Mixed Topics

COVID-19 became a leading cause of death in the United States in 2020, particularly for people over age 35, according to a new report published in JAMA on Thursday.

Adults over age 45 were more likely to die from COVID-19 than car crashes, respiratory diseases, drug overdoses, and suicide. And those over age 55 faced even higher rates of dying because of the coronavirus.

“The current exponential increase in COVID-19 is reaching a calamitous scale in the U.S.,” the authors wrote. “Putting these numbers in perspective may be difficult.”

Population health researchers at Virginia Commonwealth University put COVID-19 deaths into context by comparing this year’s numbers to the leading causes of death for March through October 2018, sorting by age.

By October 2020, COVID-19 had become the third leading cause of death overall for those between the ages of 45 and 84 years, following after heart disease and cancer. For those over age 85, COVID-19 was the second leading cause of death, surpassing cancer and following behind heart disease.

For people aged 35-44 years, COVID-19 surpassed car crashes and respiratory diseases and was slightly lower than suicide, heart disease, and cancer. For those under age 35, drug overdoses, suicide, and car crashes remained the leading causes of death.

Importantly, the authors wrote, death rates for the two leading causes – heart disease and cancer – are about 1,700 and 1,600 per day, respectively. COVID-19 deaths have surpassed these numbers individually throughout December and, on Wednesday, beat them combined. More than 3,400 deaths were reported, according to the COVID Tracking Project, marking an all-time high that continues to increase. Hospitalizations were also at a new high, with more than 113,000 COVID-19 patients in hospitals across the country, and another 232,000 new cases were reported.

“With COVID-19 mortality rates now exceeding these thresholds, this infectious disease has become deadlier than heart disease and cancer,” the authors wrote. “Its lethality may increase further as transmission increases with holiday travel and gatherings and with the intensified indoor exposure that winter brings.”

The reported number of COVID-19 deaths is likely a 20% underestimate, they wrote, attributable to delays in reporting and an increase in non–COVID-19 deaths that were undetected and untreated because of pandemic-related disruptions. Since the coronavirus is communicable and spreads easily, COVID-19 deaths are particularly unique and worrying, they said.

“Individuals who die from homicide or cancer do not transmit the risk of morbidity and mortality to those nearby,” they wrote. “Every COVID-19 death signals the possibility of more deaths among close contacts.”

The fall surge in cases and deaths is widespread nationally, as compared to the spring, with hot spots on both coasts and in rural areas, according to an accompanying editorial in JAMA from public health researchers at the Harvard T.H. Chan School of Public Health, Boston. People of color have faced twice the death rate as well, with one in 875 Black people and one in 925 Indigenous people dying from COVID-19, as compared with one in 1,625 White people.

“The year 2020 ends with COVID-19 massively surging, as it was in the spring, to be the leading cause of death,” they wrote. “The accelerating numbers of deaths fall far short of fully capturing each devastating human story: Every death represents untold loss for countless families.”

Vaccines offer hope, they said, but won’t prevent the upcoming increase in COVID-19 hospitalizations and deaths this winter. In 2021, containing the pandemic will require national coordination, resources to help overwhelmed health care workers, new support for state and local public health officials, a stimulus package for schools and businesses, and financial aid for people on the brink of eviction. The country needs federal coordination of testing, contact tracing, personal protective equipment, travel precautions, and a face mask mandate, they wrote.

“Ending this crisis will require not only further advances in treatment but also unprecedented commitment to all aspects of prevention, vaccination, and public health,” they wrote. “Only by doing so can future years see this illness revert back to the unfamiliar and unknown condition it once was.”

For the latest clinical guidance, education, research and physician resources about coronavirus, visit the AGA COVID-19 Resource Center at www.gastro.org/COVID.

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

COVID-19 became a leading cause of death in the United States in 2020, particularly for people over age 35, according to a new report published in JAMA on Thursday.

Adults over age 45 were more likely to die from COVID-19 than car crashes, respiratory diseases, drug overdoses, and suicide. And those over age 55 faced even higher rates of dying because of the coronavirus.

“The current exponential increase in COVID-19 is reaching a calamitous scale in the U.S.,” the authors wrote. “Putting these numbers in perspective may be difficult.”

Population health researchers at Virginia Commonwealth University put COVID-19 deaths into context by comparing this year’s numbers to the leading causes of death for March through October 2018, sorting by age.

By October 2020, COVID-19 had become the third leading cause of death overall for those between the ages of 45 and 84 years, following after heart disease and cancer. For those over age 85, COVID-19 was the second leading cause of death, surpassing cancer and following behind heart disease.

For people aged 35-44 years, COVID-19 surpassed car crashes and respiratory diseases and was slightly lower than suicide, heart disease, and cancer. For those under age 35, drug overdoses, suicide, and car crashes remained the leading causes of death.

Importantly, the authors wrote, death rates for the two leading causes – heart disease and cancer – are about 1,700 and 1,600 per day, respectively. COVID-19 deaths have surpassed these numbers individually throughout December and, on Wednesday, beat them combined. More than 3,400 deaths were reported, according to the COVID Tracking Project, marking an all-time high that continues to increase. Hospitalizations were also at a new high, with more than 113,000 COVID-19 patients in hospitals across the country, and another 232,000 new cases were reported.

“With COVID-19 mortality rates now exceeding these thresholds, this infectious disease has become deadlier than heart disease and cancer,” the authors wrote. “Its lethality may increase further as transmission increases with holiday travel and gatherings and with the intensified indoor exposure that winter brings.”

The reported number of COVID-19 deaths is likely a 20% underestimate, they wrote, attributable to delays in reporting and an increase in non–COVID-19 deaths that were undetected and untreated because of pandemic-related disruptions. Since the coronavirus is communicable and spreads easily, COVID-19 deaths are particularly unique and worrying, they said.

“Individuals who die from homicide or cancer do not transmit the risk of morbidity and mortality to those nearby,” they wrote. “Every COVID-19 death signals the possibility of more deaths among close contacts.”

The fall surge in cases and deaths is widespread nationally, as compared to the spring, with hot spots on both coasts and in rural areas, according to an accompanying editorial in JAMA from public health researchers at the Harvard T.H. Chan School of Public Health, Boston. People of color have faced twice the death rate as well, with one in 875 Black people and one in 925 Indigenous people dying from COVID-19, as compared with one in 1,625 White people.

“The year 2020 ends with COVID-19 massively surging, as it was in the spring, to be the leading cause of death,” they wrote. “The accelerating numbers of deaths fall far short of fully capturing each devastating human story: Every death represents untold loss for countless families.”

Vaccines offer hope, they said, but won’t prevent the upcoming increase in COVID-19 hospitalizations and deaths this winter. In 2021, containing the pandemic will require national coordination, resources to help overwhelmed health care workers, new support for state and local public health officials, a stimulus package for schools and businesses, and financial aid for people on the brink of eviction. The country needs federal coordination of testing, contact tracing, personal protective equipment, travel precautions, and a face mask mandate, they wrote.

“Ending this crisis will require not only further advances in treatment but also unprecedented commitment to all aspects of prevention, vaccination, and public health,” they wrote. “Only by doing so can future years see this illness revert back to the unfamiliar and unknown condition it once was.”

For the latest clinical guidance, education, research and physician resources about coronavirus, visit the AGA COVID-19 Resource Center at www.gastro.org/COVID.

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

COVID-19 became a leading cause of death in the United States in 2020, particularly for people over age 35, according to a new report published in JAMA on Thursday.

Adults over age 45 were more likely to die from COVID-19 than car crashes, respiratory diseases, drug overdoses, and suicide. And those over age 55 faced even higher rates of dying because of the coronavirus.

“The current exponential increase in COVID-19 is reaching a calamitous scale in the U.S.,” the authors wrote. “Putting these numbers in perspective may be difficult.”

Population health researchers at Virginia Commonwealth University put COVID-19 deaths into context by comparing this year’s numbers to the leading causes of death for March through October 2018, sorting by age.

By October 2020, COVID-19 had become the third leading cause of death overall for those between the ages of 45 and 84 years, following after heart disease and cancer. For those over age 85, COVID-19 was the second leading cause of death, surpassing cancer and following behind heart disease.

For people aged 35-44 years, COVID-19 surpassed car crashes and respiratory diseases and was slightly lower than suicide, heart disease, and cancer. For those under age 35, drug overdoses, suicide, and car crashes remained the leading causes of death.

Importantly, the authors wrote, death rates for the two leading causes – heart disease and cancer – are about 1,700 and 1,600 per day, respectively. COVID-19 deaths have surpassed these numbers individually throughout December and, on Wednesday, beat them combined. More than 3,400 deaths were reported, according to the COVID Tracking Project, marking an all-time high that continues to increase. Hospitalizations were also at a new high, with more than 113,000 COVID-19 patients in hospitals across the country, and another 232,000 new cases were reported.

“With COVID-19 mortality rates now exceeding these thresholds, this infectious disease has become deadlier than heart disease and cancer,” the authors wrote. “Its lethality may increase further as transmission increases with holiday travel and gatherings and with the intensified indoor exposure that winter brings.”

The reported number of COVID-19 deaths is likely a 20% underestimate, they wrote, attributable to delays in reporting and an increase in non–COVID-19 deaths that were undetected and untreated because of pandemic-related disruptions. Since the coronavirus is communicable and spreads easily, COVID-19 deaths are particularly unique and worrying, they said.

“Individuals who die from homicide or cancer do not transmit the risk of morbidity and mortality to those nearby,” they wrote. “Every COVID-19 death signals the possibility of more deaths among close contacts.”

The fall surge in cases and deaths is widespread nationally, as compared to the spring, with hot spots on both coasts and in rural areas, according to an accompanying editorial in JAMA from public health researchers at the Harvard T.H. Chan School of Public Health, Boston. People of color have faced twice the death rate as well, with one in 875 Black people and one in 925 Indigenous people dying from COVID-19, as compared with one in 1,625 White people.

“The year 2020 ends with COVID-19 massively surging, as it was in the spring, to be the leading cause of death,” they wrote. “The accelerating numbers of deaths fall far short of fully capturing each devastating human story: Every death represents untold loss for countless families.”

Vaccines offer hope, they said, but won’t prevent the upcoming increase in COVID-19 hospitalizations and deaths this winter. In 2021, containing the pandemic will require national coordination, resources to help overwhelmed health care workers, new support for state and local public health officials, a stimulus package for schools and businesses, and financial aid for people on the brink of eviction. The country needs federal coordination of testing, contact tracing, personal protective equipment, travel precautions, and a face mask mandate, they wrote.

“Ending this crisis will require not only further advances in treatment but also unprecedented commitment to all aspects of prevention, vaccination, and public health,” they wrote. “Only by doing so can future years see this illness revert back to the unfamiliar and unknown condition it once was.”

For the latest clinical guidance, education, research and physician resources about coronavirus, visit the AGA COVID-19 Resource Center at www.gastro.org/COVID.

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

Congress has ordered the holdouts among U.S. states to have their Medicaid programs cover expenses related to participation in certain clinical trials, a move that was hailed by the American Society of Clinical Oncology and other groups as a boost to trials as well as to patients with serious illness who have lower incomes.

A massive wrap-up spending/COVID-19 relief bill that was signed into law Dec. 27 carried with it a mandate on Medicaid. States are ordered to put in place Medicaid payment policies for routine items and services, such as the cost of physician visits or laboratory tests, that are provided in connection with participation in clinical trials for serious and life-threatening conditions. The law includes a January 2022 target date for this coverage through Medicaid.

Medicare and other large insurers already pick up the tab for these kinds of expenses, leaving Medicaid as an outlier, ASCO noted in a press statement. ASCO and other cancer groups have for years pressed Medicaid to cover routine expenses for people participating in clinical trials. Already, 15 states, including California, require their Medicaid programs to cover these expenses, according to ASCO.

“We believe that the trials can bring extra benefits to patients,” said Monica M. Bertagnolli, MD, of Dana-Farber Cancer Institute, Boston. Dr. Bertagnolli has worked for years to secure Medicaid coverage for expenses connected to clinical trials.

Although Medicaid covers costs of standard care for cancer patients, people enrolled in the program may have concerns about participating in clinical studies, said Dr. Bertagnolli, chair of the Association for Clinical Oncology, which was established by ASCO to promote wider access to cancer care. Having extra medical expenses may be more than these patients can tolerate.

“Many of them just say, ‘I can’t take that financial risk, so I’ll just stay with standard of care,’ “ Dr. Bertagnolli said in an interview.
 

Equity issues

Medicaid has expanded greatly, owing to financial aid provided to states through the Affordable Care Act of 2010.

