nature of Section 7.3 more acutely perhaps than ever during the Trump presidency. This spurred numerous articles criticizing the guideline as an outdated “gag rule”2 that harms the public image of psychiatry.3 Some psychiatrists violated the rule to warn the public of the dangers of a president with “incipient dementia”4 occupying the most powerful position on earth.
Following President Trump’s exit from the White House, the alarm bells surrounding his presidency have quieted. Criticisms of the Goldwater rule, on the other hand, have persisted. Many of these criticisms now call for the rule to be refined, allowing for psychiatrists to give their professional opinions about public figures, but with certain guidelines on how to do so.5 Few have yet to make a sober case for the outright abolition of Section 7.3.6
Self-regulating and internal policing are important factors in the continued independence of the medical profession, and we should continue to hold each other to high professional standards. That being said, do psychiatrists need training wheels to prevent us from devolving into unprofessional social commentators? Other medical specialties do not see the need to implement a rule preventing their colleagues from expressing expertise in fear of embarrassment. Do we not have faith in our ability to conduct ourselves professionally? Is the Goldwater rule an admission of a juvenile lack of self-control within our field?
Not only do other medical specialties not forcibly handhold their members in public settings, but other “providers” in the realm of mental health likewise do not implement such strict self-restraints. Psychiatry staying silent on the matter of public figures leaves a void filled by other, arguably less qualified, individuals. Subsequently, the public discord risks being flooded with pseudoscientific pontification and distorted views of psychiatric illness. The cycle of speculating on the mental fitness of the president has outlived President Trump, with concerns about Joe Biden’s incoherence and waning cognition.7 Therein is an important argument to be made for the public duty of psychiatrists, with their greater expertise and clinical acumen, to weigh in on matters of societal importance in an attempt to dispel dangerous misconceptions.
Practical limitations are often raised and serve as the cornerstone for the Goldwater rule. Specifically, the limitation being that a psychiatrist cannot provide a professional opinion about an individual without a proper in-person evaluation. The psychiatric interview could be considered the most in-depth and comprehensive evaluation in all of medicine. Even so, is a trained psychiatrist presented with grandiosity, flight-of-ideas, and pressured speech unable to comment on the possibility of mania without a lengthy and comprehensive evaluation? How much disorganization of behavior and dialogue does one need to observe to recognize psychosis? For the experienced psychiatrist, many of these behavioral hallmarks are akin to an ST elevation on an EKG representing a heart attack.
When considering less extreme examples of mental affliction, such as depression and anxiety, many signs – including demeanor, motor activity, manner of speaking, and other aspects of behavior – are apparent to the perceptive psychiatrist without needing an extensive interview that dives into the depths of a person’s social history and childhood. After all, our own criteria for depression and mania do not require the presence of social stressors or childhood trauma. Even personality disorders can be reasonably postulated when a person behaves in a particular fashion. The recognition of transitional objects, items used to provide psychological comfort, including the “teddy bear sign” are common and scientifically studied methods to recognize personality disorder.8
The necessity for an in-person evaluation has become less compelling over the years. In our modern age, important social moments are memorialized in countless videos that are arguably more relevant, more accurate, and less subjective than a psychiatric interview. Furthermore, forensic psychiatrists routinely comment on individuals they have not examined for a variety of reasons, from postmortem analysis to the refusal of the client to be interviewed. Moreover, and with significant contradiction, many leaders in the field of psychiatry view integrated care, the practice of psychiatrists advising primary care doctors, often without even seeing patients, to be the future of psychiatry.9
Some reading this may scoff at the above examples. Perhaps Section 7.3 speaks to an underlying insecurity in our field regarding our ability to accurately diagnose. That insecurity is not unfounded. In terms of the DSM-5, the bar for reliability has been lowered to a kappa of 0.2-0.4, from a previous standard of 0.6, in an attempt to avoid critiques of unreliability.10 Yet herein lies a powerful recognition of the necessity of the Goldwater rule. If psychiatrists cannot reliably agree on the presence of diagnoses in the controlled setting of scientific study, how can we expect to speak with coherence and consistency on highly mediatized and provoking topics?
The defense – that the difficulty psychiatrists have at providing an accurate diagnosis stems from the immense complexity of the system being evaluated, the human mind – is a valid one. Attempts to force such complex pathology, with all its many variables, into the check-box approach implemented in the DSM inevitably leads to problems with diagnostic reliability. Still, as psychiatrists we retain a level of expertise in assessing and treating complex disorders of the mind that no other field can claim.
The duty physicians have not only to work toward the health of their individual patients, but also to act in service of the public health and well-being of communities in which our patients live, is well established. How ethical is it then for psychiatry to absolve itself from duty when it comes to public figures at the center of shaping public opinion? There are numerous recent, high-profile instances where our expertise may have helped shine light in an otherwise murky public discussion filled with disinformation. The death of George Floyd and the year of turmoil that followed is a salient example. The conservatorship of Britney Spears and the resulting societal outcry is another. Even setting the matter of diagnosis aside, we can help illuminate the societal implications of conservatorship laws,11 in addition to providing input on how to safely and responsibly approach an individual who is in crisis, under the influence of multiple illicit substances, and possibly suffering from excited delirium.
Whether psychiatry has progressed enough as a medical specialty to trust ourselves with the option of providing professional opinions on public figures is an ongoing debate. The persistence of the Goldwater rule is a strong testament to the internal lack of confidence among psychiatrists regarding our ability to provide accurate diagnoses, act with integrity in the public space, and foster a positive public image. That lack of confidence may be well deserved. However, it is possible that our field will never go through the necessary pains of maturing as long as Section 7.3 remains in place.
Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Compton has no conflicts of interest. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.
References
1. American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry. Section 7. American Psychiatric Association; 2013 edition.
2. Glass LL. The Goldwater rule is broken. Here’s how to fix it. STAT News. 2018 June 18.
3. Plymyer D. The Goldwater rule paradox. 2020 Aug 7.
4. Lieberman JA. Trump’s brain and the 25th Amendment. Vice. 2017 Sep 8.
5. Blotcky AD et al. The Goldwater rule is fine, if refined. Here’s how to do it. Psychiatric Times. 2022 Jan 6;39(1).
6. Blotcky AD and Norrholm SD. After Trump, end the Goldwater rule once and for all. New York Daily News. 2020 Dec 22.
7. Stephens B. Biden should not run again – And he should say he won’t. New York Times. 2021 Dec 14.
8. Schmaling KB et al. The positive teddy bear sign: Transitional objects in the medical setting. J Nerv Ment Dis. 1994 Dec;182(12):725.
9. Badre N et al. Psychopharmacologic management in integrated care: Challenges for residency education. Acad Psychiatry. 2015; 39(4):466-9.
10. Kraemer HC et al. DSM-5: How reliable is reliable enough? Am J Psychiatry. 2012 Jan;169(1):13-5.
11. Badre N and Compton C. Britney Spears – Reflections on conservatorship. Clinical Psychiatry News. 2021 Nov 16.
Since it appeared in the first edition of the American Psychiatric Association’s Principles of Medical Ethics in 1973, the “Goldwater rule” – often referred to in terms of where in the APA’s guideline it can be found, Section 7.3 – has placed a stringent prohibition on psychiatrists offering professional opinions about public figures “unless he or she has conducted an examination and has been granted proper authorization for such a statement.”1
Some psychiatrists experienced the restrictive nature of Section 7.3 more acutely perhaps than ever during the Trump presidency. This spurred numerous articles criticizing the guideline as an outdated “gag rule”2 that harms the public image of psychiatry.3 Some psychiatrists violated the rule to warn the public of the dangers of a president with “incipient dementia”4 occupying the most powerful position on earth.
Following President Trump’s exit from the White House, the alarm bells surrounding his presidency have quieted. Criticisms of the Goldwater rule, on the other hand, have persisted. Many of these criticisms now call for the rule to be refined, allowing for psychiatrists to give their professional opinions about public figures, but with certain guidelines on how to do so.5 Few have yet to make a sober case for the outright abolition of Section 7.3.6
Self-regulating and internal policing are important factors in the continued independence of the medical profession, and we should continue to hold each other to high professional standards. That being said, do psychiatrists need training wheels to prevent us from devolving into unprofessional social commentators? Other medical specialties do not see the need to implement a rule preventing their colleagues from expressing expertise in fear of embarrassment. Do we not have faith in our ability to conduct ourselves professionally? Is the Goldwater rule an admission of a juvenile lack of self-control within our field?
Not only do other medical specialties not forcibly handhold their members in public settings, but other “providers” in the realm of mental health likewise do not implement such strict self-restraints. Psychiatry staying silent on the matter of public figures leaves a void filled by other, arguably less qualified, individuals. Subsequently, the public discord risks being flooded with pseudoscientific pontification and distorted views of psychiatric illness. The cycle of speculating on the mental fitness of the president has outlived President Trump, with concerns about Joe Biden’s incoherence and waning cognition.7 Therein is an important argument to be made for the public duty of psychiatrists, with their greater expertise and clinical acumen, to weigh in on matters of societal importance in an attempt to dispel dangerous misconceptions.
Practical limitations are often raised and serve as the cornerstone for the Goldwater rule. Specifically, the limitation being that a psychiatrist cannot provide a professional opinion about an individual without a proper in-person evaluation. The psychiatric interview could be considered the most in-depth and comprehensive evaluation in all of medicine. Even so, is a trained psychiatrist presented with grandiosity, flight-of-ideas, and pressured speech unable to comment on the possibility of mania without a lengthy and comprehensive evaluation? How much disorganization of behavior and dialogue does one need to observe to recognize psychosis? For the experienced psychiatrist, many of these behavioral hallmarks are akin to an ST elevation on an EKG representing a heart attack.
When considering less extreme examples of mental affliction, such as depression and anxiety, many signs – including demeanor, motor activity, manner of speaking, and other aspects of behavior – are apparent to the perceptive psychiatrist without needing an extensive interview that dives into the depths of a person’s social history and childhood. After all, our own criteria for depression and mania do not require the presence of social stressors or childhood trauma. Even personality disorders can be reasonably postulated when a person behaves in a particular fashion. The recognition of transitional objects, items used to provide psychological comfort, including the “teddy bear sign” are common and scientifically studied methods to recognize personality disorder.8
The necessity for an in-person evaluation has become less compelling over the years. In our modern age, important social moments are memorialized in countless videos that are arguably more relevant, more accurate, and less subjective than a psychiatric interview. Furthermore, forensic psychiatrists routinely comment on individuals they have not examined for a variety of reasons, from postmortem analysis to the refusal of the client to be interviewed. Moreover, and with significant contradiction, many leaders in the field of psychiatry view integrated care, the practice of psychiatrists advising primary care doctors, often without even seeing patients, to be the future of psychiatry.9
Some reading this may scoff at the above examples. Perhaps Section 7.3 speaks to an underlying insecurity in our field regarding our ability to accurately diagnose. That insecurity is not unfounded. In terms of the DSM-5, the bar for reliability has been lowered to a kappa of 0.2-0.4, from a previous standard of 0.6, in an attempt to avoid critiques of unreliability.10 Yet herein lies a powerful recognition of the necessity of the Goldwater rule. If psychiatrists cannot reliably agree on the presence of diagnoses in the controlled setting of scientific study, how can we expect to speak with coherence and consistency on highly mediatized and provoking topics?
The defense – that the difficulty psychiatrists have at providing an accurate diagnosis stems from the immense complexity of the system being evaluated, the human mind – is a valid one. Attempts to force such complex pathology, with all its many variables, into the check-box approach implemented in the DSM inevitably leads to problems with diagnostic reliability. Still, as psychiatrists we retain a level of expertise in assessing and treating complex disorders of the mind that no other field can claim.
The duty physicians have not only to work toward the health of their individual patients, but also to act in service of the public health and well-being of communities in which our patients live, is well established. How ethical is it then for psychiatry to absolve itself from duty when it comes to public figures at the center of shaping public opinion? There are numerous recent, high-profile instances where our expertise may have helped shine light in an otherwise murky public discussion filled with disinformation. The death of George Floyd and the year of turmoil that followed is a salient example. The conservatorship of Britney Spears and the resulting societal outcry is another. Even setting the matter of diagnosis aside, we can help illuminate the societal implications of conservatorship laws,11 in addition to providing input on how to safely and responsibly approach an individual who is in crisis, under the influence of multiple illicit substances, and possibly suffering from excited delirium.
Whether psychiatry has progressed enough as a medical specialty to trust ourselves with the option of providing professional opinions on public figures is an ongoing debate. The persistence of the Goldwater rule is a strong testament to the internal lack of confidence among psychiatrists regarding our ability to provide accurate diagnoses, act with integrity in the public space, and foster a positive public image. That lack of confidence may be well deserved. However, it is possible that our field will never go through the necessary pains of maturing as long as Section 7.3 remains in place.
Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Compton has no conflicts of interest. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.
References
1. American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry. Section 7. American Psychiatric Association; 2013 edition.
2. Glass LL. The Goldwater rule is broken. Here’s how to fix it. STAT News. 2018 June 18.
3. Plymyer D. The Goldwater rule paradox. 2020 Aug 7.
4. Lieberman JA. Trump’s brain and the 25th Amendment. Vice. 2017 Sep 8.
5. Blotcky AD et al. The Goldwater rule is fine, if refined. Here’s how to do it. Psychiatric Times. 2022 Jan 6;39(1).
6. Blotcky AD and Norrholm SD. After Trump, end the Goldwater rule once and for all. New York Daily News. 2020 Dec 22.
7. Stephens B. Biden should not run again – And he should say he won’t. New York Times. 2021 Dec 14.
8. Schmaling KB et al. The positive teddy bear sign: Transitional objects in the medical setting. J Nerv Ment Dis. 1994 Dec;182(12):725.
9. Badre N et al. Psychopharmacologic management in integrated care: Challenges for residency education. Acad Psychiatry. 2015; 39(4):466-9.
10. Kraemer HC et al. DSM-5: How reliable is reliable enough? Am J Psychiatry. 2012 Jan;169(1):13-5.
11. Badre N and Compton C. Britney Spears – Reflections on conservatorship. Clinical Psychiatry News. 2021 Nov 16.
Since it appeared in the first edition of the American Psychiatric Association’s Principles of Medical Ethics in 1973, the “Goldwater rule” – often referred to in terms of where in the APA’s guideline it can be found, Section 7.3 – has placed a stringent prohibition on psychiatrists offering professional opinions about public figures “unless he or she has conducted an examination and has been granted proper authorization for such a statement.”1
Some psychiatrists experienced the restrictive nature of Section 7.3 more acutely perhaps than ever during the Trump presidency. This spurred numerous articles criticizing the guideline as an outdated “gag rule”2 that harms the public image of psychiatry.3 Some psychiatrists violated the rule to warn the public of the dangers of a president with “incipient dementia”4 occupying the most powerful position on earth.
Following President Trump’s exit from the White House, the alarm bells surrounding his presidency have quieted. Criticisms of the Goldwater rule, on the other hand, have persisted. Many of these criticisms now call for the rule to be refined, allowing for psychiatrists to give their professional opinions about public figures, but with certain guidelines on how to do so.5 Few have yet to make a sober case for the outright abolition of Section 7.3.6
Self-regulating and internal policing are important factors in the continued independence of the medical profession, and we should continue to hold each other to high professional standards. That being said, do psychiatrists need training wheels to prevent us from devolving into unprofessional social commentators? Other medical specialties do not see the need to implement a rule preventing their colleagues from expressing expertise in fear of embarrassment. Do we not have faith in our ability to conduct ourselves professionally? Is the Goldwater rule an admission of a juvenile lack of self-control within our field?
Not only do other medical specialties not forcibly handhold their members in public settings, but other “providers” in the realm of mental health likewise do not implement such strict self-restraints. Psychiatry staying silent on the matter of public figures leaves a void filled by other, arguably less qualified, individuals. Subsequently, the public discord risks being flooded with pseudoscientific pontification and distorted views of psychiatric illness. The cycle of speculating on the mental fitness of the president has outlived President Trump, with concerns about Joe Biden’s incoherence and waning cognition.7 Therein is an important argument to be made for the public duty of psychiatrists, with their greater expertise and clinical acumen, to weigh in on matters of societal importance in an attempt to dispel dangerous misconceptions.
Practical limitations are often raised and serve as the cornerstone for the Goldwater rule. Specifically, the limitation being that a psychiatrist cannot provide a professional opinion about an individual without a proper in-person evaluation. The psychiatric interview could be considered the most in-depth and comprehensive evaluation in all of medicine. Even so, is a trained psychiatrist presented with grandiosity, flight-of-ideas, and pressured speech unable to comment on the possibility of mania without a lengthy and comprehensive evaluation? How much disorganization of behavior and dialogue does one need to observe to recognize psychosis? For the experienced psychiatrist, many of these behavioral hallmarks are akin to an ST elevation on an EKG representing a heart attack.
When considering less extreme examples of mental affliction, such as depression and anxiety, many signs – including demeanor, motor activity, manner of speaking, and other aspects of behavior – are apparent to the perceptive psychiatrist without needing an extensive interview that dives into the depths of a person’s social history and childhood. After all, our own criteria for depression and mania do not require the presence of social stressors or childhood trauma. Even personality disorders can be reasonably postulated when a person behaves in a particular fashion. The recognition of transitional objects, items used to provide psychological comfort, including the “teddy bear sign” are common and scientifically studied methods to recognize personality disorder.8
The necessity for an in-person evaluation has become less compelling over the years. In our modern age, important social moments are memorialized in countless videos that are arguably more relevant, more accurate, and less subjective than a psychiatric interview. Furthermore, forensic psychiatrists routinely comment on individuals they have not examined for a variety of reasons, from postmortem analysis to the refusal of the client to be interviewed. Moreover, and with significant contradiction, many leaders in the field of psychiatry view integrated care, the practice of psychiatrists advising primary care doctors, often without even seeing patients, to be the future of psychiatry.9
Some reading this may scoff at the above examples. Perhaps Section 7.3 speaks to an underlying insecurity in our field regarding our ability to accurately diagnose. That insecurity is not unfounded. In terms of the DSM-5, the bar for reliability has been lowered to a kappa of 0.2-0.4, from a previous standard of 0.6, in an attempt to avoid critiques of unreliability.10 Yet herein lies a powerful recognition of the necessity of the Goldwater rule. If psychiatrists cannot reliably agree on the presence of diagnoses in the controlled setting of scientific study, how can we expect to speak with coherence and consistency on highly mediatized and provoking topics?
The defense – that the difficulty psychiatrists have at providing an accurate diagnosis stems from the immense complexity of the system being evaluated, the human mind – is a valid one. Attempts to force such complex pathology, with all its many variables, into the check-box approach implemented in the DSM inevitably leads to problems with diagnostic reliability. Still, as psychiatrists we retain a level of expertise in assessing and treating complex disorders of the mind that no other field can claim.
The duty physicians have not only to work toward the health of their individual patients, but also to act in service of the public health and well-being of communities in which our patients live, is well established. How ethical is it then for psychiatry to absolve itself from duty when it comes to public figures at the center of shaping public opinion? There are numerous recent, high-profile instances where our expertise may have helped shine light in an otherwise murky public discussion filled with disinformation. The death of George Floyd and the year of turmoil that followed is a salient example. The conservatorship of Britney Spears and the resulting societal outcry is another. Even setting the matter of diagnosis aside, we can help illuminate the societal implications of conservatorship laws,11 in addition to providing input on how to safely and responsibly approach an individual who is in crisis, under the influence of multiple illicit substances, and possibly suffering from excited delirium.
Whether psychiatry has progressed enough as a medical specialty to trust ourselves with the option of providing professional opinions on public figures is an ongoing debate. The persistence of the Goldwater rule is a strong testament to the internal lack of confidence among psychiatrists regarding our ability to provide accurate diagnoses, act with integrity in the public space, and foster a positive public image. That lack of confidence may be well deserved. However, it is possible that our field will never go through the necessary pains of maturing as long as Section 7.3 remains in place.
Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Compton has no conflicts of interest. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.
References
1. American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry. Section 7. American Psychiatric Association; 2013 edition.
2. Glass LL. The Goldwater rule is broken. Here’s how to fix it. STAT News. 2018 June 18.
3. Plymyer D. The Goldwater rule paradox. 2020 Aug 7.
4. Lieberman JA. Trump’s brain and the 25th Amendment. Vice. 2017 Sep 8.
5. Blotcky AD et al. The Goldwater rule is fine, if refined. Here’s how to do it. Psychiatric Times. 2022 Jan 6;39(1).
6. Blotcky AD and Norrholm SD. After Trump, end the Goldwater rule once and for all. New York Daily News. 2020 Dec 22.
7. Stephens B. Biden should not run again – And he should say he won’t. New York Times. 2021 Dec 14.
8. Schmaling KB et al. The positive teddy bear sign: Transitional objects in the medical setting. J Nerv Ment Dis. 1994 Dec;182(12):725.
9. Badre N et al. Psychopharmacologic management in integrated care: Challenges for residency education. Acad Psychiatry. 2015; 39(4):466-9.
10. Kraemer HC et al. DSM-5: How reliable is reliable enough? Am J Psychiatry. 2012 Jan;169(1):13-5.
11. Badre N and Compton C. Britney Spears – Reflections on conservatorship. Clinical Psychiatry News. 2021 Nov 16.
‘Don’t say gay’: The politicization of gender-diverse youth
The past several weeks have been rather tumultuous for LGBTQ Americans, particularly transgender youth. The Texas attorney general penned a legal opinion stating that hormone therapy and puberty blockers for transgender youth constitute “child abuse” under Texas law. Following the statement, Texas governor Greg Abbott swiftly issued a directive to protective services to launch investigations into families providing such services to their children. Almost simultaneously, the Florida Senate approved the Parental Rights in Education bill (dubbed the “Don’t Say Gay” bill by opponents), which limits how sexual orientation and gender identity are taught in the classroom.
Despite the benefits of gender-affirming care for gender-diverse youth, 22 states have introduced legislation that bans the provision of gender-affirming medical care under the age of 18, even with the consent of parents or legal guardians.1 Unfortunately, gender-diverse youth are more likely than are their cisgender peers to experience poverty, homelessness, depression, suicide, and violence.1 As a result of ongoing stigma, many gender-diverse patients are hesitant to seek out professional medical care, which includes mental health care, routine health care, and gender-affirming therapies. The positive effects of gender-affirming care for transgender youth are clear, and life saving for many. Gender-affirming medical interventions improve social and mental health outcomes, such as decreased suicidal ideation, depression, and improved peer relations that last until adulthood.1
As with all aspects in medicine, providers and families of gender-diverse youth need to balance the four ethical principles that guide decision-making and informed consent. For practitioners working with the pediatric/adolescent populations, the age at which pediatric or adolescent patients can truly provide consent or assent is still not determined.2 This presents a unique set of challenges in the realm of gender-affirming care particularly when children/adolescents and their parents have differing perspectives on proposed treatment plans. For example, when discussing fertility preservation, a 16-year-old patient is much more likely to understand implications of future fertility than a 9-year-old patient. Furthermore, providers must find the delicate balance between maximizing treatment benefits (beneficence) while minimizing harm (nonmaleficence), while also discussing the uncertainty about the long-term risks of gender-affirming treatments.2 The final obligation for health care providers is ensuring all patients have equitable access to care (justice) – which is why we must all oppose legislation that criminalizes treatment for gender-diverse youth, regardless of our individual opinions on gender-affirming care for patients.