To date, 38 of 50 U.S. states have accepted federal aid to lift income limits for Medicaid eligibility, according to a tally kept by the nonprofit Kaiser Family Foundation. This Medicaid expansion has given more of the nation’s working poor access to health.care, including cancer treatment. Between 2013 and January 2020, enrollment in Medicaid in expansion states increased by about 12.4 million, according to the Medicaid and CHIP Payment and Access Commission.

Medicaid is the nation’s dominant health insurer. Enrollment has been around 70 million in recent months.

That tops the 61 million enrolled in Medicare, the federal program for people aged 65 and older and those with disabilities. (There’s some overlap between Medicare and Medicaid. About 12.8 million persons were dually eligible for these programs in 2018.) UnitedHealth, a giant private insurer, has about 43 million domestic customers.

Medicaid also serves many of the groups of people for which researchers have been seeking to increase participation in clinical trials. ASCO’s Association for Clinical Oncology and dozens of its partners raised this point in a letter to congressional leaders on Feb. 15, 2020.

“Lack of participation in clinical trials from the Medicaid population means these patients are being excluded from potentially life-saving trials and are not reflected in the outcome of the clinical research,” the groups wrote. “Increased access to clinical trial participation for Medicaid enrollees helps ensure medical research results more accurately capture and reflect the populations of this country.”

The ACA’s Medicaid expansion is working to address some of the racial gaps in insurance coverage, according to a January 2020 report from the nonprofit Commonwealth Fund.

Black and Hispanic adults are almost twice as likely as are White adults to have incomes that are less than 200% of the federal poverty level, according to the Commonwealth Fund report. The report also said that people in these groups reported significantly higher rates of cost-related problems in receiving care before the Medicaid expansion began in 2014.

The uninsured rate for Black adults dropped from 24.4% in 2013 to 14.4% in 2018; the rate for Hispanic adults fell from 40.2% to 24.9%, according to the Commonwealth Fund report.

There are concerns, though, about attempts by some governors to impose onerous restrictions on adults enrolled in Medicaid, Dr. Bertagnolli said. She was president of ASCO in 2018 when the group called on the Centers for Medicare & Medicaid Services to reject state requests to create restrictions that could hinder people’s access to cancer screening or care.

The Trump administration encouraged governors to adopt work requirements. As a result, a dozen states approved these policies, according to a November report from the nonprofit Center on Budget and Policy Priorities. The efforts were blocked by courts.

Data from the limited period of implementation in Arkansas, Michigan, and New Hampshire provide evidence that these kinds of requirements don’t work as intended, according to the CBPP report.

“In all three states, evidence suggests that people who were working and people with serious health needs who should have been eligible for exemptions lost coverage or were at risk of losing coverage due to red tape,” CBPP analysts Jennifer Wagner and Jessica Schubel wrote in their report.

In 2019, The New England Journal of Medicine published an article about the early stages of the Arkansas experiment with Medicaid work rules. Almost 17,000 adults lost their health care coverage in the initial months of implementation, but there appeared to be no significant difference in employment, Benjamin Sommers, MD, PhD, of the Harvard School of Public Health, Boston, and colleagues wrote in their article.

For many people in Arkansas, coverage was lost because of difficulties in reporting compliance with the Medicaid work rule, not because of the employment mandate itself, according to the authors. More than 95% of persons who were targeted by Arkansas’ Medicaid work policy already met its requirements or should have been exempt, they wrote.

Democrats have tended to oppose efforts to attach work requirements, which can include volunteer activities or career training, to Medicaid. Dr. Bertagnolli said there is a need to guard against any future bid to add work requirements to the program.

Extra bureaucratic hurdles may pose an especially tough burden on working adults enrolled in Medicaid, she said.

People who qualify for the program may already be worried about their finances while juggling continued demands of child care and employment, she said. They don’t need to be put at risk of losing access to medical care over administrative rules while undergoing cancer treatment, she said.

“We have to take care of people who are sick. That’s just the way it is,” Dr. Bertagnolli said.

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

Congress has ordered the holdouts among U.S. states to have their Medicaid programs cover expenses related to participation in certain clinical trials, a move that was hailed by the American Society of Clinical Oncology and other groups as a boost to trials as well as to patients with serious illness who have lower incomes.

A massive wrap-up spending/COVID-19 relief bill that was signed into law Dec. 27 carried with it a mandate on Medicaid. States are ordered to put in place Medicaid payment policies for routine items and services, such as the cost of physician visits or laboratory tests, that are provided in connection with participation in clinical trials for serious and life-threatening conditions. The law includes a January 2022 target date for this coverage through Medicaid.

Medicare and other large insurers already pick up the tab for these kinds of expenses, leaving Medicaid as an outlier, ASCO noted in a press statement. ASCO and other cancer groups have for years pressed Medicaid to cover routine expenses for people participating in clinical trials. Already, 15 states, including California, require their Medicaid programs to cover these expenses, according to ASCO.

“We believe that the trials can bring extra benefits to patients,” said Monica M. Bertagnolli, MD, of Dana-Farber Cancer Institute, Boston. Dr. Bertagnolli has worked for years to secure Medicaid coverage for expenses connected to clinical trials.

Although Medicaid covers costs of standard care for cancer patients, people enrolled in the program may have concerns about participating in clinical studies, said Dr. Bertagnolli, chair of the Association for Clinical Oncology, which was established by ASCO to promote wider access to cancer care. Having extra medical expenses may be more than these patients can tolerate.

“Many of them just say, ‘I can’t take that financial risk, so I’ll just stay with standard of care,’ “ Dr. Bertagnolli said in an interview.
 

Equity issues

Medicaid has expanded greatly, owing to financial aid provided to states through the Affordable Care Act of 2010.

To date, 38 of 50 U.S. states have accepted federal aid to lift income limits for Medicaid eligibility, according to a tally kept by the nonprofit Kaiser Family Foundation. This Medicaid expansion has given more of the nation’s working poor access to health.care, including cancer treatment. Between 2013 and January 2020, enrollment in Medicaid in expansion states increased by about 12.4 million, according to the Medicaid and CHIP Payment and Access Commission.

Medicaid is the nation’s dominant health insurer. Enrollment has been around 70 million in recent months.

That tops the 61 million enrolled in Medicare, the federal program for people aged 65 and older and those with disabilities. (There’s some overlap between Medicare and Medicaid. About 12.8 million persons were dually eligible for these programs in 2018.) UnitedHealth, a giant private insurer, has about 43 million domestic customers.

Medicaid also serves many of the groups of people for which researchers have been seeking to increase participation in clinical trials. ASCO’s Association for Clinical Oncology and dozens of its partners raised this point in a letter to congressional leaders on Feb. 15, 2020.

“Lack of participation in clinical trials from the Medicaid population means these patients are being excluded from potentially life-saving trials and are not reflected in the outcome of the clinical research,” the groups wrote. “Increased access to clinical trial participation for Medicaid enrollees helps ensure medical research results more accurately capture and reflect the populations of this country.”

The ACA’s Medicaid expansion is working to address some of the racial gaps in insurance coverage, according to a January 2020 report from the nonprofit Commonwealth Fund.

Black and Hispanic adults are almost twice as likely as are White adults to have incomes that are less than 200% of the federal poverty level, according to the Commonwealth Fund report. The report also said that people in these groups reported significantly higher rates of cost-related problems in receiving care before the Medicaid expansion began in 2014.

The uninsured rate for Black adults dropped from 24.4% in 2013 to 14.4% in 2018; the rate for Hispanic adults fell from 40.2% to 24.9%, according to the Commonwealth Fund report.

There are concerns, though, about attempts by some governors to impose onerous restrictions on adults enrolled in Medicaid, Dr. Bertagnolli said. She was president of ASCO in 2018 when the group called on the Centers for Medicare & Medicaid Services to reject state requests to create restrictions that could hinder people’s access to cancer screening or care.

The Trump administration encouraged governors to adopt work requirements. As a result, a dozen states approved these policies, according to a November report from the nonprofit Center on Budget and Policy Priorities. The efforts were blocked by courts.

Data from the limited period of implementation in Arkansas, Michigan, and New Hampshire provide evidence that these kinds of requirements don’t work as intended, according to the CBPP report.

“In all three states, evidence suggests that people who were working and people with serious health needs who should have been eligible for exemptions lost coverage or were at risk of losing coverage due to red tape,” CBPP analysts Jennifer Wagner and Jessica Schubel wrote in their report.

In 2019, The New England Journal of Medicine published an article about the early stages of the Arkansas experiment with Medicaid work rules. Almost 17,000 adults lost their health care coverage in the initial months of implementation, but there appeared to be no significant difference in employment, Benjamin Sommers, MD, PhD, of the Harvard School of Public Health, Boston, and colleagues wrote in their article.

For many people in Arkansas, coverage was lost because of difficulties in reporting compliance with the Medicaid work rule, not because of the employment mandate itself, according to the authors. More than 95% of persons who were targeted by Arkansas’ Medicaid work policy already met its requirements or should have been exempt, they wrote.

Democrats have tended to oppose efforts to attach work requirements, which can include volunteer activities or career training, to Medicaid. Dr. Bertagnolli said there is a need to guard against any future bid to add work requirements to the program.

Extra bureaucratic hurdles may pose an especially tough burden on working adults enrolled in Medicaid, she said.

People who qualify for the program may already be worried about their finances while juggling continued demands of child care and employment, she said. They don’t need to be put at risk of losing access to medical care over administrative rules while undergoing cancer treatment, she said.

“We have to take care of people who are sick. That’s just the way it is,” Dr. Bertagnolli said.

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

Congress has ordered the holdouts among U.S. states to have their Medicaid programs cover expenses related to participation in certain clinical trials, a move that was hailed by the American Society of Clinical Oncology and other groups as a boost to trials as well as to patients with serious illness who have lower incomes.

A massive wrap-up spending/COVID-19 relief bill that was signed into law Dec. 27 carried with it a mandate on Medicaid. States are ordered to put in place Medicaid payment policies for routine items and services, such as the cost of physician visits or laboratory tests, that are provided in connection with participation in clinical trials for serious and life-threatening conditions. The law includes a January 2022 target date for this coverage through Medicaid.

Medicare and other large insurers already pick up the tab for these kinds of expenses, leaving Medicaid as an outlier, ASCO noted in a press statement. ASCO and other cancer groups have for years pressed Medicaid to cover routine expenses for people participating in clinical trials. Already, 15 states, including California, require their Medicaid programs to cover these expenses, according to ASCO.

“We believe that the trials can bring extra benefits to patients,” said Monica M. Bertagnolli, MD, of Dana-Farber Cancer Institute, Boston. Dr. Bertagnolli has worked for years to secure Medicaid coverage for expenses connected to clinical trials.

Although Medicaid covers costs of standard care for cancer patients, people enrolled in the program may have concerns about participating in clinical studies, said Dr. Bertagnolli, chair of the Association for Clinical Oncology, which was established by ASCO to promote wider access to cancer care. Having extra medical expenses may be more than these patients can tolerate.

“Many of them just say, ‘I can’t take that financial risk, so I’ll just stay with standard of care,’ “ Dr. Bertagnolli said in an interview.
 

Equity issues

Medicaid has expanded greatly, owing to financial aid provided to states through the Affordable Care Act of 2010.

To date, 38 of 50 U.S. states have accepted federal aid to lift income limits for Medicaid eligibility, according to a tally kept by the nonprofit Kaiser Family Foundation. This Medicaid expansion has given more of the nation’s working poor access to health.care, including cancer treatment. Between 2013 and January 2020, enrollment in Medicaid in expansion states increased by about 12.4 million, according to the Medicaid and CHIP Payment and Access Commission.

Medicaid is the nation’s dominant health insurer. Enrollment has been around 70 million in recent months.

That tops the 61 million enrolled in Medicare, the federal program for people aged 65 and older and those with disabilities. (There’s some overlap between Medicare and Medicaid. About 12.8 million persons were dually eligible for these programs in 2018.) UnitedHealth, a giant private insurer, has about 43 million domestic customers.

Medicaid also serves many of the groups of people for which researchers have been seeking to increase participation in clinical trials. ASCO’s Association for Clinical Oncology and dozens of its partners raised this point in a letter to congressional leaders on Feb. 15, 2020.

“Lack of participation in clinical trials from the Medicaid population means these patients are being excluded from potentially life-saving trials and are not reflected in the outcome of the clinical research,” the groups wrote. “Increased access to clinical trial participation for Medicaid enrollees helps ensure medical research results more accurately capture and reflect the populations of this country.”

The ACA’s Medicaid expansion is working to address some of the racial gaps in insurance coverage, according to a January 2020 report from the nonprofit Commonwealth Fund.