Opponents of gender-affirming care for transgender youth often cite concern about permanent effects or psychological distress if a child begins gender-affirming therapy and then chooses to discontinue. While the medical community should be, and is alarmed about patients who detransition, the solution to limiting the number of patients who experience regret or detransition is most certainly not criminalizing or universally banning gender-affirming care for all patients.3 Experts in transgender medicine and surgery (some of whom are transgender themselves) have expressed apprehension regarding the evaluation of gender-diverse children and youth. The concern is not whether gender-diverse youth should receive gender-affirming treatments, but rather they questioned the assessments made by providers who may be less fully qualified to deliver treatment and who deviate from well-established standards of care.4 The logical solution would be to further improve upon the current standards of care, ensure providers have appropriate training, and to expand multidisciplinary models of gender-affirming centers for youth.
If politicians were truly worried about the welfare of gender-diverse children, there would be a shift in the allocation of funds or resources to improve research endeavors and establish effective multidisciplinary clinics to meet the needs of this marginalized patient population. While the medical community should carefully examine gender-affirming care in transgender youth, criminalizing care is unconscionable. Our community needs more evidence-based research, providers, and centers, not politics.
The LGBTQ community and providers are rightfully fearful of the repercussions of such legislation. And the politicians and supporters of such bills should be equally apprehensive of the negative consequences this legislation will have on the mental health of transgender youth.
While the model for gender-affirming medicine and surgery needs continual assessment to ensure all patients, regardless of age and goals of transition, are receiving evidence-based, quality care, these discussions and subsequent decision-making should occur among medical professionals, not among politicians and the lay press.4
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Hughes LD et al. ‘These laws will be devastating’: Provider perspectives on legislation banning gender-affirming care for transgender adolescents. J Adol Health;2021;69:976-82.
2. Kimberly LL et al. Ethical issues in gender-affirming care for youth. Pediatrics. Pediatrics;018;142(6)e20181537.
3. Ashley F. Psychol Sexual Orient Gender Divers. APA PsycNet. 2021.
4. Ault A. Transgender docs warn about gender-affirmative care for youth. WebMD. 2021 Nov. Accessed March 14, 2022.
The past several weeks have been rather tumultuous for LGBTQ Americans, particularly transgender youth. The Texas attorney general penned a legal opinion stating that hormone therapy and puberty blockers for transgender youth constitute “child abuse” under Texas law. Following the statement, Texas governor Greg Abbott swiftly issued a directive to protective services to launch investigations into families providing such services to their children. Almost simultaneously, the Florida Senate approved the Parental Rights in Education bill (dubbed the “Don’t Say Gay” bill by opponents), which limits how sexual orientation and gender identity are taught in the classroom.
Despite the benefits of gender-affirming care for gender-diverse youth, 22 states have introduced legislation that bans the provision of gender-affirming medical care under the age of 18, even with the consent of parents or legal guardians.1 Unfortunately, gender-diverse youth are more likely than are their cisgender peers to experience poverty, homelessness, depression, suicide, and violence.1 As a result of ongoing stigma, many gender-diverse patients are hesitant to seek out professional medical care, which includes mental health care, routine health care, and gender-affirming therapies. The positive effects of gender-affirming care for transgender youth are clear, and life saving for many. Gender-affirming medical interventions improve social and mental health outcomes, such as decreased suicidal ideation, depression, and improved peer relations that last until adulthood.1
As with all aspects in medicine, providers and families of gender-diverse youth need to balance the four ethical principles that guide decision-making and informed consent. For practitioners working with the pediatric/adolescent populations, the age at which pediatric or adolescent patients can truly provide consent or assent is still not determined.2 This presents a unique set of challenges in the realm of gender-affirming care particularly when children/adolescents and their parents have differing perspectives on proposed treatment plans. For example, when discussing fertility preservation, a 16-year-old patient is much more likely to understand implications of future fertility than a 9-year-old patient. Furthermore, providers must find the delicate balance between maximizing treatment benefits (beneficence) while minimizing harm (nonmaleficence), while also discussing the uncertainty about the long-term risks of gender-affirming treatments.2 The final obligation for health care providers is ensuring all patients have equitable access to care (justice) – which is why we must all oppose legislation that criminalizes treatment for gender-diverse youth, regardless of our individual opinions on gender-affirming care for patients.
Opponents of gender-affirming care for transgender youth often cite concern about permanent effects or psychological distress if a child begins gender-affirming therapy and then chooses to discontinue. While the medical community should be, and is alarmed about patients who detransition, the solution to limiting the number of patients who experience regret or detransition is most certainly not criminalizing or universally banning gender-affirming care for all patients.3 Experts in transgender medicine and surgery (some of whom are transgender themselves) have expressed apprehension regarding the evaluation of gender-diverse children and youth. The concern is not whether gender-diverse youth should receive gender-affirming treatments, but rather they questioned the assessments made by providers who may be less fully qualified to deliver treatment and who deviate from well-established standards of care.4 The logical solution would be to further improve upon the current standards of care, ensure providers have appropriate training, and to expand multidisciplinary models of gender-affirming centers for youth.
If politicians were truly worried about the welfare of gender-diverse children, there would be a shift in the allocation of funds or resources to improve research endeavors and establish effective multidisciplinary clinics to meet the needs of this marginalized patient population. While the medical community should carefully examine gender-affirming care in transgender youth, criminalizing care is unconscionable. Our community needs more evidence-based research, providers, and centers, not politics.
The LGBTQ community and providers are rightfully fearful of the repercussions of such legislation. And the politicians and supporters of such bills should be equally apprehensive of the negative consequences this legislation will have on the mental health of transgender youth.
While the model for gender-affirming medicine and surgery needs continual assessment to ensure all patients, regardless of age and goals of transition, are receiving evidence-based, quality care, these discussions and subsequent decision-making should occur among medical professionals, not among politicians and the lay press.4
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Hughes LD et al. ‘These laws will be devastating’: Provider perspectives on legislation banning gender-affirming care for transgender adolescents. J Adol Health;2021;69:976-82.
2. Kimberly LL et al. Ethical issues in gender-affirming care for youth. Pediatrics. Pediatrics;018;142(6)e20181537.
3. Ashley F. Psychol Sexual Orient Gender Divers. APA PsycNet. 2021.
4. Ault A. Transgender docs warn about gender-affirmative care for youth. WebMD. 2021 Nov. Accessed March 14, 2022.
The past several weeks have been rather tumultuous for LGBTQ Americans, particularly transgender youth. The Texas attorney general penned a legal opinion stating that hormone therapy and puberty blockers for transgender youth constitute “child abuse” under Texas law. Following the statement, Texas governor Greg Abbott swiftly issued a directive to protective services to launch investigations into families providing such services to their children. Almost simultaneously, the Florida Senate approved the Parental Rights in Education bill (dubbed the “Don’t Say Gay” bill by opponents), which limits how sexual orientation and gender identity are taught in the classroom.
Despite the benefits of gender-affirming care for gender-diverse youth, 22 states have introduced legislation that bans the provision of gender-affirming medical care under the age of 18, even with the consent of parents or legal guardians.1 Unfortunately, gender-diverse youth are more likely than are their cisgender peers to experience poverty, homelessness, depression, suicide, and violence.1 As a result of ongoing stigma, many gender-diverse patients are hesitant to seek out professional medical care, which includes mental health care, routine health care, and gender-affirming therapies. The positive effects of gender-affirming care for transgender youth are clear, and life saving for many. Gender-affirming medical interventions improve social and mental health outcomes, such as decreased suicidal ideation, depression, and improved peer relations that last until adulthood.1
As with all aspects in medicine, providers and families of gender-diverse youth need to balance the four ethical principles that guide decision-making and informed consent. For practitioners working with the pediatric/adolescent populations, the age at which pediatric or adolescent patients can truly provide consent or assent is still not determined.2 This presents a unique set of challenges in the realm of gender-affirming care particularly when children/adolescents and their parents have differing perspectives on proposed treatment plans. For example, when discussing fertility preservation, a 16-year-old patient is much more likely to understand implications of future fertility than a 9-year-old patient. Furthermore, providers must find the delicate balance between maximizing treatment benefits (beneficence) while minimizing harm (nonmaleficence), while also discussing the uncertainty about the long-term risks of gender-affirming treatments.2 The final obligation for health care providers is ensuring all patients have equitable access to care (justice) – which is why we must all oppose legislation that criminalizes treatment for gender-diverse youth, regardless of our individual opinions on gender-affirming care for patients.
Opponents of gender-affirming care for transgender youth often cite concern about permanent effects or psychological distress if a child begins gender-affirming therapy and then chooses to discontinue. While the medical community should be, and is alarmed about patients who detransition, the solution to limiting the number of patients who experience regret or detransition is most certainly not criminalizing or universally banning gender-affirming care for all patients.3 Experts in transgender medicine and surgery (some of whom are transgender themselves) have expressed apprehension regarding the evaluation of gender-diverse children and youth. The concern is not whether gender-diverse youth should receive gender-affirming treatments, but rather they questioned the assessments made by providers who may be less fully qualified to deliver treatment and who deviate from well-established standards of care.4 The logical solution would be to further improve upon the current standards of care, ensure providers have appropriate training, and to expand multidisciplinary models of gender-affirming centers for youth.
If politicians were truly worried about the welfare of gender-diverse children, there would be a shift in the allocation of funds or resources to improve research endeavors and establish effective multidisciplinary clinics to meet the needs of this marginalized patient population. While the medical community should carefully examine gender-affirming care in transgender youth, criminalizing care is unconscionable. Our community needs more evidence-based research, providers, and centers, not politics.
The LGBTQ community and providers are rightfully fearful of the repercussions of such legislation. And the politicians and supporters of such bills should be equally apprehensive of the negative consequences this legislation will have on the mental health of transgender youth.
While the model for gender-affirming medicine and surgery needs continual assessment to ensure all patients, regardless of age and goals of transition, are receiving evidence-based, quality care, these discussions and subsequent decision-making should occur among medical professionals, not among politicians and the lay press.4
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Hughes LD et al. ‘These laws will be devastating’: Provider perspectives on legislation banning gender-affirming care for transgender adolescents. J Adol Health;2021;69:976-82.
2. Kimberly LL et al. Ethical issues in gender-affirming care for youth. Pediatrics. Pediatrics;018;142(6)e20181537.
3. Ashley F. Psychol Sexual Orient Gender Divers. APA PsycNet. 2021.
4. Ault A. Transgender docs warn about gender-affirmative care for youth. WebMD. 2021 Nov. Accessed March 14, 2022.
How social drivers of health lead to physician burnout
The vast majority of U.S. physicians regularly treat patients with socioeconomic challenges – from financial instability and a lack of transportation to eviction threats and domestic problems – but are deeply frustrated by their inability to adequately address these issues, a new survey has found.
The survey, conducted in February by The Physicians Foundation, queried 1,502 doctors (500 primary care physicians and 1,002 specialists) about their experience with social drivers – also known as determinants – of health (SDOH). Among the key findings: More than 60% of respondents said they had little or no time to effectively address the SDOH needs of their patients, yet nearly 9 in 10 (87%) said they would like to be able to do so in the future.
Most (63%) said they feel burned out when they try to help patients with their SDOH needs; and nearly 7 in 10 (68%) said managing SDOH for their patients has a “major impact” on their mental health and well-being.
This news organization spoke with Gary Price, MD, president of The Physicians Foundation, about the findings.
Q: These issues aren’t new. Why did you undertake this survey now?
The Physicians Foundation has surveyed America’s physicians for a decade on their practice and the broader health care environment, which included questions on SDOH. However, this is the first one we’ve done that concentrated entirely on SDOH. We think it’s particularly timely now.
The COVID-19 pandemic focused a very harsh spotlight on the tremendous impact SDOH can have on patient health, care outcomes, costs, physician burden, and the physician-patient relationship. It’s become increasingly apparent that for our country to achieve health equity and improve our health care system, including physician satisfaction, we must address the impact of SDOH on patients and physicians.
Even before the pandemic, we had an epidemic of physician burnout. That was driven in large part by the huge amount of time being wasted on administrative tasks such as pre-approvals, insurance forms, and working with electronic medical records. Now we’re recognizing that the causes of physician burnout are much larger than that.
Q: The results of the survey show that physicians are seeing the effects of SDOH no matter where they practice – rural (81%), urban (81%), suburban (73%) – how old they are, or their own racial or ethnic heritage. Is that surprising?
I was, in fact, surprised by the pervasiveness. Every physician is seeing the impact of social drivers on their patients every day. For a long time, physicians tried to ignore these problems because they couldn’t deal with them at the practice level; it was too big a task. But if we’re going to decrease the cost of health care and increase the quality of outcomes and decrease the enormous disparities we see, we’re going to have to deal with these SDOH.
I think the problem is grim, but physicians recognize this issue. It’s not one that they traditionally are trained to deal with – and, more importantly, they are not reimbursed on these issues. But despite that, they all want to help.
Q: The survey found that 83% of physicians believed their inability to adequately deal with SDOH moderately (60%) or significantly (23%) contributed to their feelings of burnout. Why do you think physicians find these problems so frustrating and stressful?
The definition of burnout is feeling that you’re being held responsible for things you no longer have any control or authority over. A patient’s inability to find transportation to get to an appointment, or who has financial instability that can lead them to have to make a choice between buying medicine or buying food for their family, isn’t something a physician can change. The overwhelming majority of physicians in our survey not only recognize that their patients have needs in these areas, but they don’t have time to be able to deal with them the way that they’d like to – either the resources aren’t there, or they aren’t effective, or they simply don’t know where to turn.
This phenomenon has been quantified by research. A 2020 study in JAMA, by the Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medicine, found that physicians who had a larger burden of patients with more social needs received lower quality scores from Medicare and were less likely to receive bonuses for the care they provided. But the lower scores were related to the patients’ socioeconomic environment and had nothing do with the quality of the care they received.
Q: Researchers have looked at the relationship between SDOH and burnout, and what happens when physicians incorporate resources to address social issues into their practice. And it seems that doing so can help ease burnout at least a little.
That makes perfect sense. You’re now giving them the ability to intervene and do something about a health-related issue that’s going to help their patients get better quicker. At the same time, addressing these social issues can reduce health care costs to the system while improving outcomes. For example, when a patient with diabetes who needs insulin has their electricity cut off, they can no longer refrigerate the insulin. So simply having their electricity restored could keep them from being hospitalized for a diabetic coma because they weren’t able to follow their treatment.
The Health Leads Grow and Catalyze project, which we helped fund in 2014-2018, trained college students to make lists of key resources patients might require – like food, electricity, or heat – and work with physicians in the emergency room to get a prescription for that need. We’ve seen a very excellent return on investment and it’s now in health systems all over the country.
Q: The survey does a good job of highlighting the nature and scope of the problem, but what about solutions? What, if anything, can physicians be doing now to reduce the burden of SDOH for their patients?
The most important thing we’re doing now is drawing attention to the problem, not only to the impact it’s having on patients’ health but the health and well-being of our physicians.
The greatest challenge physicians said they faced was not having enough time to address these issues in their practice, and that stems directly from a lot of time that gets wasted on other things – preapprovals, inefficient EHRs, checkboxes. Our doctors reported that even when they know where the resources exist, they are hard to access or unavailable when they want them.
Almost all these things are going to require innovative solutions, and in some cases might vary by the individual. With transportation, for example, maybe we need a system like Meals on Wheels, where part of the solution could be a system of volunteer drivers to take patients to appointments. Or we might need more funding for transportation directly aimed at people who don’t have access to a bus line. But when you think about how much a ride in an ambulance costs versus how much it would cost to get someone to the doctor before they got sick enough to require that ambulance, that kind of expenditure makes a lot of sense for driving down individual and system costs.
Q: The problem of unconscious bias in medicine has been receiving increasing attention. Do you think this bias is related to the issues of SDOH the new survey reveals?
Discrimination and racism are examples of SDOH. Implicit bias can happen in any aspect of our lives and interactions with others – so for physicians this can happen with our patients. Our survey didn’t specifically dive into how bias plays a role in addressing the impact of SDOH, but as a society we can no longer ignore any factor that hinders a person from accessing high-quality, cost-effective health care, including our own unconscious bias.
A version of this article first appeared on Medscape.com.
The vast majority of U.S. physicians regularly treat patients with socioeconomic challenges – from financial instability and a lack of transportation to eviction threats and domestic problems – but are deeply frustrated by their inability to adequately address these issues, a new survey has found.
The survey, conducted in February by The Physicians Foundation, queried 1,502 doctors (500 primary care physicians and 1,002 specialists) about their experience with social drivers – also known as determinants – of health (SDOH). Among the key findings: More than 60% of respondents said they had little or no time to effectively address the SDOH needs of their patients, yet nearly 9 in 10 (87%) said they would like to be able to do so in the future.
Most (63%) said they feel burned out when they try to help patients with their SDOH needs; and nearly 7 in 10 (68%) said managing SDOH for their patients has a “major impact” on their mental health and well-being.
This news organization spoke with Gary Price, MD, president of The Physicians Foundation, about the findings.
Q: These issues aren’t new. Why did you undertake this survey now?
The Physicians Foundation has surveyed America’s physicians for a decade on their practice and the broader health care environment, which included questions on SDOH. However, this is the first one we’ve done that concentrated entirely on SDOH. We think it’s particularly timely now.
The COVID-19 pandemic focused a very harsh spotlight on the tremendous impact SDOH can have on patient health, care outcomes, costs, physician burden, and the physician-patient relationship. It’s become increasingly apparent that for our country to achieve health equity and improve our health care system, including physician satisfaction, we must address the impact of SDOH on patients and physicians.
Even before the pandemic, we had an epidemic of physician burnout. That was driven in large part by the huge amount of time being wasted on administrative tasks such as pre-approvals, insurance forms, and working with electronic medical records. Now we’re recognizing that the causes of physician burnout are much larger than that.
Q: The results of the survey show that physicians are seeing the effects of SDOH no matter where they practice – rural (81%), urban (81%), suburban (73%) – how old they are, or their own racial or ethnic heritage. Is that surprising?
I was, in fact, surprised by the pervasiveness. Every physician is seeing the impact of social drivers on their patients every day. For a long time, physicians tried to ignore these problems because they couldn’t deal with them at the practice level; it was too big a task. But if we’re going to decrease the cost of health care and increase the quality of outcomes and decrease the enormous disparities we see, we’re going to have to deal with these SDOH.
I think the problem is grim, but physicians recognize this issue. It’s not one that they traditionally are trained to deal with – and, more importantly, they are not reimbursed on these issues. But despite that, they all want to help.
Q: The survey found that 83% of physicians believed their inability to adequately deal with SDOH moderately (60%) or significantly (23%) contributed to their feelings of burnout. Why do you think physicians find these problems so frustrating and stressful?
The definition of burnout is feeling that you’re being held responsible for things you no longer have any control or authority over. A patient’s inability to find transportation to get to an appointment, or who has financial instability that can lead them to have to make a choice between buying medicine or buying food for their family, isn’t something a physician can change. The overwhelming majority of physicians in our survey not only recognize that their patients have needs in these areas, but they don’t have time to be able to deal with them the way that they’d like to – either the resources aren’t there, or they aren’t effective, or they simply don’t know where to turn.
This phenomenon has been quantified by research. A 2020 study in JAMA, by the Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medicine, found that physicians who had a larger burden of patients with more social needs received lower quality scores from Medicare and were less likely to receive bonuses for the care they provided. But the lower scores were related to the patients’ socioeconomic environment and had nothing do with the quality of the care they received.
Q: Researchers have looked at the relationship between SDOH and burnout, and what happens when physicians incorporate resources to address social issues into their practice. And it seems that doing so can help ease burnout at least a little.
That makes perfect sense. You’re now giving them the ability to intervene and do something about a health-related issue that’s going to help their patients get better quicker. At the same time, addressing these social issues can reduce health care costs to the system while improving outcomes. For example, when a patient with diabetes who needs insulin has their electricity cut off, they can no longer refrigerate the insulin. So simply having their electricity restored could keep them from being hospitalized for a diabetic coma because they weren’t able to follow their treatment.
The Health Leads Grow and Catalyze project, which we helped fund in 2014-2018, trained college students to make lists of key resources patients might require – like food, electricity, or heat – and work with physicians in the emergency room to get a prescription for that need. We’ve seen a very excellent return on investment and it’s now in health systems all over the country.
Q: The survey does a good job of highlighting the nature and scope of the problem, but what about solutions? What, if anything, can physicians be doing now to reduce the burden of SDOH for their patients?
The most important thing we’re doing now is drawing attention to the problem, not only to the impact it’s having on patients’ health but the health and well-being of our physicians.
The greatest challenge physicians said they faced was not having enough time to address these issues in their practice, and that stems directly from a lot of time that gets wasted on other things – preapprovals, inefficient EHRs, checkboxes. Our doctors reported that even when they know where the resources exist, they are hard to access or unavailable when they want them.
Almost all these things are going to require innovative solutions, and in some cases might vary by the individual. With transportation, for example, maybe we need a system like Meals on Wheels, where part of the solution could be a system of volunteer drivers to take patients to appointments. Or we might need more funding for transportation directly aimed at people who don’t have access to a bus line. But when you think about how much a ride in an ambulance costs versus how much it would cost to get someone to the doctor before they got sick enough to require that ambulance, that kind of expenditure makes a lot of sense for driving down individual and system costs.
Q: The problem of unconscious bias in medicine has been receiving increasing attention. Do you think this bias is related to the issues of SDOH the new survey reveals?
Discrimination and racism are examples of SDOH. Implicit bias can happen in any aspect of our lives and interactions with others – so for physicians this can happen with our patients. Our survey didn’t specifically dive into how bias plays a role in addressing the impact of SDOH, but as a society we can no longer ignore any factor that hinders a person from accessing high-quality, cost-effective health care, including our own unconscious bias.
A version of this article first appeared on Medscape.com.
The vast majority of U.S. physicians regularly treat patients with socioeconomic challenges – from financial instability and a lack of transportation to eviction threats and domestic problems – but are deeply frustrated by their inability to adequately address these issues, a new survey has found.
The survey, conducted in February by The Physicians Foundation, queried 1,502 doctors (500 primary care physicians and 1,002 specialists) about their experience with social drivers – also known as determinants – of health (SDOH). Among the key findings: More than 60% of respondents said they had little or no time to effectively address the SDOH needs of their patients, yet nearly 9 in 10 (87%) said they would like to be able to do so in the future.
Most (63%) said they feel burned out when they try to help patients with their SDOH needs; and nearly 7 in 10 (68%) said managing SDOH for their patients has a “major impact” on their mental health and well-being.
This news organization spoke with Gary Price, MD, president of The Physicians Foundation, about the findings.
Q: These issues aren’t new. Why did you undertake this survey now?
The Physicians Foundation has surveyed America’s physicians for a decade on their practice and the broader health care environment, which included questions on SDOH. However, this is the first one we’ve done that concentrated entirely on SDOH. We think it’s particularly timely now.
The COVID-19 pandemic focused a very harsh spotlight on the tremendous impact SDOH can have on patient health, care outcomes, costs, physician burden, and the physician-patient relationship. It’s become increasingly apparent that for our country to achieve health equity and improve our health care system, including physician satisfaction, we must address the impact of SDOH on patients and physicians.