Black and Hispanic adults are almost twice as likely as are White adults to have incomes that are less than 200% of the federal poverty level, according to the Commonwealth Fund report. The report also said that people in these groups reported significantly higher rates of cost-related problems in receiving care before the Medicaid expansion began in 2014.

The uninsured rate for Black adults dropped from 24.4% in 2013 to 14.4% in 2018; the rate for Hispanic adults fell from 40.2% to 24.9%, according to the Commonwealth Fund report.

There are concerns, though, about attempts by some governors to impose onerous restrictions on adults enrolled in Medicaid, Dr. Bertagnolli said. She was president of ASCO in 2018 when the group called on the Centers for Medicare & Medicaid Services to reject state requests to create restrictions that could hinder people’s access to cancer screening or care.

The Trump administration encouraged governors to adopt work requirements. As a result, a dozen states approved these policies, according to a November report from the nonprofit Center on Budget and Policy Priorities. The efforts were blocked by courts.

Data from the limited period of implementation in Arkansas, Michigan, and New Hampshire provide evidence that these kinds of requirements don’t work as intended, according to the CBPP report.

“In all three states, evidence suggests that people who were working and people with serious health needs who should have been eligible for exemptions lost coverage or were at risk of losing coverage due to red tape,” CBPP analysts Jennifer Wagner and Jessica Schubel wrote in their report.

In 2019, The New England Journal of Medicine published an article about the early stages of the Arkansas experiment with Medicaid work rules. Almost 17,000 adults lost their health care coverage in the initial months of implementation, but there appeared to be no significant difference in employment, Benjamin Sommers, MD, PhD, of the Harvard School of Public Health, Boston, and colleagues wrote in their article.

For many people in Arkansas, coverage was lost because of difficulties in reporting compliance with the Medicaid work rule, not because of the employment mandate itself, according to the authors. More than 95% of persons who were targeted by Arkansas’ Medicaid work policy already met its requirements or should have been exempt, they wrote.

Democrats have tended to oppose efforts to attach work requirements, which can include volunteer activities or career training, to Medicaid. Dr. Bertagnolli said there is a need to guard against any future bid to add work requirements to the program.

Extra bureaucratic hurdles may pose an especially tough burden on working adults enrolled in Medicaid, she said.

People who qualify for the program may already be worried about their finances while juggling continued demands of child care and employment, she said. They don’t need to be put at risk of losing access to medical care over administrative rules while undergoing cancer treatment, she said.

“We have to take care of people who are sick. That’s just the way it is,” Dr. Bertagnolli said.

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

Happy New Year! We all are counting on 2021 to be much different and better than 2020. As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.

I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.

I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.

Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.

Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.

“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson

John I. Allen, MD, MBA, AGAF
Editor in Chief

Happy New Year! We all are counting on 2021 to be much different and better than 2020. As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.

I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.

I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.

Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.

Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.

“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson

John I. Allen, MD, MBA, AGAF
Editor in Chief

Happy New Year! We all are counting on 2021 to be much different and better than 2020. As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.

I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.

I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.

Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.

Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.

“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson

John I. Allen, MD, MBA, AGAF
Editor in Chief

GASTROENTEROLOGY

October 2020
How to incorporate a chief fellow into a gastroenterology fellowship program. Mohammad Bilal et al. 2020 Oct;159(4):1227-30. doi: 10.1053/j.gastro.2020.09.001

Lower adenoma miss rate of computer-aided detection-assisted colonoscopy vs routine white-light colonoscopy in a prospective tandem study. Pu Wang et al. 2020 Oct;159(4):1252-61.e5. doi: 10.1053/j.gastro.2020.06.023

November 2020
Simulation-based mastery learning with virtual coaching: experience in training standardized upper endoscopy to novice endoscopists. Roy Soetikno et al. 2020 Nov;159(5):1632-6. doi: 10.1053/j.gastro.2020.06.096

Risk of small bowel adenocarcinoma, adenomas, and carcinoids in a nationwide cohort of individuals with celiac disease. Louise Emilsson et al. 2020 Nov;159(5):1686-94.e2 doi: 10.1053/j.gastro.2020.07.007

December 2020
Increased intestinal permeability is associated with later development of Crohn’s disease. Williams Turpin et al. 2020 Dec;159(6):2092-100.e5. doi: 10.1053/j.gastro.2020.08.005

January 2021
The role of angiotensin converting enzyme 2 in modulating gut microbiota, intestinal inflammation, and coronavirus infection. Josef M. Penninger et al. 2020 Oct 30:S0016-5085(20)35327-0. doi: 10.1053/j.gastro.2020.07.067

Behavioral and diet therapies in integrated care for patients with irritable bowel syndrome. William D. Chey et al. 2020 Oct 19:S0016-5085(20)35281-1. doi: 10.1053/j.gastro.2020.06.099

Efficacy and safety of tradipitant in patients with diabetic and idiopathic gastroparesis in a randomized, placebo-controlled trial. Jesse L. Carlin et al 2020 Jul 18;S0016-5085(20)34958-1. doi: 10.1053/j.gastro.2020.07.029

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

November 2020
The virtual gastroenterology clinic. Toyia James-Stevenson. 2020 Nov;18(12):2679-82. doi: 10.1016/j.cgh.2020.06.012

Risk factors associated with early-onset colorectal cancer. Valerie Gausman et al. 2020 Nov;18(12):2752-9.e2. doi: 10.1016/j.cgh.2019.10.009

Association of daily aspirin therapy with hepatocellular carcinoma risk in patients with chronic hepatitis c virus infection. Teng-Yu Lee et al. 2020 Nov;18(12):2784-92.e7. doi: 10.1016/j.cgh.2020.04.036

December 2020
Sensitivity of fecal immunochemical test for colorectal cancer detection differs according to stage and location. Tobias Niedermaier et al. 2020 Dec;18(13):2920-2928.e6. doi: 10.1016/j.cgh.2020.01.025

Effects of colesevelam on bowel symptoms, biomarkers, and colonic mucosal gene expression in patients with bile acid diarrhea in a randomized trial. Priya Vijayvargiya et al. 2020 Dec;18(13):2962-70.e6. doi: 10.1016/j.cgh.2020.02.027

Endoscopy for gastric cancer screening is cost effective for Asian Americans in the United States. Shailja C. Shah et al. 2020 Dec;18(13):3026-39. doi: 10.1016/j.cgh.2020.07.031

January 2021
C.O.V.I.D.: A survival guide for GI fellowship training during the COVID-19 pandemic. Tzu-Hao Lee et al. 2021 Jan;19(1):6-9. doi: 10.1016/j.cgh.2020.10.001

Use of proton pump inhibitors increases risk of incident kidney stones. Michael Simonov et al. 2021 Jan;19(1):72-9.e21. doi: 10.1016/j.cgh.2020.02.053

TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY

Endoscopic extraction of large foreign bodies utilizing a novel push-pull extraction technique. Koushik K. Das and Michael L. Kochman. 2020 Oct;22(4):172-7. doi: 10.1016/j.tige.2020.06.004

GASTROENTEROLOGY

October 2020
How to incorporate a chief fellow into a gastroenterology fellowship program. Mohammad Bilal et al. 2020 Oct;159(4):1227-30. doi: 10.1053/j.gastro.2020.09.001

Lower adenoma miss rate of computer-aided detection-assisted colonoscopy vs routine white-light colonoscopy in a prospective tandem study. Pu Wang et al. 2020 Oct;159(4):1252-61.e5. doi: 10.1053/j.gastro.2020.06.023

November 2020
Simulation-based mastery learning with virtual coaching: experience in training standardized upper endoscopy to novice endoscopists. Roy Soetikno et al. 2020 Nov;159(5):1632-6. doi: 10.1053/j.gastro.2020.06.096

Risk of small bowel adenocarcinoma, adenomas, and carcinoids in a nationwide cohort of individuals with celiac disease. Louise Emilsson et al. 2020 Nov;159(5):1686-94.e2 doi: 10.1053/j.gastro.2020.07.007

December 2020
Increased intestinal permeability is associated with later development of Crohn’s disease. Williams Turpin et al. 2020 Dec;159(6):2092-100.e5. doi: 10.1053/j.gastro.2020.08.005

January 2021
The role of angiotensin converting enzyme 2 in modulating gut microbiota, intestinal inflammation, and coronavirus infection. Josef M. Penninger et al. 2020 Oct 30:S0016-5085(20)35327-0. doi: 10.1053/j.gastro.2020.07.067

Behavioral and diet therapies in integrated care for patients with irritable bowel syndrome. William D. Chey et al. 2020 Oct 19:S0016-5085(20)35281-1. doi: 10.1053/j.gastro.2020.06.099

Efficacy and safety of tradipitant in patients with diabetic and idiopathic gastroparesis in a randomized, placebo-controlled trial. Jesse L. Carlin et al 2020 Jul 18;S0016-5085(20)34958-1. doi: 10.1053/j.gastro.2020.07.029

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

November 2020
The virtual gastroenterology clinic. Toyia James-Stevenson. 2020 Nov;18(12):2679-82. doi: 10.1016/j.cgh.2020.06.012

Risk factors associated with early-onset colorectal cancer. Valerie Gausman et al. 2020 Nov;18(12):2752-9.e2. doi: 10.1016/j.cgh.2019.10.009

Association of daily aspirin therapy with hepatocellular carcinoma risk in patients with chronic hepatitis c virus infection. Teng-Yu Lee et al. 2020 Nov;18(12):2784-92.e7. doi: 10.1016/j.cgh.2020.04.036

December 2020
Sensitivity of fecal immunochemical test for colorectal cancer detection differs according to stage and location. Tobias Niedermaier et al. 2020 Dec;18(13):2920-2928.e6. doi: 10.1016/j.cgh.2020.01.025

Effects of colesevelam on bowel symptoms, biomarkers, and colonic mucosal gene expression in patients with bile acid diarrhea in a randomized trial. Priya Vijayvargiya et al. 2020 Dec;18(13):2962-70.e6. doi: 10.1016/j.cgh.2020.02.027

Endoscopy for gastric cancer screening is cost effective for Asian Americans in the United States. Shailja C. Shah et al. 2020 Dec;18(13):3026-39. doi: 10.1016/j.cgh.2020.07.031

January 2021
C.O.V.I.D.: A survival guide for GI fellowship training during the COVID-19 pandemic. Tzu-Hao Lee et al. 2021 Jan;19(1):6-9. doi: 10.1016/j.cgh.2020.10.001

Use of proton pump inhibitors increases risk of incident kidney stones. Michael Simonov et al. 2021 Jan;19(1):72-9.e21. doi: 10.1016/j.cgh.2020.02.053

TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY

Endoscopic extraction of large foreign bodies utilizing a novel push-pull extraction technique. Koushik K. Das and Michael L. Kochman. 2020 Oct;22(4):172-7. doi: 10.1016/j.tige.2020.06.004

GASTROENTEROLOGY

October 2020
How to incorporate a chief fellow into a gastroenterology fellowship program. Mohammad Bilal et al. 2020 Oct;159(4):1227-30. doi: 10.1053/j.gastro.2020.09.001

Lower adenoma miss rate of computer-aided detection-assisted colonoscopy vs routine white-light colonoscopy in a prospective tandem study. Pu Wang et al. 2020 Oct;159(4):1252-61.e5. doi: 10.1053/j.gastro.2020.06.023

November 2020
Simulation-based mastery learning with virtual coaching: experience in training standardized upper endoscopy to novice endoscopists. Roy Soetikno et al. 2020 Nov;159(5):1632-6. doi: 10.1053/j.gastro.2020.06.096

Risk of small bowel adenocarcinoma, adenomas, and carcinoids in a nationwide cohort of individuals with celiac disease. Louise Emilsson et al. 2020 Nov;159(5):1686-94.e2 doi: 10.1053/j.gastro.2020.07.007

December 2020
Increased intestinal permeability is associated with later development of Crohn’s disease. Williams Turpin et al. 2020 Dec;159(6):2092-100.e5. doi: 10.1053/j.gastro.2020.08.005

January 2021
The role of angiotensin converting enzyme 2 in modulating gut microbiota, intestinal inflammation, and coronavirus infection. Josef M. Penninger et al. 2020 Oct 30:S0016-5085(20)35327-0. doi: 10.1053/j.gastro.2020.07.067

Behavioral and diet therapies in integrated care for patients with irritable bowel syndrome. William D. Chey et al. 2020 Oct 19:S0016-5085(20)35281-1. doi: 10.1053/j.gastro.2020.06.099

Efficacy and safety of tradipitant in patients with diabetic and idiopathic gastroparesis in a randomized, placebo-controlled trial. Jesse L. Carlin et al 2020 Jul 18;S0016-5085(20)34958-1. doi: 10.1053/j.gastro.2020.07.029