Even before the pandemic, we had an epidemic of physician burnout. That was driven in large part by the huge amount of time being wasted on administrative tasks such as pre-approvals, insurance forms, and working with electronic medical records. Now we’re recognizing that the causes of physician burnout are much larger than that.
Q: The results of the survey show that physicians are seeing the effects of SDOH no matter where they practice – rural (81%), urban (81%), suburban (73%) – how old they are, or their own racial or ethnic heritage. Is that surprising?
I was, in fact, surprised by the pervasiveness. Every physician is seeing the impact of social drivers on their patients every day. For a long time, physicians tried to ignore these problems because they couldn’t deal with them at the practice level; it was too big a task. But if we’re going to decrease the cost of health care and increase the quality of outcomes and decrease the enormous disparities we see, we’re going to have to deal with these SDOH.
I think the problem is grim, but physicians recognize this issue. It’s not one that they traditionally are trained to deal with – and, more importantly, they are not reimbursed on these issues. But despite that, they all want to help.
Q: The survey found that 83% of physicians believed their inability to adequately deal with SDOH moderately (60%) or significantly (23%) contributed to their feelings of burnout. Why do you think physicians find these problems so frustrating and stressful?
The definition of burnout is feeling that you’re being held responsible for things you no longer have any control or authority over. A patient’s inability to find transportation to get to an appointment, or who has financial instability that can lead them to have to make a choice between buying medicine or buying food for their family, isn’t something a physician can change. The overwhelming majority of physicians in our survey not only recognize that their patients have needs in these areas, but they don’t have time to be able to deal with them the way that they’d like to – either the resources aren’t there, or they aren’t effective, or they simply don’t know where to turn.
This phenomenon has been quantified by research. A 2020 study in JAMA, by the Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medicine, found that physicians who had a larger burden of patients with more social needs received lower quality scores from Medicare and were less likely to receive bonuses for the care they provided. But the lower scores were related to the patients’ socioeconomic environment and had nothing do with the quality of the care they received.
Q: Researchers have looked at the relationship between SDOH and burnout, and what happens when physicians incorporate resources to address social issues into their practice. And it seems that doing so can help ease burnout at least a little.
That makes perfect sense. You’re now giving them the ability to intervene and do something about a health-related issue that’s going to help their patients get better quicker. At the same time, addressing these social issues can reduce health care costs to the system while improving outcomes. For example, when a patient with diabetes who needs insulin has their electricity cut off, they can no longer refrigerate the insulin. So simply having their electricity restored could keep them from being hospitalized for a diabetic coma because they weren’t able to follow their treatment.
The Health Leads Grow and Catalyze project, which we helped fund in 2014-2018, trained college students to make lists of key resources patients might require – like food, electricity, or heat – and work with physicians in the emergency room to get a prescription for that need. We’ve seen a very excellent return on investment and it’s now in health systems all over the country.
Q: The survey does a good job of highlighting the nature and scope of the problem, but what about solutions? What, if anything, can physicians be doing now to reduce the burden of SDOH for their patients?
The most important thing we’re doing now is drawing attention to the problem, not only to the impact it’s having on patients’ health but the health and well-being of our physicians.
The greatest challenge physicians said they faced was not having enough time to address these issues in their practice, and that stems directly from a lot of time that gets wasted on other things – preapprovals, inefficient EHRs, checkboxes. Our doctors reported that even when they know where the resources exist, they are hard to access or unavailable when they want them.
Almost all these things are going to require innovative solutions, and in some cases might vary by the individual. With transportation, for example, maybe we need a system like Meals on Wheels, where part of the solution could be a system of volunteer drivers to take patients to appointments. Or we might need more funding for transportation directly aimed at people who don’t have access to a bus line. But when you think about how much a ride in an ambulance costs versus how much it would cost to get someone to the doctor before they got sick enough to require that ambulance, that kind of expenditure makes a lot of sense for driving down individual and system costs.
Q: The problem of unconscious bias in medicine has been receiving increasing attention. Do you think this bias is related to the issues of SDOH the new survey reveals?
Discrimination and racism are examples of SDOH. Implicit bias can happen in any aspect of our lives and interactions with others – so for physicians this can happen with our patients. Our survey didn’t specifically dive into how bias plays a role in addressing the impact of SDOH, but as a society we can no longer ignore any factor that hinders a person from accessing high-quality, cost-effective health care, including our own unconscious bias.
A version of this article first appeared on Medscape.com.
Family Physician: Abortion care is health and primary care
I am aware of how intersecting social, economic, familial, and environmental factors influence what is best for patient’s lives, and I consider having this awareness to be part of being a family medicine physician.
People being able to make choices about their reproductive health and their reproductive futures without unnecessary and harmful barriers is a part of a person’s overall health that family medicine physicians should recognize and prioritize. Helping people achieve their reproductive health care goals includes helping patients access abortion care if that is the care that they decide that they need.
According to the Guttmacher Institute, 2021 was “the worst year for abortion rights in almost half a century” as 108 abortion restrictions were enacted throughout the country. The most damaging restriction was introduced in Texas in the fall of 2021 called SB8, which has virtually stopped all abortion care in person for any person with a pregnancy greater than 6 weeks’ gestation. Now, in 2022 we are seeing several other states, including Idaho and Oklahoma, set to pass similar laws that will essentially halt most abortion care in the clinical setting in those states.
Abortion access had already been a problem in much of the country prior to 2021 because of burdensome and not medically necessary restrictions. Based on current political trends we are getting to a place where it is not hard to imagine that up to half of the states in this country will not allow their communities to access abortion care in the clinical setting at all in the very near future. This is not reproductive freedom, and I am outraged that people are being forced to travel hundreds of miles for their abortion care, forced to continue pregnancies that they don’t want, or forced to find other ways to obtain medication abortion pills.
While obtaining medication abortion pills online and managing the abortion process at home is safe and recognized as safe by the World Health Organization, no one should be forced to utilize a certain type of care based on their state of residence, in my opinion.
Providing evidence-based medicine to patients is ‘my duty’
Abortion care is health care and is primary care. One in four women will have an abortion by the age of 45, and we know that transgender, nonbinary, and gender-expansive people also have abortions. That means on any given day as family medicine physicians we are likely taking care of more than one person who has had an abortion, will have an abortion, and/or is considering an abortion. Therefore, all family medicine physicians need to be prepared to counsel patients about all of their pregnancy options, answer questions about pregnancy and abortion, and help people get the compassionate care that they deserve.
Our patients turn to us as trusted sources of information. When they reach out to us, I consider providing evidence-based medicine to patients – that includes factual information about abortion care if and when our patients need it – to be my duty as a family medicine physician.
Resources on abortion care for family medicine physicians
For family medicine physicians who did not have adequate exposure to abortion care during residency, there are many evidence-based resources to review in order to become more knowledgeable in abortion care.
In many areas of medicine, we have to continue to learn and seek out references, and abortion care is no different. One could argue that understanding abortion care and providing patients with factual information about their options and abortion care is even more important because of stigma surrounding abortion care and the rampant lies about abortion care that are easily accessible and that even other medical professionals and politicians spread. There are even fake clinics, often called “crisis pregnancy centers”, that intimidate, lie about abortion, and coerce patients to make decisions that are against their desires. Thus, being that trusted source of factual information about abortion care is even more important in the face of so many lies.
There are several organizations that are dedicated to education surrounding abortion care, in particular within the primary care setting. The Reproductive Health Access Project (RHAP), Reproductive Health Education in Family Medicine (RHEDI), and Training in Early Abortion for Comprehensive Healthcare (TEACH) all provide free resources on abortion care, how to incorporate abortion care into primary care, and how to teach medical students and residents about abortion care.
In addition, the National Network of Abortion Funds connects people to community-led organizations that provide assistance related to direct financial and logistical support for obtaining abortion care. I believe it is critical that we familiarize ourselves with our local abortion funds and share what we learn about these resources with our patients.
As abortion access continues to be further stripped away from many people that we take care of, I think standing up for what is right and what is our duty as physicians becomes more important. That duty is to provide our patients with evidence-based medicine and compassionate care so that our communities can obtain reproductive health outcomes and freedom that are best for their lives.
Dr. Lockley is a family physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at fpnews@mdedge.com.
I am aware of how intersecting social, economic, familial, and environmental factors influence what is best for patient’s lives, and I consider having this awareness to be part of being a family medicine physician.
People being able to make choices about their reproductive health and their reproductive futures without unnecessary and harmful barriers is a part of a person’s overall health that family medicine physicians should recognize and prioritize. Helping people achieve their reproductive health care goals includes helping patients access abortion care if that is the care that they decide that they need.
According to the Guttmacher Institute, 2021 was “the worst year for abortion rights in almost half a century” as 108 abortion restrictions were enacted throughout the country. The most damaging restriction was introduced in Texas in the fall of 2021 called SB8, which has virtually stopped all abortion care in person for any person with a pregnancy greater than 6 weeks’ gestation. Now, in 2022 we are seeing several other states, including Idaho and Oklahoma, set to pass similar laws that will essentially halt most abortion care in the clinical setting in those states.
Abortion access had already been a problem in much of the country prior to 2021 because of burdensome and not medically necessary restrictions. Based on current political trends we are getting to a place where it is not hard to imagine that up to half of the states in this country will not allow their communities to access abortion care in the clinical setting at all in the very near future. This is not reproductive freedom, and I am outraged that people are being forced to travel hundreds of miles for their abortion care, forced to continue pregnancies that they don’t want, or forced to find other ways to obtain medication abortion pills.
While obtaining medication abortion pills online and managing the abortion process at home is safe and recognized as safe by the World Health Organization, no one should be forced to utilize a certain type of care based on their state of residence, in my opinion.
Providing evidence-based medicine to patients is ‘my duty’
Abortion care is health care and is primary care. One in four women will have an abortion by the age of 45, and we know that transgender, nonbinary, and gender-expansive people also have abortions. That means on any given day as family medicine physicians we are likely taking care of more than one person who has had an abortion, will have an abortion, and/or is considering an abortion. Therefore, all family medicine physicians need to be prepared to counsel patients about all of their pregnancy options, answer questions about pregnancy and abortion, and help people get the compassionate care that they deserve.
Our patients turn to us as trusted sources of information. When they reach out to us, I consider providing evidence-based medicine to patients – that includes factual information about abortion care if and when our patients need it – to be my duty as a family medicine physician.
Resources on abortion care for family medicine physicians
For family medicine physicians who did not have adequate exposure to abortion care during residency, there are many evidence-based resources to review in order to become more knowledgeable in abortion care.
In many areas of medicine, we have to continue to learn and seek out references, and abortion care is no different. One could argue that understanding abortion care and providing patients with factual information about their options and abortion care is even more important because of stigma surrounding abortion care and the rampant lies about abortion care that are easily accessible and that even other medical professionals and politicians spread. There are even fake clinics, often called “crisis pregnancy centers”, that intimidate, lie about abortion, and coerce patients to make decisions that are against their desires. Thus, being that trusted source of factual information about abortion care is even more important in the face of so many lies.
There are several organizations that are dedicated to education surrounding abortion care, in particular within the primary care setting. The Reproductive Health Access Project (RHAP), Reproductive Health Education in Family Medicine (RHEDI), and Training in Early Abortion for Comprehensive Healthcare (TEACH) all provide free resources on abortion care, how to incorporate abortion care into primary care, and how to teach medical students and residents about abortion care.
In addition, the National Network of Abortion Funds connects people to community-led organizations that provide assistance related to direct financial and logistical support for obtaining abortion care. I believe it is critical that we familiarize ourselves with our local abortion funds and share what we learn about these resources with our patients.
As abortion access continues to be further stripped away from many people that we take care of, I think standing up for what is right and what is our duty as physicians becomes more important. That duty is to provide our patients with evidence-based medicine and compassionate care so that our communities can obtain reproductive health outcomes and freedom that are best for their lives.
Dr. Lockley is a family physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at fpnews@mdedge.com.
I am aware of how intersecting social, economic, familial, and environmental factors influence what is best for patient’s lives, and I consider having this awareness to be part of being a family medicine physician.
People being able to make choices about their reproductive health and their reproductive futures without unnecessary and harmful barriers is a part of a person’s overall health that family medicine physicians should recognize and prioritize. Helping people achieve their reproductive health care goals includes helping patients access abortion care if that is the care that they decide that they need.
According to the Guttmacher Institute, 2021 was “the worst year for abortion rights in almost half a century” as 108 abortion restrictions were enacted throughout the country. The most damaging restriction was introduced in Texas in the fall of 2021 called SB8, which has virtually stopped all abortion care in person for any person with a pregnancy greater than 6 weeks’ gestation. Now, in 2022 we are seeing several other states, including Idaho and Oklahoma, set to pass similar laws that will essentially halt most abortion care in the clinical setting in those states.
Abortion access had already been a problem in much of the country prior to 2021 because of burdensome and not medically necessary restrictions. Based on current political trends we are getting to a place where it is not hard to imagine that up to half of the states in this country will not allow their communities to access abortion care in the clinical setting at all in the very near future. This is not reproductive freedom, and I am outraged that people are being forced to travel hundreds of miles for their abortion care, forced to continue pregnancies that they don’t want, or forced to find other ways to obtain medication abortion pills.
While obtaining medication abortion pills online and managing the abortion process at home is safe and recognized as safe by the World Health Organization, no one should be forced to utilize a certain type of care based on their state of residence, in my opinion.
Providing evidence-based medicine to patients is ‘my duty’
Abortion care is health care and is primary care. One in four women will have an abortion by the age of 45, and we know that transgender, nonbinary, and gender-expansive people also have abortions. That means on any given day as family medicine physicians we are likely taking care of more than one person who has had an abortion, will have an abortion, and/or is considering an abortion. Therefore, all family medicine physicians need to be prepared to counsel patients about all of their pregnancy options, answer questions about pregnancy and abortion, and help people get the compassionate care that they deserve.
Our patients turn to us as trusted sources of information. When they reach out to us, I consider providing evidence-based medicine to patients – that includes factual information about abortion care if and when our patients need it – to be my duty as a family medicine physician.
Resources on abortion care for family medicine physicians
For family medicine physicians who did not have adequate exposure to abortion care during residency, there are many evidence-based resources to review in order to become more knowledgeable in abortion care.
In many areas of medicine, we have to continue to learn and seek out references, and abortion care is no different. One could argue that understanding abortion care and providing patients with factual information about their options and abortion care is even more important because of stigma surrounding abortion care and the rampant lies about abortion care that are easily accessible and that even other medical professionals and politicians spread. There are even fake clinics, often called “crisis pregnancy centers”, that intimidate, lie about abortion, and coerce patients to make decisions that are against their desires. Thus, being that trusted source of factual information about abortion care is even more important in the face of so many lies.
There are several organizations that are dedicated to education surrounding abortion care, in particular within the primary care setting. The Reproductive Health Access Project (RHAP), Reproductive Health Education in Family Medicine (RHEDI), and Training in Early Abortion for Comprehensive Healthcare (TEACH) all provide free resources on abortion care, how to incorporate abortion care into primary care, and how to teach medical students and residents about abortion care.
In addition, the National Network of Abortion Funds connects people to community-led organizations that provide assistance related to direct financial and logistical support for obtaining abortion care. I believe it is critical that we familiarize ourselves with our local abortion funds and share what we learn about these resources with our patients.
As abortion access continues to be further stripped away from many people that we take care of, I think standing up for what is right and what is our duty as physicians becomes more important. That duty is to provide our patients with evidence-based medicine and compassionate care so that our communities can obtain reproductive health outcomes and freedom that are best for their lives.
Dr. Lockley is a family physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at fpnews@mdedge.com.
Knowns and unknowns about SSRI use during pregnancy in 2022
The last 15-20 years have brought enormous attention to the relevant clinical issues regarding prescribing antidepressants during pregnancy. Concern about the effects of fetal exposure to selective serotonin reuptake inhibitors (SSRIs) is appropriate given the consistent data that approximately 7% of women use antidepressants during pregnancy, and that risk for relapse of depression during pregnancy in women who have stopped antidepressants during pregnancy is very high.
We have learned so much from studies of relevant questions regarding SSRI exposure. Concerns about increased risk for organ malformation have been set aside. An extraordinary number of studies across a broad range of patients around the globe looked at the issue of risk for organ malformation following in utero SSRI exposure – even looking specifically at risk for cardiac malformations, which had been an earlier concern in the literature – with the evidence supporting absence of increased risk. Also clarified has been, first, the absence of risk of complications such as persistent pulmonary hypertension of the newborn (PPHN) and, second, a delineation of the prevalence and clinical implications of transient neonatal symptoms such as jitteriness and tachypnea in offspring of women who used antidepressants during pregnancy – so-called “poor neonatal adaptation syndrome.”
However, for so many clinicians and for patients, the missing piece in the risk-benefit equation has been the issue of long-term neurodevelopmental sequelae in children whose mothers used antidepressants during pregnancy. While the accumulated data have shown sparse evidence linking SSRI exposure with autism or attention-deficit/hyperactivity disorder (ADHD), the evidence has been mixed regarding neurobehavioral sequelae associated with fetal exposure using developmental outcomes such as language ability, cognition, academic performance, language, math, and other cognitive outcomes. As far back as the 1990s, colleagues in Canada failed to show a difference in neurobehavioral outcomes in 5- to 7-year-old children whose mothers used SSRIs or older tricyclic antidepressants during pregnancy compared to nonexposed women (N Engl J Med. 1997 Jan 23;336[4]:258-62). Even early on, it was noted that one of the strongest predictors of neurodevelopmental outcome was untreated maternal psychiatric illness.
Since those early studies and over the last decade, there have been numerous small studies with conflicting data regarding a whole host of neurodevelopmental outcomes with inconsistent methodologies, different assessments, and failure to control for the presence or absence of maternal psychiatric illness during pregnancy – one of the most critical predictors of neurodevelopmental outcome and one we are beginning to appreciate plays a very significant role.
Most recently, the authors of a very large population-based retrospective cohort study in Denmark linked population-based registries with obstetrical data and examined language and math performance among 575,369 public schoolchildren whose mothers used or didn’t use antidepressants during pregnancy (JAMA. 2021 Nov 2;326[17]:1725-35). These investigators found a decrease in mean test scores for language (53.4 vs. 56.6) and math (52.1 vs. 57.4) in children whose mothers received antidepressant prescriptions during pregnancy compared with children who did not have that exposure. However, when they adjusted for maternal psychiatric illness and other relevant confounders, the finding went to null for language (adjusted difference, –0.1; 95% confidence interval, –0.6 to 0.3), but did not for math (adjusted difference, −2.2; 95% CI, −2.7 to −1.6). The results ultimately showed a modest finding for exposure and a small decrement in mathematical performance. The takeaway is that antidepressant use may be a proxy for neurodevelopmental deficit but is unlikely to be the etiology or direct cause of that deficit.
With that said, patients and their doctors can be reassured with respect to how much we have learned about SSRIs during pregnancy across the last decade. Yet there are appropriate concerns about long-term neurodevelopmental sequelae in this patient population. I think that what we can say in 2022 is that there is a growing appreciation for the effect of maternal psychiatric illness on long-term outcomes in children and the effect of maternal psychiatric illness on risk for postpartum depression, which we know influences long-term neurodevelopmental outcomes in children. Perhaps more than in years past, there is now also an appreciation of the effect of a dysregulated stress axis on the intrauterine fetal neuronal programming, which is perhaps the newest frontier, and which may hold the answers with respect to how to weigh the effect of maternal psychiatric illness on decisions about psychotropic use during pregnancy. But for today, there is an appreciation that exposure to maternal psychopathology is not a benign exposure.
Although some of the data remain incomplete, in 2022, patients will continue to make individual decisions based on the available data, factoring in the effect of maternal adversity in a more deliberate way and with a refined lens through with which to see their options with respect to using or not using SSRIs during pregnancy.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
The last 15-20 years have brought enormous attention to the relevant clinical issues regarding prescribing antidepressants during pregnancy. Concern about the effects of fetal exposure to selective serotonin reuptake inhibitors (SSRIs) is appropriate given the consistent data that approximately 7% of women use antidepressants during pregnancy, and that risk for relapse of depression during pregnancy in women who have stopped antidepressants during pregnancy is very high.
We have learned so much from studies of relevant questions regarding SSRI exposure. Concerns about increased risk for organ malformation have been set aside. An extraordinary number of studies across a broad range of patients around the globe looked at the issue of risk for organ malformation following in utero SSRI exposure – even looking specifically at risk for cardiac malformations, which had been an earlier concern in the literature – with the evidence supporting absence of increased risk. Also clarified has been, first, the absence of risk of complications such as persistent pulmonary hypertension of the newborn (PPHN) and, second, a delineation of the prevalence and clinical implications of transient neonatal symptoms such as jitteriness and tachypnea in offspring of women who used antidepressants during pregnancy – so-called “poor neonatal adaptation syndrome.”
However, for so many clinicians and for patients, the missing piece in the risk-benefit equation has been the issue of long-term neurodevelopmental sequelae in children whose mothers used antidepressants during pregnancy. While the accumulated data have shown sparse evidence linking SSRI exposure with autism or attention-deficit/hyperactivity disorder (ADHD), the evidence has been mixed regarding neurobehavioral sequelae associated with fetal exposure using developmental outcomes such as language ability, cognition, academic performance, language, math, and other cognitive outcomes. As far back as the 1990s, colleagues in Canada failed to show a difference in neurobehavioral outcomes in 5- to 7-year-old children whose mothers used SSRIs or older tricyclic antidepressants during pregnancy compared to nonexposed women (N Engl J Med. 1997 Jan 23;336[4]:258-62). Even early on, it was noted that one of the strongest predictors of neurodevelopmental outcome was untreated maternal psychiatric illness.
Since those early studies and over the last decade, there have been numerous small studies with conflicting data regarding a whole host of neurodevelopmental outcomes with inconsistent methodologies, different assessments, and failure to control for the presence or absence of maternal psychiatric illness during pregnancy – one of the most critical predictors of neurodevelopmental outcome and one we are beginning to appreciate plays a very significant role.
Most recently, the authors of a very large population-based retrospective cohort study in Denmark linked population-based registries with obstetrical data and examined language and math performance among 575,369 public schoolchildren whose mothers used or didn’t use antidepressants during pregnancy (JAMA. 2021 Nov 2;326[17]:1725-35). These investigators found a decrease in mean test scores for language (53.4 vs. 56.6) and math (52.1 vs. 57.4) in children whose mothers received antidepressant prescriptions during pregnancy compared with children who did not have that exposure. However, when they adjusted for maternal psychiatric illness and other relevant confounders, the finding went to null for language (adjusted difference, –0.1; 95% confidence interval, –0.6 to 0.3), but did not for math (adjusted difference, −2.2; 95% CI, −2.7 to −1.6). The results ultimately showed a modest finding for exposure and a small decrement in mathematical performance. The takeaway is that antidepressant use may be a proxy for neurodevelopmental deficit but is unlikely to be the etiology or direct cause of that deficit.