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

November 2020
The virtual gastroenterology clinic. Toyia James-Stevenson. 2020 Nov;18(12):2679-82. doi: 10.1016/j.cgh.2020.06.012

Risk factors associated with early-onset colorectal cancer. Valerie Gausman et al. 2020 Nov;18(12):2752-9.e2. doi: 10.1016/j.cgh.2019.10.009

Association of daily aspirin therapy with hepatocellular carcinoma risk in patients with chronic hepatitis c virus infection. Teng-Yu Lee et al. 2020 Nov;18(12):2784-92.e7. doi: 10.1016/j.cgh.2020.04.036

December 2020
Sensitivity of fecal immunochemical test for colorectal cancer detection differs according to stage and location. Tobias Niedermaier et al. 2020 Dec;18(13):2920-2928.e6. doi: 10.1016/j.cgh.2020.01.025

Effects of colesevelam on bowel symptoms, biomarkers, and colonic mucosal gene expression in patients with bile acid diarrhea in a randomized trial. Priya Vijayvargiya et al. 2020 Dec;18(13):2962-70.e6. doi: 10.1016/j.cgh.2020.02.027

Endoscopy for gastric cancer screening is cost effective for Asian Americans in the United States. Shailja C. Shah et al. 2020 Dec;18(13):3026-39. doi: 10.1016/j.cgh.2020.07.031

January 2021
C.O.V.I.D.: A survival guide for GI fellowship training during the COVID-19 pandemic. Tzu-Hao Lee et al. 2021 Jan;19(1):6-9. doi: 10.1016/j.cgh.2020.10.001

Use of proton pump inhibitors increases risk of incident kidney stones. Michael Simonov et al. 2021 Jan;19(1):72-9.e21. doi: 10.1016/j.cgh.2020.02.053

TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY

Endoscopic extraction of large foreign bodies utilizing a novel push-pull extraction technique. Koushik K. Das and Michael L. Kochman. 2020 Oct;22(4):172-7. doi: 10.1016/j.tige.2020.06.004

The Department of Agriculture and the Department of Health & Human Services released new dietary guidelines Dec. 29 that for the first time include recommended dietary patterns for infants and toddlers.

LoveTheWind/iStock/Getty Images

Although the new guidelines were informed by an advisory committee’s scientific report, officials omitted certain recommendations that would have reduced allowances for added sugars and alcohol intake.

The 2020-2025 Dietary Guidelines for Americans “carried forward the committee’s emphasis on limiting these dietary components, but did not include changes to quantitative recommendations, as there was not a preponderance of evidence in the material the committee reviewed to support specific changes, as required by law,” the agencies said in a news release.

The guidelines encourage Americans to “Make Every Bite Count” through four overarching suggestions: 

• Follow a healthy dietary pattern at every life stage.
• Customize nutrient-dense food and beverage choices to reflect preferences, cultural traditions, and budgets.
• Focus on meeting dietary needs from five food groups – vegetables, fruits, grains, dairy and fortified soy alternatives, and proteins – and stay within calorie limits.
• Limit foods and beverages that are higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages.

The guidance “can help all Americans lead healthier lives by making every bite count,” Secretary of Agriculture Sonny Perdue said.
 

Proposed cutoffs rejected

The guidelines omit a recommendation from the advisory committee’s scientific report to reduce intake of added sugars from less than 10% of calories to less than 6% of calories.

It also omits a recommendation that men and women who drink alcohol limit themselves to one drink per day. It maintains guidance from the 2015-2020 edition that allows two drinks per day for men.

The agencies published a document explaining why they omitted the advisory committee›s conclusions.

The American Heart Association in July had praised the suggestion to reduce added sugars. The proposed change would have helped “steer the public toward a more heart-healthy path in their daily diets,” Mitchell S.V. Elkind, MD, president of the AHA, said at the time. The association would “strongly oppose any efforts to weaken these recommendations,” he added.

In its response to the new guidelines, Dr. Elkind praised the emphasis on a healthy diet “at every life stage” but called out a missed opportunity.

“We are disappointed that USDA and HHS did not accept all of the Dietary Guidelines Advisory Committee’s science-based recommendations in the final guidelines for 2020, including the recommendation to lower added sugars consumption to less than 6% of calories,” he said in a prepared statement.
 

Guidance for infants and toddlers

The guidelines advise that for about the first 6 months of life, infants should exclusively receive breast milk. Infants should continue to receive breast milk through at least the first year of life, and longer if desired. Infants should be fed iron-fortified infant formula during the first year of life when breast milk is unavailable, and infants should receive supplemental vitamin D soon after birth, the guidelines advise. 

At about 6 months, infants should be introduced to a variety of nutrient-dense complementary foods, including potentially allergenic foods. Infants should eat foods that are rich in iron and zinc, particularly if they are fed breast milk. 

The guidelines also include dietary and caloric advice for pregnant and lactating women with daily or weekly amounts of food from different groups and subgroups.

Dr. Elkind highlighted the significance of these additions.

“We are pleased that for the first time, the guidelines provide recommendations for pregnant and breastfeeding women as well as infants and toddlers, underscoring the importance of maternal health and proper nutrition across the lifespan,” he said.
 

For all ages

From 12 months through older adulthood, people should follow a healthy dietary pattern to meet nutrient needs, help achieve a healthy body weight, and reduce the risk of chronic disease.

According to the guidelines, core elements of a healthy diet include:

• Vegetables of all types (dark green; red and orange; beans, peas, and lentils; starchy; and other types).
• Fruits (especially whole fruit).
• Grains, at least half of which are whole grain. 
• Dairy, including fat-free or low-fat milk, yogurt, and cheese, and lactose-free versions; and fortified soy beverages and yogurt as alternatives.
• Protein foods, including lean meats, poultry, and eggs; seafood; beans, peas, and lentils; and nuts, seeds, and soy products.
• Oils, including vegetable oils and oils in food, such as seafood and nuts.

The guidelines spell out limits to added sugars, sodium, saturated fat, and alcohol. The recommendation to limit added sugars to less than 10% of calories per day starts at age 2 years. Before age 2, foods and beverages with added sugars should be avoided.

Saturated fat should be limited to less than 10% of calories per day starting at age 2. And sodium intake should be limited to 2,300 mg/day for those age 14 and older, but just 1,200 mg/day for toddlers, 1,500 mg/day for children aged 4-8, and 1,800 mg/day for children 9-13.

“Adults of legal drinking age can choose not to drink or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed,” the agencies said. “Drinking less is better for health than drinking more. There are some adults who should not drink alcohol, such as women who are pregnant.”

An appendix includes estimated calorie needs based on a person’s age, sex, height, weight, and level of physical activity. A need to lose, maintain, or gain weight are among the factors that influence how many calories should be consumed, the guidelines note.

The guidelines are designed for use by health care professionals and policymakers. The USDA has launched a new MyPlate website to help consumers incorporate the dietary guidance.

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

The Department of Agriculture and the Department of Health & Human Services released new dietary guidelines Dec. 29 that for the first time include recommended dietary patterns for infants and toddlers.

LoveTheWind/iStock/Getty Images

Although the new guidelines were informed by an advisory committee’s scientific report, officials omitted certain recommendations that would have reduced allowances for added sugars and alcohol intake.

The 2020-2025 Dietary Guidelines for Americans “carried forward the committee’s emphasis on limiting these dietary components, but did not include changes to quantitative recommendations, as there was not a preponderance of evidence in the material the committee reviewed to support specific changes, as required by law,” the agencies said in a news release.

The guidelines encourage Americans to “Make Every Bite Count” through four overarching suggestions: 

• Follow a healthy dietary pattern at every life stage.
• Customize nutrient-dense food and beverage choices to reflect preferences, cultural traditions, and budgets.
• Focus on meeting dietary needs from five food groups – vegetables, fruits, grains, dairy and fortified soy alternatives, and proteins – and stay within calorie limits.
• Limit foods and beverages that are higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages.

The guidance “can help all Americans lead healthier lives by making every bite count,” Secretary of Agriculture Sonny Perdue said.
 

Proposed cutoffs rejected

The guidelines omit a recommendation from the advisory committee’s scientific report to reduce intake of added sugars from less than 10% of calories to less than 6% of calories.

It also omits a recommendation that men and women who drink alcohol limit themselves to one drink per day. It maintains guidance from the 2015-2020 edition that allows two drinks per day for men.

The agencies published a document explaining why they omitted the advisory committee›s conclusions.

The American Heart Association in July had praised the suggestion to reduce added sugars. The proposed change would have helped “steer the public toward a more heart-healthy path in their daily diets,” Mitchell S.V. Elkind, MD, president of the AHA, said at the time. The association would “strongly oppose any efforts to weaken these recommendations,” he added.

In its response to the new guidelines, Dr. Elkind praised the emphasis on a healthy diet “at every life stage” but called out a missed opportunity.

“We are disappointed that USDA and HHS did not accept all of the Dietary Guidelines Advisory Committee’s science-based recommendations in the final guidelines for 2020, including the recommendation to lower added sugars consumption to less than 6% of calories,” he said in a prepared statement.
 

Guidance for infants and toddlers

The guidelines advise that for about the first 6 months of life, infants should exclusively receive breast milk. Infants should continue to receive breast milk through at least the first year of life, and longer if desired. Infants should be fed iron-fortified infant formula during the first year of life when breast milk is unavailable, and infants should receive supplemental vitamin D soon after birth, the guidelines advise. 

At about 6 months, infants should be introduced to a variety of nutrient-dense complementary foods, including potentially allergenic foods. Infants should eat foods that are rich in iron and zinc, particularly if they are fed breast milk. 

The guidelines also include dietary and caloric advice for pregnant and lactating women with daily or weekly amounts of food from different groups and subgroups.

Dr. Elkind highlighted the significance of these additions.

“We are pleased that for the first time, the guidelines provide recommendations for pregnant and breastfeeding women as well as infants and toddlers, underscoring the importance of maternal health and proper nutrition across the lifespan,” he said.
 

For all ages

From 12 months through older adulthood, people should follow a healthy dietary pattern to meet nutrient needs, help achieve a healthy body weight, and reduce the risk of chronic disease.

According to the guidelines, core elements of a healthy diet include:

• Vegetables of all types (dark green; red and orange; beans, peas, and lentils; starchy; and other types).
• Fruits (especially whole fruit).
• Grains, at least half of which are whole grain. 
• Dairy, including fat-free or low-fat milk, yogurt, and cheese, and lactose-free versions; and fortified soy beverages and yogurt as alternatives.
• Protein foods, including lean meats, poultry, and eggs; seafood; beans, peas, and lentils; and nuts, seeds, and soy products.
• Oils, including vegetable oils and oils in food, such as seafood and nuts.

The guidelines spell out limits to added sugars, sodium, saturated fat, and alcohol. The recommendation to limit added sugars to less than 10% of calories per day starts at age 2 years. Before age 2, foods and beverages with added sugars should be avoided.

Saturated fat should be limited to less than 10% of calories per day starting at age 2. And sodium intake should be limited to 2,300 mg/day for those age 14 and older, but just 1,200 mg/day for toddlers, 1,500 mg/day for children aged 4-8, and 1,800 mg/day for children 9-13.

“Adults of legal drinking age can choose not to drink or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed,” the agencies said. “Drinking less is better for health than drinking more. There are some adults who should not drink alcohol, such as women who are pregnant.”

An appendix includes estimated calorie needs based on a person’s age, sex, height, weight, and level of physical activity. A need to lose, maintain, or gain weight are among the factors that influence how many calories should be consumed, the guidelines note.

The guidelines are designed for use by health care professionals and policymakers. The USDA has launched a new MyPlate website to help consumers incorporate the dietary guidance.

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

The Department of Agriculture and the Department of Health & Human Services released new dietary guidelines Dec. 29 that for the first time include recommended dietary patterns for infants and toddlers.

LoveTheWind/iStock/Getty Images

Although the new guidelines were informed by an advisory committee’s scientific report, officials omitted certain recommendations that would have reduced allowances for added sugars and alcohol intake.

The 2020-2025 Dietary Guidelines for Americans “carried forward the committee’s emphasis on limiting these dietary components, but did not include changes to quantitative recommendations, as there was not a preponderance of evidence in the material the committee reviewed to support specific changes, as required by law,” the agencies said in a news release.

The guidelines encourage Americans to “Make Every Bite Count” through four overarching suggestions: 

• Follow a healthy dietary pattern at every life stage.
• Customize nutrient-dense food and beverage choices to reflect preferences, cultural traditions, and budgets.
• Focus on meeting dietary needs from five food groups – vegetables, fruits, grains, dairy and fortified soy alternatives, and proteins – and stay within calorie limits.
• Limit foods and beverages that are higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages.

The guidance “can help all Americans lead healthier lives by making every bite count,” Secretary of Agriculture Sonny Perdue said.
 

Proposed cutoffs rejected

The guidelines omit a recommendation from the advisory committee’s scientific report to reduce intake of added sugars from less than 10% of calories to less than 6% of calories.

It also omits a recommendation that men and women who drink alcohol limit themselves to one drink per day. It maintains guidance from the 2015-2020 edition that allows two drinks per day for men.

The agencies published a document explaining why they omitted the advisory committee›s conclusions.

The American Heart Association in July had praised the suggestion to reduce added sugars. The proposed change would have helped “steer the public toward a more heart-healthy path in their daily diets,” Mitchell S.V. Elkind, MD, president of the AHA, said at the time. The association would “strongly oppose any efforts to weaken these recommendations,” he added.

In its response to the new guidelines, Dr. Elkind praised the emphasis on a healthy diet “at every life stage” but called out a missed opportunity.

“We are disappointed that USDA and HHS did not accept all of the Dietary Guidelines Advisory Committee’s science-based recommendations in the final guidelines for 2020, including the recommendation to lower added sugars consumption to less than 6% of calories,” he said in a prepared statement.
 

Guidance for infants and toddlers

The guidelines advise that for about the first 6 months of life, infants should exclusively receive breast milk. Infants should continue to receive breast milk through at least the first year of life, and longer if desired. Infants should be fed iron-fortified infant formula during the first year of life when breast milk is unavailable, and infants should receive supplemental vitamin D soon after birth, the guidelines advise. 

At about 6 months, infants should be introduced to a variety of nutrient-dense complementary foods, including potentially allergenic foods. Infants should eat foods that are rich in iron and zinc, particularly if they are fed breast milk. 

The guidelines also include dietary and caloric advice for pregnant and lactating women with daily or weekly amounts of food from different groups and subgroups.

Dr. Elkind highlighted the significance of these additions.

“We are pleased that for the first time, the guidelines provide recommendations for pregnant and breastfeeding women as well as infants and toddlers, underscoring the importance of maternal health and proper nutrition across the lifespan,” he said.
 

For all ages

From 12 months through older adulthood, people should follow a healthy dietary pattern to meet nutrient needs, help achieve a healthy body weight, and reduce the risk of chronic disease.

According to the guidelines, core elements of a healthy diet include:

• Vegetables of all types (dark green; red and orange; beans, peas, and lentils; starchy; and other types).
• Fruits (especially whole fruit).
• Grains, at least half of which are whole grain. 
• Dairy, including fat-free or low-fat milk, yogurt, and cheese, and lactose-free versions; and fortified soy beverages and yogurt as alternatives.
• Protein foods, including lean meats, poultry, and eggs; seafood; beans, peas, and lentils; and nuts, seeds, and soy products.
• Oils, including vegetable oils and oils in food, such as seafood and nuts.

The guidelines spell out limits to added sugars, sodium, saturated fat, and alcohol. The recommendation to limit added sugars to less than 10% of calories per day starts at age 2 years. Before age 2, foods and beverages with added sugars should be avoided.

Saturated fat should be limited to less than 10% of calories per day starting at age 2. And sodium intake should be limited to 2,300 mg/day for those age 14 and older, but just 1,200 mg/day for toddlers, 1,500 mg/day for children aged 4-8, and 1,800 mg/day for children 9-13.

“Adults of legal drinking age can choose not to drink or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed,” the agencies said. “Drinking less is better for health than drinking more. There are some adults who should not drink alcohol, such as women who are pregnant.”

An appendix includes estimated calorie needs based on a person’s age, sex, height, weight, and level of physical activity. A need to lose, maintain, or gain weight are among the factors that influence how many calories should be consumed, the guidelines note.

The guidelines are designed for use by health care professionals and policymakers. The USDA has launched a new MyPlate website to help consumers incorporate the dietary guidance.

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

A diagnosis of atopic dermatitis in individuals ages 15 years or older, compared with controls without atopic dermatitis, was nearly twice as likely to be associated with autoimmune disease, in a case control study derived from Swedish national health care registry data.

Atopic dermatitis (AD) is known to be associated with other atopic conditions, and there is increasing evidence it is associated with some nonatopic conditions, including some cancers, cardiovascular disease, and neuropsychiatric disorders, according to Lina U. Ivert, MD, of the dermatology and venereology unit at the Karolinska Institutet, Stockholm, and coauthors. There are also some data indicating that autoimmune diseases, particularly those involving the skin and gastrointestinal tract, are more common in people with AD.

The aim of their study, published in the British Journal of Dermatology, was to investigate a wide spectrum of autoimmune diseases for associations with AD in a large-scale, population-based study using Swedish registers. Findings could lead to better monitoring of comorbidities and deeper understanding of disease burden and AD pathophysiology, they noted.
 

Large-scale study

With data from the Swedish Board of Health and Welfare’s National Patient Register on inpatient diagnoses since 1964 and specialist outpatient visits since 2001, the investigators included all patients aged 15 years and older with AD diagnoses (104,832) and matched them with controls from the general population (1,022,435). The authors noted that the large number of people included in the analysis allowed for robust estimates, and underscored that 80% of the AD patients included had received their diagnosis in a dermatology department, which reduces the risk of misclassification.

Association with autoimmune disease

The investigators found an association between AD and autoimmune disease, with an adjusted odds ratio) of 1.97 (95% confidence interval, 1.93-2.01). The association was present with several organ systems, particularly the skin and gastrointestinal tract, and with connective tissue diseases. The strongest associations with autoimmune skin diseases were found for dermatitis herpetiformis (aOR, 9.76; 95% CI, 8.10-11.8), alopecia areata (aOR, 5.11; 95% CI, 4.75-5.49), and chronic urticaria (aOR, 4.82; 95% CI, 4.48-5.19).

AD was associated with gastrointestinal diseases, including celiac disease (aOR, 1.96; 95% CI, 1.84-2.09), Crohn disease (aOR 1.83; CI, 1.71-1.96), and ulcerative colitis (aOR 1.58; 95% CI, 1.49-1.68).

Connective tissue diseases significantly associated with AD included systemic lupus erythematosus (aOR, 1.65; 95% CI, 1.42-1.90), ankylosing spondylitis (aOR, 1.46; 95% CI, 1.29-1.66), and RA (aOR, 1.44; 95% CI,1.34-1.54]). Hematologic or hepatic autoimmune disease associations with AD were not observed.
 

Stronger association with multiple diseases

The association between AD and two or more autoimmune diseases was significantly stronger than the association between AD and having one autoimmune disease. For example, the OR for AD among people with three to five autoimmune diseases was 3.33 (95% CI, 2.86-3.87), and was stronger in men (OR, 3.96; 95% CI, 2.92-5.37) than in women (OR, 3.14; 95% CI, 2.63-3.74).
 

Sex differences

In the study overall, the association with AD and autoimmune diseases was stronger in men (aOR, 2.18; 95% CI, 2.10-2.25), compared with women (aOR, 1.89; 95% CI, 1.85-1.93), but this “sex difference was only statistically significant between AD and RA and between AD and Celiac disease,” they noted.

Associations between AD and dermatomyositis, systemic scleroderma, systemic lupus erythematosus, Hashimoto’s disease, Graves disease, multiple sclerosis, and polymyalgia rheumatica were found only in women. Dr. Ivert and coauthors observed that “women are in general more likely to develop autoimmune diseases, and 80% of patients with autoimmune diseases are women.”
 

Provocative questions

Commenting on the findings, Jonathan Silverberg, MD, PhD, MPH, associate professor of dermatology, George Washington University, Washington, said, “At a high level, it is important for clinicians to recognize that atopic dermatitis is a systemic immune-mediated disease. AD is associated with higher rates of comorbid autoimmune disease, similar to psoriasis and other chronic inflammatory skin diseases.”

“At this point, there is nothing immediately actionable about these results,” noted Dr. Silverberg, who was not an author of this study. “That said, in my mind, they raise some provocative questions: What is the difference between AD in adults who do versus those who do not get comorbid autoimmune disease? Does AD then present differently? Does it respond to the same therapies? These will have to be the subject of future research.”

The study was funded by the Swedish Asthma and Allergy Association Research Foundation, Hudfonden (the Welander-Finsen Foundation), and the Swedish Society for Dermatology and Venereology. The authors disclosed no conflicts of interest.

SOURCE: Ivert LU et al. Br J Dermatol. 2020 Oct 22. doi: 10.1111/bjd.19624.

A diagnosis of atopic dermatitis in individuals ages 15 years or older, compared with controls without atopic dermatitis, was nearly twice as likely to be associated with autoimmune disease, in a case control study derived from Swedish national health care registry data.

Atopic dermatitis (AD) is known to be associated with other atopic conditions, and there is increasing evidence it is associated with some nonatopic conditions, including some cancers, cardiovascular disease, and neuropsychiatric disorders, according to Lina U. Ivert, MD, of the dermatology and venereology unit at the Karolinska Institutet, Stockholm, and coauthors. There are also some data indicating that autoimmune diseases, particularly those involving the skin and gastrointestinal tract, are more common in people with AD.

The aim of their study, published in the British Journal of Dermatology, was to investigate a wide spectrum of autoimmune diseases for associations with AD in a large-scale, population-based study using Swedish registers. Findings could lead to better monitoring of comorbidities and deeper understanding of disease burden and AD pathophysiology, they noted.
 

Large-scale study

With data from the Swedish Board of Health and Welfare’s National Patient Register on inpatient diagnoses since 1964 and specialist outpatient visits since 2001, the investigators included all patients aged 15 years and older with AD diagnoses (104,832) and matched them with controls from the general population (1,022,435). The authors noted that the large number of people included in the analysis allowed for robust estimates, and underscored that 80% of the AD patients included had received their diagnosis in a dermatology department, which reduces the risk of misclassification.

Association with autoimmune disease

The investigators found an association between AD and autoimmune disease, with an adjusted odds ratio) of 1.97 (95% confidence interval, 1.93-2.01). The association was present with several organ systems, particularly the skin and gastrointestinal tract, and with connective tissue diseases. The strongest associations with autoimmune skin diseases were found for dermatitis herpetiformis (aOR, 9.76; 95% CI, 8.10-11.8), alopecia areata (aOR, 5.11; 95% CI, 4.75-5.49), and chronic urticaria (aOR, 4.82; 95% CI, 4.48-5.19).

AD was associated with gastrointestinal diseases, including celiac disease (aOR, 1.96; 95% CI, 1.84-2.09), Crohn disease (aOR 1.83; CI, 1.71-1.96), and ulcerative colitis (aOR 1.58; 95% CI, 1.49-1.68).

Connective tissue diseases significantly associated with AD included systemic lupus erythematosus (aOR, 1.65; 95% CI, 1.42-1.90), ankylosing spondylitis (aOR, 1.46; 95% CI, 1.29-1.66), and RA (aOR, 1.44; 95% CI,1.34-1.54]). Hematologic or hepatic autoimmune disease associations with AD were not observed.
 

Stronger association with multiple diseases

The association between AD and two or more autoimmune diseases was significantly stronger than the association between AD and having one autoimmune disease. For example, the OR for AD among people with three to five autoimmune diseases was 3.33 (95% CI, 2.86-3.87), and was stronger in men (OR, 3.96; 95% CI, 2.92-5.37) than in women (OR, 3.14; 95% CI, 2.63-3.74).
 

Sex differences

In the study overall, the association with AD and autoimmune diseases was stronger in men (aOR, 2.18; 95% CI, 2.10-2.25), compared with women (aOR, 1.89; 95% CI, 1.85-1.93), but this “sex difference was only statistically significant between AD and RA and between AD and Celiac disease,” they noted.

Associations between AD and dermatomyositis, systemic scleroderma, systemic lupus erythematosus, Hashimoto’s disease, Graves disease, multiple sclerosis, and polymyalgia rheumatica were found only in women. Dr. Ivert and coauthors observed that “women are in general more likely to develop autoimmune diseases, and 80% of patients with autoimmune diseases are women.”
 

Provocative questions

Commenting on the findings, Jonathan Silverberg, MD, PhD, MPH, associate professor of dermatology, George Washington University, Washington, said, “At a high level, it is important for clinicians to recognize that atopic dermatitis is a systemic immune-mediated disease. AD is associated with higher rates of comorbid autoimmune disease, similar to psoriasis and other chronic inflammatory skin diseases.”