With that said, patients and their doctors can be reassured with respect to how much we have learned about SSRIs during pregnancy across the last decade. Yet there are appropriate concerns about long-term neurodevelopmental sequelae in this patient population. I think that what we can say in 2022 is that there is a growing appreciation for the effect of maternal psychiatric illness on long-term outcomes in children and the effect of maternal psychiatric illness on risk for postpartum depression, which we know influences long-term neurodevelopmental outcomes in children. Perhaps more than in years past, there is now also an appreciation of the effect of a dysregulated stress axis on the intrauterine fetal neuronal programming, which is perhaps the newest frontier, and which may hold the answers with respect to how to weigh the effect of maternal psychiatric illness on decisions about psychotropic use during pregnancy. But for today, there is an appreciation that exposure to maternal psychopathology is not a benign exposure.
Although some of the data remain incomplete, in 2022, patients will continue to make individual decisions based on the available data, factoring in the effect of maternal adversity in a more deliberate way and with a refined lens through with which to see their options with respect to using or not using SSRIs during pregnancy.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
The last 15-20 years have brought enormous attention to the relevant clinical issues regarding prescribing antidepressants during pregnancy. Concern about the effects of fetal exposure to selective serotonin reuptake inhibitors (SSRIs) is appropriate given the consistent data that approximately 7% of women use antidepressants during pregnancy, and that risk for relapse of depression during pregnancy in women who have stopped antidepressants during pregnancy is very high.
We have learned so much from studies of relevant questions regarding SSRI exposure. Concerns about increased risk for organ malformation have been set aside. An extraordinary number of studies across a broad range of patients around the globe looked at the issue of risk for organ malformation following in utero SSRI exposure – even looking specifically at risk for cardiac malformations, which had been an earlier concern in the literature – with the evidence supporting absence of increased risk. Also clarified has been, first, the absence of risk of complications such as persistent pulmonary hypertension of the newborn (PPHN) and, second, a delineation of the prevalence and clinical implications of transient neonatal symptoms such as jitteriness and tachypnea in offspring of women who used antidepressants during pregnancy – so-called “poor neonatal adaptation syndrome.”
However, for so many clinicians and for patients, the missing piece in the risk-benefit equation has been the issue of long-term neurodevelopmental sequelae in children whose mothers used antidepressants during pregnancy. While the accumulated data have shown sparse evidence linking SSRI exposure with autism or attention-deficit/hyperactivity disorder (ADHD), the evidence has been mixed regarding neurobehavioral sequelae associated with fetal exposure using developmental outcomes such as language ability, cognition, academic performance, language, math, and other cognitive outcomes. As far back as the 1990s, colleagues in Canada failed to show a difference in neurobehavioral outcomes in 5- to 7-year-old children whose mothers used SSRIs or older tricyclic antidepressants during pregnancy compared to nonexposed women (N Engl J Med. 1997 Jan 23;336[4]:258-62). Even early on, it was noted that one of the strongest predictors of neurodevelopmental outcome was untreated maternal psychiatric illness.
Since those early studies and over the last decade, there have been numerous small studies with conflicting data regarding a whole host of neurodevelopmental outcomes with inconsistent methodologies, different assessments, and failure to control for the presence or absence of maternal psychiatric illness during pregnancy – one of the most critical predictors of neurodevelopmental outcome and one we are beginning to appreciate plays a very significant role.
Most recently, the authors of a very large population-based retrospective cohort study in Denmark linked population-based registries with obstetrical data and examined language and math performance among 575,369 public schoolchildren whose mothers used or didn’t use antidepressants during pregnancy (JAMA. 2021 Nov 2;326[17]:1725-35). These investigators found a decrease in mean test scores for language (53.4 vs. 56.6) and math (52.1 vs. 57.4) in children whose mothers received antidepressant prescriptions during pregnancy compared with children who did not have that exposure. However, when they adjusted for maternal psychiatric illness and other relevant confounders, the finding went to null for language (adjusted difference, –0.1; 95% confidence interval, –0.6 to 0.3), but did not for math (adjusted difference, −2.2; 95% CI, −2.7 to −1.6). The results ultimately showed a modest finding for exposure and a small decrement in mathematical performance. The takeaway is that antidepressant use may be a proxy for neurodevelopmental deficit but is unlikely to be the etiology or direct cause of that deficit.
With that said, patients and their doctors can be reassured with respect to how much we have learned about SSRIs during pregnancy across the last decade. Yet there are appropriate concerns about long-term neurodevelopmental sequelae in this patient population. I think that what we can say in 2022 is that there is a growing appreciation for the effect of maternal psychiatric illness on long-term outcomes in children and the effect of maternal psychiatric illness on risk for postpartum depression, which we know influences long-term neurodevelopmental outcomes in children. Perhaps more than in years past, there is now also an appreciation of the effect of a dysregulated stress axis on the intrauterine fetal neuronal programming, which is perhaps the newest frontier, and which may hold the answers with respect to how to weigh the effect of maternal psychiatric illness on decisions about psychotropic use during pregnancy. But for today, there is an appreciation that exposure to maternal psychopathology is not a benign exposure.
Although some of the data remain incomplete, in 2022, patients will continue to make individual decisions based on the available data, factoring in the effect of maternal adversity in a more deliberate way and with a refined lens through with which to see their options with respect to using or not using SSRIs during pregnancy.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
Get the science right
Get the science right. I have spent years researching and reflecting on what makes the best physicians, the best medicine, the optimal organized medical system, and the best medical ethics and law to support all of it. I have traveled to almost innumerable conferences to discuss these topics with colleagues who have similar goals. Time and time again, I come back to the conclusion that, in the modern era, the second-most important thing to do is to get the science right.
The practice of medicine in my Western world can be traced back to Hippocrates and earlier. The practice of nursing has other milestones. The healing arts have different points of origin in other cultures, such as China. In a modern world of mass communication, these various historical paths are converging on scientific evidence. The science to support medicine has always had flaws, but it has fared better than the other options. Sometimes, the science was so sketchy that the key was to believe in whatever the shaman was providing. But for the past 100 years, science, rather than tradition and hierarchy, has been relied upon to guide policy and action. For the past 50 years, evidence-based medicine has ascended. Have we become better than the snake oil salesmen of the late 19th century?
Modern health care is far from perfect. The pandemic has been a major stressor to the health care system. The pandemic has revealed flaws and weaknesses, including inequity in access to care, health illiteracy, and a shaky moral compass balancing individual liberty and social good. Overall, despite multiple mistakes dealing with a novel threat, I think the institutions promoting science have performed well during the pandemic, especially when compared with the moral and governmental institutions encouraging ethical behavior and making policies to promote justice.
My highest praise would be for the professionalism of health care workers. Nurses and physicians have staffed the hospitals and clinics caring for people when the hallways were overflowing for days without end. Without the commitment, the teamwork, and the courage to provide that care, the death toll would have been much higher and the suffering unimaginable. My observation is that these people were not motivated by an abstract primum non nocere, first do no harm. It was the commitment to love one’s neighbor and care for the sick. This dedication is the first most important thing in professionalism.
Part of what fuels that commitment is a belief that what they are doing makes a difference. The belief is stronger when there is measurable, scientific evidence that a difference is being made. The scientific decisions have not been perfect, but at this point the evidence is clear that the shutdown flattened the curve. Vaccines saved lives and will continue to do so. Masks saved lives. Nursing care, particularly intensive care, reduced the case fatality rate and assuaged suffering and grief.
What lessons about training new providers can be gleaned from the past 2 years? Those who teach professionalism for physicians, nurses, and other health care workers should strengthen the common value systems that undergird the commitment people have to the patients and the professions. In the face of postmodern nihilism and relativism, virtues need to be clarified and reinforced. In the face of political polarization which seeks to make a political affiliation the locus of loyalty and commitment, emphasize the fellowship of the health care professions.
To me as a scientist, a key lesson is that we need to be better at getting the science right. Two years ago I was wiping some groceries with alcohol and quarantining cans in shopping bags in the corner of the kitchen for 24 hours before shelving them. I still push elevator buttons with my knuckles. The Centers for Disease Control and Prevention needs to revamp their policy making procedures.
Institutions must work to reestablish the public trust in science. That is a challenge because while many amazing scientific advances have occurred (i.e., my MRI last week showed far more going on than my orthopedist and physical therapist detected based on clinical exam). Imaging such as MR and ultrasound have been major advances in diagnostic medicine, but there are also repeated examples demonstrating where medicine has been wrong. In the past 6 months I have read new guidelines for ear tubes, for neonatal jaundice, for newborn sepsis, and for newborn hypoglycemia. All indicate to me that my training 30 years ago was on target and the interval “improvements” in practice have been worthless Brownian motion based on false scientific discoveries. My recommendation would be that pediatrics do one-third as much research but do that research three times better and get it right.
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
Get the science right. I have spent years researching and reflecting on what makes the best physicians, the best medicine, the optimal organized medical system, and the best medical ethics and law to support all of it. I have traveled to almost innumerable conferences to discuss these topics with colleagues who have similar goals. Time and time again, I come back to the conclusion that, in the modern era, the second-most important thing to do is to get the science right.
The practice of medicine in my Western world can be traced back to Hippocrates and earlier. The practice of nursing has other milestones. The healing arts have different points of origin in other cultures, such as China. In a modern world of mass communication, these various historical paths are converging on scientific evidence. The science to support medicine has always had flaws, but it has fared better than the other options. Sometimes, the science was so sketchy that the key was to believe in whatever the shaman was providing. But for the past 100 years, science, rather than tradition and hierarchy, has been relied upon to guide policy and action. For the past 50 years, evidence-based medicine has ascended. Have we become better than the snake oil salesmen of the late 19th century?
Modern health care is far from perfect. The pandemic has been a major stressor to the health care system. The pandemic has revealed flaws and weaknesses, including inequity in access to care, health illiteracy, and a shaky moral compass balancing individual liberty and social good. Overall, despite multiple mistakes dealing with a novel threat, I think the institutions promoting science have performed well during the pandemic, especially when compared with the moral and governmental institutions encouraging ethical behavior and making policies to promote justice.
My highest praise would be for the professionalism of health care workers. Nurses and physicians have staffed the hospitals and clinics caring for people when the hallways were overflowing for days without end. Without the commitment, the teamwork, and the courage to provide that care, the death toll would have been much higher and the suffering unimaginable. My observation is that these people were not motivated by an abstract primum non nocere, first do no harm. It was the commitment to love one’s neighbor and care for the sick. This dedication is the first most important thing in professionalism.
Part of what fuels that commitment is a belief that what they are doing makes a difference. The belief is stronger when there is measurable, scientific evidence that a difference is being made. The scientific decisions have not been perfect, but at this point the evidence is clear that the shutdown flattened the curve. Vaccines saved lives and will continue to do so. Masks saved lives. Nursing care, particularly intensive care, reduced the case fatality rate and assuaged suffering and grief.
What lessons about training new providers can be gleaned from the past 2 years? Those who teach professionalism for physicians, nurses, and other health care workers should strengthen the common value systems that undergird the commitment people have to the patients and the professions. In the face of postmodern nihilism and relativism, virtues need to be clarified and reinforced. In the face of political polarization which seeks to make a political affiliation the locus of loyalty and commitment, emphasize the fellowship of the health care professions.
To me as a scientist, a key lesson is that we need to be better at getting the science right. Two years ago I was wiping some groceries with alcohol and quarantining cans in shopping bags in the corner of the kitchen for 24 hours before shelving them. I still push elevator buttons with my knuckles. The Centers for Disease Control and Prevention needs to revamp their policy making procedures.
Institutions must work to reestablish the public trust in science. That is a challenge because while many amazing scientific advances have occurred (i.e., my MRI last week showed far more going on than my orthopedist and physical therapist detected based on clinical exam). Imaging such as MR and ultrasound have been major advances in diagnostic medicine, but there are also repeated examples demonstrating where medicine has been wrong. In the past 6 months I have read new guidelines for ear tubes, for neonatal jaundice, for newborn sepsis, and for newborn hypoglycemia. All indicate to me that my training 30 years ago was on target and the interval “improvements” in practice have been worthless Brownian motion based on false scientific discoveries. My recommendation would be that pediatrics do one-third as much research but do that research three times better and get it right.