“At this point, there is nothing immediately actionable about these results,” noted Dr. Silverberg, who was not an author of this study. “That said, in my mind, they raise some provocative questions: What is the difference between AD in adults who do versus those who do not get comorbid autoimmune disease? Does AD then present differently? Does it respond to the same therapies? These will have to be the subject of future research.”

The study was funded by the Swedish Asthma and Allergy Association Research Foundation, Hudfonden (the Welander-Finsen Foundation), and the Swedish Society for Dermatology and Venereology. The authors disclosed no conflicts of interest.

SOURCE: Ivert LU et al. Br J Dermatol. 2020 Oct 22. doi: 10.1111/bjd.19624.

A diagnosis of atopic dermatitis in individuals ages 15 years or older, compared with controls without atopic dermatitis, was nearly twice as likely to be associated with autoimmune disease, in a case control study derived from Swedish national health care registry data.

Atopic dermatitis (AD) is known to be associated with other atopic conditions, and there is increasing evidence it is associated with some nonatopic conditions, including some cancers, cardiovascular disease, and neuropsychiatric disorders, according to Lina U. Ivert, MD, of the dermatology and venereology unit at the Karolinska Institutet, Stockholm, and coauthors. There are also some data indicating that autoimmune diseases, particularly those involving the skin and gastrointestinal tract, are more common in people with AD.

The aim of their study, published in the British Journal of Dermatology, was to investigate a wide spectrum of autoimmune diseases for associations with AD in a large-scale, population-based study using Swedish registers. Findings could lead to better monitoring of comorbidities and deeper understanding of disease burden and AD pathophysiology, they noted.
 

Large-scale study

With data from the Swedish Board of Health and Welfare’s National Patient Register on inpatient diagnoses since 1964 and specialist outpatient visits since 2001, the investigators included all patients aged 15 years and older with AD diagnoses (104,832) and matched them with controls from the general population (1,022,435). The authors noted that the large number of people included in the analysis allowed for robust estimates, and underscored that 80% of the AD patients included had received their diagnosis in a dermatology department, which reduces the risk of misclassification.

Association with autoimmune disease

The investigators found an association between AD and autoimmune disease, with an adjusted odds ratio) of 1.97 (95% confidence interval, 1.93-2.01). The association was present with several organ systems, particularly the skin and gastrointestinal tract, and with connective tissue diseases. The strongest associations with autoimmune skin diseases were found for dermatitis herpetiformis (aOR, 9.76; 95% CI, 8.10-11.8), alopecia areata (aOR, 5.11; 95% CI, 4.75-5.49), and chronic urticaria (aOR, 4.82; 95% CI, 4.48-5.19).

AD was associated with gastrointestinal diseases, including celiac disease (aOR, 1.96; 95% CI, 1.84-2.09), Crohn disease (aOR 1.83; CI, 1.71-1.96), and ulcerative colitis (aOR 1.58; 95% CI, 1.49-1.68).

Connective tissue diseases significantly associated with AD included systemic lupus erythematosus (aOR, 1.65; 95% CI, 1.42-1.90), ankylosing spondylitis (aOR, 1.46; 95% CI, 1.29-1.66), and RA (aOR, 1.44; 95% CI,1.34-1.54]). Hematologic or hepatic autoimmune disease associations with AD were not observed.
 

Stronger association with multiple diseases

The association between AD and two or more autoimmune diseases was significantly stronger than the association between AD and having one autoimmune disease. For example, the OR for AD among people with three to five autoimmune diseases was 3.33 (95% CI, 2.86-3.87), and was stronger in men (OR, 3.96; 95% CI, 2.92-5.37) than in women (OR, 3.14; 95% CI, 2.63-3.74).
 

Sex differences

In the study overall, the association with AD and autoimmune diseases was stronger in men (aOR, 2.18; 95% CI, 2.10-2.25), compared with women (aOR, 1.89; 95% CI, 1.85-1.93), but this “sex difference was only statistically significant between AD and RA and between AD and Celiac disease,” they noted.

Associations between AD and dermatomyositis, systemic scleroderma, systemic lupus erythematosus, Hashimoto’s disease, Graves disease, multiple sclerosis, and polymyalgia rheumatica were found only in women. Dr. Ivert and coauthors observed that “women are in general more likely to develop autoimmune diseases, and 80% of patients with autoimmune diseases are women.”
 

Provocative questions

Commenting on the findings, Jonathan Silverberg, MD, PhD, MPH, associate professor of dermatology, George Washington University, Washington, said, “At a high level, it is important for clinicians to recognize that atopic dermatitis is a systemic immune-mediated disease. AD is associated with higher rates of comorbid autoimmune disease, similar to psoriasis and other chronic inflammatory skin diseases.”

“At this point, there is nothing immediately actionable about these results,” noted Dr. Silverberg, who was not an author of this study. “That said, in my mind, they raise some provocative questions: What is the difference between AD in adults who do versus those who do not get comorbid autoimmune disease? Does AD then present differently? Does it respond to the same therapies? These will have to be the subject of future research.”

The study was funded by the Swedish Asthma and Allergy Association Research Foundation, Hudfonden (the Welander-Finsen Foundation), and the Swedish Society for Dermatology and Venereology. The authors disclosed no conflicts of interest.

SOURCE: Ivert LU et al. Br J Dermatol. 2020 Oct 22. doi: 10.1111/bjd.19624.

Psychiatry has made significant scientific advances over the past century. However, it is still saddled with archaic terms, with pejorative connotations, disguised as official medical diagnoses. It is time to “cancel” those terms and replace them with ones that are neutral and have not accumulated baggage.

This process of “creative destruction” of psychiatric terminology is long overdue. It is frankly disturbing that the psychiatric jargon used around the time that the American Psychiatric Association was established 175 years ago (1844) is now considered insults and epithets. We no longer work in “lunatic asylums for the insane,” and our patients with intellectual disabilities are no longer classified as “morons,” “idiots,” or “imbeciles.” Such “diagnoses” have certainly contributed to the stigma of psychiatric brain disorders. Even the noble word “asylum” has acquired a negative valence because in the past it referred to hospitals that housed persons with serious mental illness.

Thankfully, some of the outrageous terms fabricated during the condemnable and dark era of slavery 2 centuries ago were never adopted by organized psychiatry. The absurd diagnosis of “negritude,” whose tenet was that black skin is a disease curable by whitening the skin, was “invented” by none other than Benjamin Rush, the Father of Psychiatry, whose conflicted soul was depicted by concomitantly owning a slave and positioning himself as an ardent abolitionist!

Terms that need to be replaced

Fast-forward to the modern era and consider the following:

Borderline personality disorder. It is truly tragic how this confusing and non-scientific term is used as an official diagnosis for a set of seriously ill persons. It is loaded with obloquy, indignity, and derision that completely ignore the tumult, self-harm, and disability with which patients who carry this label are burdened throughout their lives, despite being intelligent. This is a serious brain disorder that has been shown to be highly genetic and is characterized by many well-established structural brain abnormalities that have been documented in neuroimaging studies.^1,2 Borderline personality should not be classified as a personality disorder but as an illness with multiple signs and symptoms, including mood lability, anger, impulsivity, self-cutting, suicidal urges, feelings of abandonment, and micro-psychotic episodes. A more clinically accurate term should be coined very soon to replace borderline personality, which should be discarded to the trash heap of obsolete psychiatric terms, and no longer inflicted on patients.

Neurosis. What is the justification for continuing to use the term “neurotic” for a person who has an anxiety disorder? Is it used because Jung and Freud propagated the term “neurosis” (after it was coined by William Cullen in 1769)? Neurosis has degenerated from a psychiatric diagnosis to a scornful snub that must never be used for any patient.

Schizophrenia. This diagnosis, coined by Eugen Bleuler to replace the narrow and pessimistic “dementia praecox” proposed by Emil Kraepelin in the 1920s, initially seemed to be a neutral description of a thought disorder (split associations, not split personality). Bleuler was perceptive enough to call his book Dementia Praecox or the Group of Schizophrenias, which is consistent with the modern scientific research that confirms schizophrenia is a very heterogeneous syndrome with hundreds of genetic and environmental biotypes with a similar phenotype but a wide range of severity, treatment response, and functional outcomes. However, in subsequent decades, schizophrenia became one of the most demeaning labels in psychiatry, casting a shadow of hopelessness and disability on the people who have this serious neurologic condition with many psychiatric symptoms. The term that should replace schizophrenia should be no more degrading than stroke, multiple sclerosis, or myocardial infarction.

Continue to: Over the past 15 years...

Over the past 15 years, an expanding group of schizophrenia experts have agreed that this term must be changed to one that reflects the core features of this syndrome, and have proposed terms such as “salience syndrome,” “psychosis-spectrum,” and “reality distortion and cognitive impairment disorder.”³ In fact, several countries have already adopted a new official diagnosis for schizophrenia.⁴ Japan now uses the term “integration disorder,” which has significantly reduced the stigma of this brain disorder.⁵ South Korea changed the name to “attunement disorder.” Hong Kong and Taiwan now use “dysfunction of thought and perception.” Some researchers recommend calling schizophrenia “Bleuler’s syndrome,” a neutral eponymous designation.

One of the most irritating things about the term schizophrenia is the widespread misconception that it means “split personality.” This prompts some sports announcers to call a football team “schizophrenic” if they play well in the first half and badly in the second. The stock market is labeled “schizophrenic” if it goes up one day and way down on the next. No other medical term is misused by the media as often as the term schizophrenia.

Narcissistic personality disorder. The origin of this diagnostic category is the concept of “malignant narcissism” coined by Erich Fromm in 1964, which he designated as “the quintessence of evil.” I strongly object to implying that evil is part of any psychiatric diagnosis. Numerous studies have found structural brain abnormalities (in both gray and white matter) in patients diagnosed with psychopathic traits.⁶ Later, malignant narcissism was reframed as narcissistic personality disorder in 1971 by Herbert Rosenfeld. Although malignant narcissism was never accepted by either the DSM or the International Classification of Diseases, narcissistic personality disorder has been included in the DSM for the past few decades. This diagnosis reeks of disparagement and negativity. Persons with narcissistic personality disorder have been shown to have pathological brain changes in resting-state functional connectivity,⁷ weakened frontostriatal white matter connectivity,^8,9 and a reduced frontal thickness and cortical volume.¹⁰ A distorted sense of self and others is a socially disabling disorder that should generate empathy, not disdain. Narcissistic personality disorder should be replaced by a term that accurately describes its behavioral pathology, and should not incorporate Greek mythology.

Mania. This is another unfortunate diagnosis that immediately evokes a negative image of patients who suffer from a potentially lethal brain disorder. It was fortunate that Robert Kendall coined the term “bipolar disorder” to replace “manic-depressive illness,” but mania is still being used within bipolar disorder as a prominent clinical phase. While depression accurately describes the mood in the other phase of this disorder, the term mania evokes wild, irrational behavior. Because the actual mood symptom cluster in mania is either elation/grandiosity or irritability/anger, why not replace mania with “elation/irritability phase of bipolar disorder”? It is more descriptive of the patient’s mood and is less pejorative.

Nomenclature is vital, and words do matter, especially when used as a diagnostic medical term. Psychiatry must “cancel” its archaic names, which are infused with negative connotations. Reinventing the psychiatric lexicon is a necessary act of renewal in a specialty where a poorly worded diagnostic label can morph into the equivalent of a “scarlet letter.” Think of other contemptuous terms, such as refrigerator mother, male hysteria, moral insanity, toxic parents, inadequate personality disorder, neurasthenia, or catastrophic schizophrenia.

General medicine regularly discards many of its obsolete terms.¹¹ These include terms such as ablepsy, ague, camp fever, bloody flux, chlorosis, catarrh, consumption, dropsy, French pox, phthisis, milk sickness, and scrumpox.

Think also of how society abandoned the antediluvian names of boys and girls. Few parents these days would name their son Ackley, Allard, Arundel, Awarnach, Beldon, Durward, Grower, Kenlm, or Legolan, or name their daughter Afton, Agrona, Arantxa, Corliss, Demelza, Eartha, Maida, Obsession, Radella, or Sacrifice.In summary, a necessary part of psychiatry’s progress is shedding obsolete terminology, even if it means slaughtering some widely used “traditional” vocabulary. It is a necessary act of renewal, and the image of psychiatry will be burnished by it.

Psychiatry has made significant scientific advances over the past century. However, it is still saddled with archaic terms, with pejorative connotations, disguised as official medical diagnoses. It is time to “cancel” those terms and replace them with ones that are neutral and have not accumulated baggage.

This process of “creative destruction” of psychiatric terminology is long overdue. It is frankly disturbing that the psychiatric jargon used around the time that the American Psychiatric Association was established 175 years ago (1844) is now considered insults and epithets. We no longer work in “lunatic asylums for the insane,” and our patients with intellectual disabilities are no longer classified as “morons,” “idiots,” or “imbeciles.” Such “diagnoses” have certainly contributed to the stigma of psychiatric brain disorders. Even the noble word “asylum” has acquired a negative valence because in the past it referred to hospitals that housed persons with serious mental illness.

Thankfully, some of the outrageous terms fabricated during the condemnable and dark era of slavery 2 centuries ago were never adopted by organized psychiatry. The absurd diagnosis of “negritude,” whose tenet was that black skin is a disease curable by whitening the skin, was “invented” by none other than Benjamin Rush, the Father of Psychiatry, whose conflicted soul was depicted by concomitantly owning a slave and positioning himself as an ardent abolitionist!

Terms that need to be replaced

Fast-forward to the modern era and consider the following:

Borderline personality disorder. It is truly tragic how this confusing and non-scientific term is used as an official diagnosis for a set of seriously ill persons. It is loaded with obloquy, indignity, and derision that completely ignore the tumult, self-harm, and disability with which patients who carry this label are burdened throughout their lives, despite being intelligent. This is a serious brain disorder that has been shown to be highly genetic and is characterized by many well-established structural brain abnormalities that have been documented in neuroimaging studies.^1,2 Borderline personality should not be classified as a personality disorder but as an illness with multiple signs and symptoms, including mood lability, anger, impulsivity, self-cutting, suicidal urges, feelings of abandonment, and micro-psychotic episodes. A more clinically accurate term should be coined very soon to replace borderline personality, which should be discarded to the trash heap of obsolete psychiatric terms, and no longer inflicted on patients.

Neurosis. What is the justification for continuing to use the term “neurotic” for a person who has an anxiety disorder? Is it used because Jung and Freud propagated the term “neurosis” (after it was coined by William Cullen in 1769)? Neurosis has degenerated from a psychiatric diagnosis to a scornful snub that must never be used for any patient.

Schizophrenia. This diagnosis, coined by Eugen Bleuler to replace the narrow and pessimistic “dementia praecox” proposed by Emil Kraepelin in the 1920s, initially seemed to be a neutral description of a thought disorder (split associations, not split personality). Bleuler was perceptive enough to call his book Dementia Praecox or the Group of Schizophrenias, which is consistent with the modern scientific research that confirms schizophrenia is a very heterogeneous syndrome with hundreds of genetic and environmental biotypes with a similar phenotype but a wide range of severity, treatment response, and functional outcomes. However, in subsequent decades, schizophrenia became one of the most demeaning labels in psychiatry, casting a shadow of hopelessness and disability on the people who have this serious neurologic condition with many psychiatric symptoms. The term that should replace schizophrenia should be no more degrading than stroke, multiple sclerosis, or myocardial infarction.

Continue to: Over the past 15 years...

Over the past 15 years, an expanding group of schizophrenia experts have agreed that this term must be changed to one that reflects the core features of this syndrome, and have proposed terms such as “salience syndrome,” “psychosis-spectrum,” and “reality distortion and cognitive impairment disorder.”³ In fact, several countries have already adopted a new official diagnosis for schizophrenia.⁴ Japan now uses the term “integration disorder,” which has significantly reduced the stigma of this brain disorder.⁵ South Korea changed the name to “attunement disorder.” Hong Kong and Taiwan now use “dysfunction of thought and perception.” Some researchers recommend calling schizophrenia “Bleuler’s syndrome,” a neutral eponymous designation.

One of the most irritating things about the term schizophrenia is the widespread misconception that it means “split personality.” This prompts some sports announcers to call a football team “schizophrenic” if they play well in the first half and badly in the second. The stock market is labeled “schizophrenic” if it goes up one day and way down on the next. No other medical term is misused by the media as often as the term schizophrenia.

Narcissistic personality disorder. The origin of this diagnostic category is the concept of “malignant narcissism” coined by Erich Fromm in 1964, which he designated as “the quintessence of evil.” I strongly object to implying that evil is part of any psychiatric diagnosis. Numerous studies have found structural brain abnormalities (in both gray and white matter) in patients diagnosed with psychopathic traits.⁶ Later, malignant narcissism was reframed as narcissistic personality disorder in 1971 by Herbert Rosenfeld. Although malignant narcissism was never accepted by either the DSM or the International Classification of Diseases, narcissistic personality disorder has been included in the DSM for the past few decades. This diagnosis reeks of disparagement and negativity. Persons with narcissistic personality disorder have been shown to have pathological brain changes in resting-state functional connectivity,⁷ weakened frontostriatal white matter connectivity,^8,9 and a reduced frontal thickness and cortical volume.¹⁰ A distorted sense of self and others is a socially disabling disorder that should generate empathy, not disdain. Narcissistic personality disorder should be replaced by a term that accurately describes its behavioral pathology, and should not incorporate Greek mythology.

Mania. This is another unfortunate diagnosis that immediately evokes a negative image of patients who suffer from a potentially lethal brain disorder. It was fortunate that Robert Kendall coined the term “bipolar disorder” to replace “manic-depressive illness,” but mania is still being used within bipolar disorder as a prominent clinical phase. While depression accurately describes the mood in the other phase of this disorder, the term mania evokes wild, irrational behavior. Because the actual mood symptom cluster in mania is either elation/grandiosity or irritability/anger, why not replace mania with “elation/irritability phase of bipolar disorder”? It is more descriptive of the patient’s mood and is less pejorative.

Nomenclature is vital, and words do matter, especially when used as a diagnostic medical term. Psychiatry must “cancel” its archaic names, which are infused with negative connotations. Reinventing the psychiatric lexicon is a necessary act of renewal in a specialty where a poorly worded diagnostic label can morph into the equivalent of a “scarlet letter.” Think of other contemptuous terms, such as refrigerator mother, male hysteria, moral insanity, toxic parents, inadequate personality disorder, neurasthenia, or catastrophic schizophrenia.

General medicine regularly discards many of its obsolete terms.¹¹ These include terms such as ablepsy, ague, camp fever, bloody flux, chlorosis, catarrh, consumption, dropsy, French pox, phthisis, milk sickness, and scrumpox.

Think also of how society abandoned the antediluvian names of boys and girls. Few parents these days would name their son Ackley, Allard, Arundel, Awarnach, Beldon, Durward, Grower, Kenlm, or Legolan, or name their daughter Afton, Agrona, Arantxa, Corliss, Demelza, Eartha, Maida, Obsession, Radella, or Sacrifice.In summary, a necessary part of psychiatry’s progress is shedding obsolete terminology, even if it means slaughtering some widely used “traditional” vocabulary. It is a necessary act of renewal, and the image of psychiatry will be burnished by it.

Psychiatry has made significant scientific advances over the past century. However, it is still saddled with archaic terms, with pejorative connotations, disguised as official medical diagnoses. It is time to “cancel” those terms and replace them with ones that are neutral and have not accumulated baggage.

This process of “creative destruction” of psychiatric terminology is long overdue. It is frankly disturbing that the psychiatric jargon used around the time that the American Psychiatric Association was established 175 years ago (1844) is now considered insults and epithets. We no longer work in “lunatic asylums for the insane,” and our patients with intellectual disabilities are no longer classified as “morons,” “idiots,” or “imbeciles.” Such “diagnoses” have certainly contributed to the stigma of psychiatric brain disorders. Even the noble word “asylum” has acquired a negative valence because in the past it referred to hospitals that housed persons with serious mental illness.

Thankfully, some of the outrageous terms fabricated during the condemnable and dark era of slavery 2 centuries ago were never adopted by organized psychiatry. The absurd diagnosis of “negritude,” whose tenet was that black skin is a disease curable by whitening the skin, was “invented” by none other than Benjamin Rush, the Father of Psychiatry, whose conflicted soul was depicted by concomitantly owning a slave and positioning himself as an ardent abolitionist!

Terms that need to be replaced

Fast-forward to the modern era and consider the following:

Borderline personality disorder. It is truly tragic how this confusing and non-scientific term is used as an official diagnosis for a set of seriously ill persons. It is loaded with obloquy, indignity, and derision that completely ignore the tumult, self-harm, and disability with which patients who carry this label are burdened throughout their lives, despite being intelligent. This is a serious brain disorder that has been shown to be highly genetic and is characterized by many well-established structural brain abnormalities that have been documented in neuroimaging studies.^1,2 Borderline personality should not be classified as a personality disorder but as an illness with multiple signs and symptoms, including mood lability, anger, impulsivity, self-cutting, suicidal urges, feelings of abandonment, and micro-psychotic episodes. A more clinically accurate term should be coined very soon to replace borderline personality, which should be discarded to the trash heap of obsolete psychiatric terms, and no longer inflicted on patients.

Neurosis. What is the justification for continuing to use the term “neurotic” for a person who has an anxiety disorder? Is it used because Jung and Freud propagated the term “neurosis” (after it was coined by William Cullen in 1769)? Neurosis has degenerated from a psychiatric diagnosis to a scornful snub that must never be used for any patient.

Schizophrenia. This diagnosis, coined by Eugen Bleuler to replace the narrow and pessimistic “dementia praecox” proposed by Emil Kraepelin in the 1920s, initially seemed to be a neutral description of a thought disorder (split associations, not split personality). Bleuler was perceptive enough to call his book Dementia Praecox or the Group of Schizophrenias, which is consistent with the modern scientific research that confirms schizophrenia is a very heterogeneous syndrome with hundreds of genetic and environmental biotypes with a similar phenotype but a wide range of severity, treatment response, and functional outcomes. However, in subsequent decades, schizophrenia became one of the most demeaning labels in psychiatry, casting a shadow of hopelessness and disability on the people who have this serious neurologic condition with many psychiatric symptoms. The term that should replace schizophrenia should be no more degrading than stroke, multiple sclerosis, or myocardial infarction.

Continue to: Over the past 15 years...

Over the past 15 years, an expanding group of schizophrenia experts have agreed that this term must be changed to one that reflects the core features of this syndrome, and have proposed terms such as “salience syndrome,” “psychosis-spectrum,” and “reality distortion and cognitive impairment disorder.”³ In fact, several countries have already adopted a new official diagnosis for schizophrenia.⁴ Japan now uses the term “integration disorder,” which has significantly reduced the stigma of this brain disorder.⁵ South Korea changed the name to “attunement disorder.” Hong Kong and Taiwan now use “dysfunction of thought and perception.” Some researchers recommend calling schizophrenia “Bleuler’s syndrome,” a neutral eponymous designation.

One of the most irritating things about the term schizophrenia is the widespread misconception that it means “split personality.” This prompts some sports announcers to call a football team “schizophrenic” if they play well in the first half and badly in the second. The stock market is labeled “schizophrenic” if it goes up one day and way down on the next. No other medical term is misused by the media as often as the term schizophrenia.

Narcissistic personality disorder. The origin of this diagnostic category is the concept of “malignant narcissism” coined by Erich Fromm in 1964, which he designated as “the quintessence of evil.” I strongly object to implying that evil is part of any psychiatric diagnosis. Numerous studies have found structural brain abnormalities (in both gray and white matter) in patients diagnosed with psychopathic traits.⁶ Later, malignant narcissism was reframed as narcissistic personality disorder in 1971 by Herbert Rosenfeld. Although malignant narcissism was never accepted by either the DSM or the International Classification of Diseases, narcissistic personality disorder has been included in the DSM for the past few decades. This diagnosis reeks of disparagement and negativity. Persons with narcissistic personality disorder have been shown to have pathological brain changes in resting-state functional connectivity,⁷ weakened frontostriatal white matter connectivity,^8,9 and a reduced frontal thickness and cortical volume.¹⁰ A distorted sense of self and others is a socially disabling disorder that should generate empathy, not disdain. Narcissistic personality disorder should be replaced by a term that accurately describes its behavioral pathology, and should not incorporate Greek mythology.

Mania. This is another unfortunate diagnosis that immediately evokes a negative image of patients who suffer from a potentially lethal brain disorder. It was fortunate that Robert Kendall coined the term “bipolar disorder” to replace “manic-depressive illness,” but mania is still being used within bipolar disorder as a prominent clinical phase. While depression accurately describes the mood in the other phase of this disorder, the term mania evokes wild, irrational behavior. Because the actual mood symptom cluster in mania is either elation/grandiosity or irritability/anger, why not replace mania with “elation/irritability phase of bipolar disorder”? It is more descriptive of the patient’s mood and is less pejorative.