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
Get the science right. I have spent years researching and reflecting on what makes the best physicians, the best medicine, the optimal organized medical system, and the best medical ethics and law to support all of it. I have traveled to almost innumerable conferences to discuss these topics with colleagues who have similar goals. Time and time again, I come back to the conclusion that, in the modern era, the second-most important thing to do is to get the science right.
The practice of medicine in my Western world can be traced back to Hippocrates and earlier. The practice of nursing has other milestones. The healing arts have different points of origin in other cultures, such as China. In a modern world of mass communication, these various historical paths are converging on scientific evidence. The science to support medicine has always had flaws, but it has fared better than the other options. Sometimes, the science was so sketchy that the key was to believe in whatever the shaman was providing. But for the past 100 years, science, rather than tradition and hierarchy, has been relied upon to guide policy and action. For the past 50 years, evidence-based medicine has ascended. Have we become better than the snake oil salesmen of the late 19th century?
Modern health care is far from perfect. The pandemic has been a major stressor to the health care system. The pandemic has revealed flaws and weaknesses, including inequity in access to care, health illiteracy, and a shaky moral compass balancing individual liberty and social good. Overall, despite multiple mistakes dealing with a novel threat, I think the institutions promoting science have performed well during the pandemic, especially when compared with the moral and governmental institutions encouraging ethical behavior and making policies to promote justice.
My highest praise would be for the professionalism of health care workers. Nurses and physicians have staffed the hospitals and clinics caring for people when the hallways were overflowing for days without end. Without the commitment, the teamwork, and the courage to provide that care, the death toll would have been much higher and the suffering unimaginable. My observation is that these people were not motivated by an abstract primum non nocere, first do no harm. It was the commitment to love one’s neighbor and care for the sick. This dedication is the first most important thing in professionalism.
Part of what fuels that commitment is a belief that what they are doing makes a difference. The belief is stronger when there is measurable, scientific evidence that a difference is being made. The scientific decisions have not been perfect, but at this point the evidence is clear that the shutdown flattened the curve. Vaccines saved lives and will continue to do so. Masks saved lives. Nursing care, particularly intensive care, reduced the case fatality rate and assuaged suffering and grief.
What lessons about training new providers can be gleaned from the past 2 years? Those who teach professionalism for physicians, nurses, and other health care workers should strengthen the common value systems that undergird the commitment people have to the patients and the professions. In the face of postmodern nihilism and relativism, virtues need to be clarified and reinforced. In the face of political polarization which seeks to make a political affiliation the locus of loyalty and commitment, emphasize the fellowship of the health care professions.
To me as a scientist, a key lesson is that we need to be better at getting the science right. Two years ago I was wiping some groceries with alcohol and quarantining cans in shopping bags in the corner of the kitchen for 24 hours before shelving them. I still push elevator buttons with my knuckles. The Centers for Disease Control and Prevention needs to revamp their policy making procedures.
Institutions must work to reestablish the public trust in science. That is a challenge because while many amazing scientific advances have occurred (i.e., my MRI last week showed far more going on than my orthopedist and physical therapist detected based on clinical exam). Imaging such as MR and ultrasound have been major advances in diagnostic medicine, but there are also repeated examples demonstrating where medicine has been wrong. In the past 6 months I have read new guidelines for ear tubes, for neonatal jaundice, for newborn sepsis, and for newborn hypoglycemia. All indicate to me that my training 30 years ago was on target and the interval “improvements” in practice have been worthless Brownian motion based on false scientific discoveries. My recommendation would be that pediatrics do one-third as much research but do that research three times better and get it right.
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
‘We don’t want to be an inspiration’
Over 2.5 million people have fled the ghastly war in Ukraine for safety. But, not everyone is trying to leave. Shockingly, hundreds of thousands are actually flocking toward the danger in Ukraine right now. Many of them are women.
I was commuting to work when I first heard this story on a podcast. In astonishing numbers, women have chosen to return to or stay in Ukraine because they’re needed to fight and to protect their families. My reaction, like yours, was to be inspired. What amazing courage! Twitter and Instagram will swell with images of their balaclava masked faces standing in the breach once more. Like the women in medicine who armed themselves with surgical masks and face shields and babies on their backs to join the fight against COVID-19. They will be poster girls, blue sleeves rolled up and red polka dotted bandanas covering their hair.
But that’s not what they want. “We don’t want to be an inspiration,” said one fearless Ukrainian fighter in the story, “we want to be alive.”
At the time of this writing as we celebrate the brilliant accomplishments of women on March 8, International Women’s Day, I wonder if we don’t have it slightly wrong.
Although acknowledgment is appreciated, the women I work alongside don’t need me to be inspired by them. They need me to stand with them, to help them. . The “she-session” it’s been called, refers to the million women who have not rejoined the workforce since COVID-19. This is especially acute for us in medicine where women are significantly more likely than are men to report not working full time, or not working at all.
The truth is that even in 2022, the burdens of family life are still not borne equally. Bias against mothers in particular can be insidious. Take academia, where there is little sympathy for not publishing on schedule. Perhaps there are unexplained gaps, but where exactly on a CV does one put “recurrent pregnancy loss?” Do you know how many clinics or ORs a woman must cancel to attempt maddeningly unpredictable egg retrievals and embryo transfers? A lot. Not to mention the financial burden of doing so.
During the pandemic, female physicians were more likely to manage child care, schooling, and household duties, compared to male physicians.
And yet (perhaps even because of that?) women in medicine make less money. How much? About $80,000 less on average in dermatology. Inspired? Indeed. No thanks. Let’s #BreakTheBias rather.
I’m not a policy expert nor a sociologist. I don’t know what advice might be helpful here. I’d say raising our collective consciousness of the unfairness, highlighting discrepancies, and advocating for equality are good starts. But, International Women’s Day isn’t new. It’s old. Like over a hundred years old (since 1909 to be exact). We don’t just need a better hashtag, we need to do something. Give equity in pay. Offer opportunities for leadership that accommodate the extra duty women might have outside work. Create flexibility in schedules and without the penalty of having to pump at work or leave early to pick up a child. Not to mention all the opportunities we men have to do more of the household work that women currently do.
The gallant women of Ukraine don’t need our approbation. They need our aid and our prayers. Like the women in my department, at my medical center, in my community, they aren’t posing to be made into posters. There’s work to be done and they are flocking toward it right now.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Over 2.5 million people have fled the ghastly war in Ukraine for safety. But, not everyone is trying to leave. Shockingly, hundreds of thousands are actually flocking toward the danger in Ukraine right now. Many of them are women.
I was commuting to work when I first heard this story on a podcast. In astonishing numbers, women have chosen to return to or stay in Ukraine because they’re needed to fight and to protect their families. My reaction, like yours, was to be inspired. What amazing courage! Twitter and Instagram will swell with images of their balaclava masked faces standing in the breach once more. Like the women in medicine who armed themselves with surgical masks and face shields and babies on their backs to join the fight against COVID-19. They will be poster girls, blue sleeves rolled up and red polka dotted bandanas covering their hair.
But that’s not what they want. “We don’t want to be an inspiration,” said one fearless Ukrainian fighter in the story, “we want to be alive.”
At the time of this writing as we celebrate the brilliant accomplishments of women on March 8, International Women’s Day, I wonder if we don’t have it slightly wrong.
Although acknowledgment is appreciated, the women I work alongside don’t need me to be inspired by them. They need me to stand with them, to help them. . The “she-session” it’s been called, refers to the million women who have not rejoined the workforce since COVID-19. This is especially acute for us in medicine where women are significantly more likely than are men to report not working full time, or not working at all.
The truth is that even in 2022, the burdens of family life are still not borne equally. Bias against mothers in particular can be insidious. Take academia, where there is little sympathy for not publishing on schedule. Perhaps there are unexplained gaps, but where exactly on a CV does one put “recurrent pregnancy loss?” Do you know how many clinics or ORs a woman must cancel to attempt maddeningly unpredictable egg retrievals and embryo transfers? A lot. Not to mention the financial burden of doing so.
During the pandemic, female physicians were more likely to manage child care, schooling, and household duties, compared to male physicians.
And yet (perhaps even because of that?) women in medicine make less money. How much? About $80,000 less on average in dermatology. Inspired? Indeed. No thanks. Let’s #BreakTheBias rather.
I’m not a policy expert nor a sociologist. I don’t know what advice might be helpful here. I’d say raising our collective consciousness of the unfairness, highlighting discrepancies, and advocating for equality are good starts. But, International Women’s Day isn’t new. It’s old. Like over a hundred years old (since 1909 to be exact). We don’t just need a better hashtag, we need to do something. Give equity in pay. Offer opportunities for leadership that accommodate the extra duty women might have outside work. Create flexibility in schedules and without the penalty of having to pump at work or leave early to pick up a child. Not to mention all the opportunities we men have to do more of the household work that women currently do.
The gallant women of Ukraine don’t need our approbation. They need our aid and our prayers. Like the women in my department, at my medical center, in my community, they aren’t posing to be made into posters. There’s work to be done and they are flocking toward it right now.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Over 2.5 million people have fled the ghastly war in Ukraine for safety. But, not everyone is trying to leave. Shockingly, hundreds of thousands are actually flocking toward the danger in Ukraine right now. Many of them are women.
I was commuting to work when I first heard this story on a podcast. In astonishing numbers, women have chosen to return to or stay in Ukraine because they’re needed to fight and to protect their families. My reaction, like yours, was to be inspired. What amazing courage! Twitter and Instagram will swell with images of their balaclava masked faces standing in the breach once more. Like the women in medicine who armed themselves with surgical masks and face shields and babies on their backs to join the fight against COVID-19. They will be poster girls, blue sleeves rolled up and red polka dotted bandanas covering their hair.
But that’s not what they want. “We don’t want to be an inspiration,” said one fearless Ukrainian fighter in the story, “we want to be alive.”
At the time of this writing as we celebrate the brilliant accomplishments of women on March 8, International Women’s Day, I wonder if we don’t have it slightly wrong.
Although acknowledgment is appreciated, the women I work alongside don’t need me to be inspired by them. They need me to stand with them, to help them. . The “she-session” it’s been called, refers to the million women who have not rejoined the workforce since COVID-19. This is especially acute for us in medicine where women are significantly more likely than are men to report not working full time, or not working at all.
The truth is that even in 2022, the burdens of family life are still not borne equally. Bias against mothers in particular can be insidious. Take academia, where there is little sympathy for not publishing on schedule. Perhaps there are unexplained gaps, but where exactly on a CV does one put “recurrent pregnancy loss?” Do you know how many clinics or ORs a woman must cancel to attempt maddeningly unpredictable egg retrievals and embryo transfers? A lot. Not to mention the financial burden of doing so.
During the pandemic, female physicians were more likely to manage child care, schooling, and household duties, compared to male physicians.
And yet (perhaps even because of that?) women in medicine make less money. How much? About $80,000 less on average in dermatology. Inspired? Indeed. No thanks. Let’s #BreakTheBias rather.
I’m not a policy expert nor a sociologist. I don’t know what advice might be helpful here. I’d say raising our collective consciousness of the unfairness, highlighting discrepancies, and advocating for equality are good starts. But, International Women’s Day isn’t new. It’s old. Like over a hundred years old (since 1909 to be exact). We don’t just need a better hashtag, we need to do something. Give equity in pay. Offer opportunities for leadership that accommodate the extra duty women might have outside work. Create flexibility in schedules and without the penalty of having to pump at work or leave early to pick up a child. Not to mention all the opportunities we men have to do more of the household work that women currently do.
The gallant women of Ukraine don’t need our approbation. They need our aid and our prayers. Like the women in my department, at my medical center, in my community, they aren’t posing to be made into posters. There’s work to be done and they are flocking toward it right now.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.