Nomenclature is vital, and words do matter, especially when used as a diagnostic medical term. Psychiatry must “cancel” its archaic names, which are infused with negative connotations. Reinventing the psychiatric lexicon is a necessary act of renewal in a specialty where a poorly worded diagnostic label can morph into the equivalent of a “scarlet letter.” Think of other contemptuous terms, such as refrigerator mother, male hysteria, moral insanity, toxic parents, inadequate personality disorder, neurasthenia, or catastrophic schizophrenia.

General medicine regularly discards many of its obsolete terms.¹¹ These include terms such as ablepsy, ague, camp fever, bloody flux, chlorosis, catarrh, consumption, dropsy, French pox, phthisis, milk sickness, and scrumpox.

Think also of how society abandoned the antediluvian names of boys and girls. Few parents these days would name their son Ackley, Allard, Arundel, Awarnach, Beldon, Durward, Grower, Kenlm, or Legolan, or name their daughter Afton, Agrona, Arantxa, Corliss, Demelza, Eartha, Maida, Obsession, Radella, or Sacrifice.In summary, a necessary part of psychiatry’s progress is shedding obsolete terminology, even if it means slaughtering some widely used “traditional” vocabulary. It is a necessary act of renewal, and the image of psychiatry will be burnished by it.

Nonsuicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without intent to die.¹ Cutting is the most common form of NSSI; other methods include burning, scraping/scratching skin, interfering with wound healing, hitting, biting, self-poisoning, and purposeful non-recreational risk-taking.^2,3 Although most individuals who engage in NSSI have no intention to die, suicidal ideation often precedes the initial engagement in NSSI,⁴ and a history of repeated NSSI is a risk factor for suicide attempts.⁴ In a systematic review, Cipriano et al⁵ found that NSSI is most common among adolescents and young adults, with onset most often occurring between age 12 and 14. Prevalence rates of NSSI are 7.5% to 46.5% in adolescents, 38.9% in university students, and 4% to 23% in adults.⁵

Although no medications have consistently shown efficacy for treating NSSI, research suggests cognitive-behavioral therapy and dialectical behavioral therapy may be helpful. Unfortunately, these therapies are often not available during a patient’s acute crisis.³ Because a thorough review of the treatment options for NSSI is beyond the scope of this article, here I offer tips for caring for adults who engage in NSSI. Although there are slight differences in managing NSSI in adolescents (eg, the need for parental monitoring and reducing risk of contagion), these tips also can be used with adolescents.

Explore why your patient engages in NSSI. Identifying the reasons for our patients’ NSSI makes it easier for us to empathize with them, and puts us in a better position to treat them.³ The most widely reported reasons for NSSI are to cope with distress/anguish and to exert influence on others.⁶ In a systematic review, self-reported reasons for NSSI also included punishing oneself for having positive feelings, punishing others, managing dissociation (ie, active pursuit of numbness), sensation-seeking (ie, to generate excitement or exhilaration), averting suicide (ie, warding off suicidal thoughts), maintaining or exploring boundaries, and expressing or coping with sexuality.⁶ When exploring your patient’s reasons for NSSI, determine if the behavior is based on a true suicidal desire. Because NSSI is associated with mood disorders, anxiety disorders, personality disorders, and other disorders, also assess for any underlying psychiatric conditions, and treat them accordingly because mental health treatment has been empirically proven to reduce suicide rates.^2,7

Conduct a suicide risk assessment. Regardless of your patient’s reasons for NSSI, an individualized and thorough suicide risk assessment is needed to identify modifiable, non-modifiable, and protective factors that you can consider when developing a treatment plan. Key components of such assessments include (but are not limited to) current and past urges to engage in NSSI, past NSSI and suicide attempts, access to lethal means, and ability to follow a safety plan.

Avoid exaggerating the danger and importance of NSSI. Treating a patient who engages in NSSI who is motivated by a true suicidal desire and/or has underlying psychiatric conditions may prompt you to consider hospitalization and/or prescribing psychotropic medications.³ However, because most NSSI is not due to a true suicidal desire, overreacting may unwittingly communicate to the patient that self-harm is a way to sustain someone’s attention, thus reinforcing that such behaviors can help them obtain support when distressed.³ Further, overreacting will not help patients comprehend and better cope with the reasons for their self-injurious behaviors.³

Restrict your patient’s access to lethal means. Restricting access to items such as firearms, sharp objects (eg, knives and razors), medications, implements for suffocation/hanging (eg, belts), and household poisons has been empirically proven to reduce suicide rates.⁷ Such restrictions can also potentially reduce the likelihood of NSSI. It is important to repeatedly ask your patient if they have acquired any new means, and to listen for information that indicates they possess means that they did not previously disclose. It is also important to ask if the patient has moved existing means to an area for easier access to use them.

Create a safety plan. Written safety plans can include a list of warning signs (thoughts, images, mood, situations, behaviors) that a crisis is developing, coping strategies (eg, going for a walk, exercising, engaging in a hobby, socializing with friends or family), and contact information for 24-hour crisis hotlines, emergency rooms, and mental health clinicians.⁸ The Suicide Prevention Resource Center offers a safety plan template at www.sprc.org/sites/default/files/resource-program/Brown_StanleySafetyPlanTemplate.pdf.⁸ 

Offer empathy. Individuals who engage in NSSI are making a desperate call for help that requires concerned and supportive responses.³ One such response is to provide empathy. In addition to expressing concern and compassion, empathy involves recognizing and sharing your patients’ emotions. Empathy also can help you avoid any resistance during the visit by considering what is appropriate to say to patients.

Manage countertransference. You may have negative feelings toward a patient who engages in NSSI, or may even view self-harm as a willful act designed to gain attention. However, such feelings could lead you to minimize or dismiss the importance of your patient’s behaviors, which may push them to engage in more dangerous self-harm.³ Acknowledging any feelings of derision for a patient who engages in NSSI and understanding why you have these emotions will help you better understand your patient, improve rapport, and ensure that you are not impeding the delivery of appropriate clinical care.

Nonsuicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without intent to die.¹ Cutting is the most common form of NSSI; other methods include burning, scraping/scratching skin, interfering with wound healing, hitting, biting, self-poisoning, and purposeful non-recreational risk-taking.^2,3 Although most individuals who engage in NSSI have no intention to die, suicidal ideation often precedes the initial engagement in NSSI,⁴ and a history of repeated NSSI is a risk factor for suicide attempts.⁴ In a systematic review, Cipriano et al⁵ found that NSSI is most common among adolescents and young adults, with onset most often occurring between age 12 and 14. Prevalence rates of NSSI are 7.5% to 46.5% in adolescents, 38.9% in university students, and 4% to 23% in adults.⁵

Although no medications have consistently shown efficacy for treating NSSI, research suggests cognitive-behavioral therapy and dialectical behavioral therapy may be helpful. Unfortunately, these therapies are often not available during a patient’s acute crisis.³ Because a thorough review of the treatment options for NSSI is beyond the scope of this article, here I offer tips for caring for adults who engage in NSSI. Although there are slight differences in managing NSSI in adolescents (eg, the need for parental monitoring and reducing risk of contagion), these tips also can be used with adolescents.

Explore why your patient engages in NSSI. Identifying the reasons for our patients’ NSSI makes it easier for us to empathize with them, and puts us in a better position to treat them.³ The most widely reported reasons for NSSI are to cope with distress/anguish and to exert influence on others.⁶ In a systematic review, self-reported reasons for NSSI also included punishing oneself for having positive feelings, punishing others, managing dissociation (ie, active pursuit of numbness), sensation-seeking (ie, to generate excitement or exhilaration), averting suicide (ie, warding off suicidal thoughts), maintaining or exploring boundaries, and expressing or coping with sexuality.⁶ When exploring your patient’s reasons for NSSI, determine if the behavior is based on a true suicidal desire. Because NSSI is associated with mood disorders, anxiety disorders, personality disorders, and other disorders, also assess for any underlying psychiatric conditions, and treat them accordingly because mental health treatment has been empirically proven to reduce suicide rates.^2,7

Conduct a suicide risk assessment. Regardless of your patient’s reasons for NSSI, an individualized and thorough suicide risk assessment is needed to identify modifiable, non-modifiable, and protective factors that you can consider when developing a treatment plan. Key components of such assessments include (but are not limited to) current and past urges to engage in NSSI, past NSSI and suicide attempts, access to lethal means, and ability to follow a safety plan.

Avoid exaggerating the danger and importance of NSSI. Treating a patient who engages in NSSI who is motivated by a true suicidal desire and/or has underlying psychiatric conditions may prompt you to consider hospitalization and/or prescribing psychotropic medications.³ However, because most NSSI is not due to a true suicidal desire, overreacting may unwittingly communicate to the patient that self-harm is a way to sustain someone’s attention, thus reinforcing that such behaviors can help them obtain support when distressed.³ Further, overreacting will not help patients comprehend and better cope with the reasons for their self-injurious behaviors.³

Restrict your patient’s access to lethal means. Restricting access to items such as firearms, sharp objects (eg, knives and razors), medications, implements for suffocation/hanging (eg, belts), and household poisons has been empirically proven to reduce suicide rates.⁷ Such restrictions can also potentially reduce the likelihood of NSSI. It is important to repeatedly ask your patient if they have acquired any new means, and to listen for information that indicates they possess means that they did not previously disclose. It is also important to ask if the patient has moved existing means to an area for easier access to use them.

Create a safety plan. Written safety plans can include a list of warning signs (thoughts, images, mood, situations, behaviors) that a crisis is developing, coping strategies (eg, going for a walk, exercising, engaging in a hobby, socializing with friends or family), and contact information for 24-hour crisis hotlines, emergency rooms, and mental health clinicians.⁸ The Suicide Prevention Resource Center offers a safety plan template at www.sprc.org/sites/default/files/resource-program/Brown_StanleySafetyPlanTemplate.pdf.⁸ 

Offer empathy. Individuals who engage in NSSI are making a desperate call for help that requires concerned and supportive responses.³ One such response is to provide empathy. In addition to expressing concern and compassion, empathy involves recognizing and sharing your patients’ emotions. Empathy also can help you avoid any resistance during the visit by considering what is appropriate to say to patients.

Manage countertransference. You may have negative feelings toward a patient who engages in NSSI, or may even view self-harm as a willful act designed to gain attention. However, such feelings could lead you to minimize or dismiss the importance of your patient’s behaviors, which may push them to engage in more dangerous self-harm.³ Acknowledging any feelings of derision for a patient who engages in NSSI and understanding why you have these emotions will help you better understand your patient, improve rapport, and ensure that you are not impeding the delivery of appropriate clinical care.

Nonsuicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without intent to die.¹ Cutting is the most common form of NSSI; other methods include burning, scraping/scratching skin, interfering with wound healing, hitting, biting, self-poisoning, and purposeful non-recreational risk-taking.^2,3 Although most individuals who engage in NSSI have no intention to die, suicidal ideation often precedes the initial engagement in NSSI,⁴ and a history of repeated NSSI is a risk factor for suicide attempts.⁴ In a systematic review, Cipriano et al⁵ found that NSSI is most common among adolescents and young adults, with onset most often occurring between age 12 and 14. Prevalence rates of NSSI are 7.5% to 46.5% in adolescents, 38.9% in university students, and 4% to 23% in adults.⁵

Although no medications have consistently shown efficacy for treating NSSI, research suggests cognitive-behavioral therapy and dialectical behavioral therapy may be helpful. Unfortunately, these therapies are often not available during a patient’s acute crisis.³ Because a thorough review of the treatment options for NSSI is beyond the scope of this article, here I offer tips for caring for adults who engage in NSSI. Although there are slight differences in managing NSSI in adolescents (eg, the need for parental monitoring and reducing risk of contagion), these tips also can be used with adolescents.

Explore why your patient engages in NSSI. Identifying the reasons for our patients’ NSSI makes it easier for us to empathize with them, and puts us in a better position to treat them.³ The most widely reported reasons for NSSI are to cope with distress/anguish and to exert influence on others.⁶ In a systematic review, self-reported reasons for NSSI also included punishing oneself for having positive feelings, punishing others, managing dissociation (ie, active pursuit of numbness), sensation-seeking (ie, to generate excitement or exhilaration), averting suicide (ie, warding off suicidal thoughts), maintaining or exploring boundaries, and expressing or coping with sexuality.⁶ When exploring your patient’s reasons for NSSI, determine if the behavior is based on a true suicidal desire. Because NSSI is associated with mood disorders, anxiety disorders, personality disorders, and other disorders, also assess for any underlying psychiatric conditions, and treat them accordingly because mental health treatment has been empirically proven to reduce suicide rates.^2,7

Conduct a suicide risk assessment. Regardless of your patient’s reasons for NSSI, an individualized and thorough suicide risk assessment is needed to identify modifiable, non-modifiable, and protective factors that you can consider when developing a treatment plan. Key components of such assessments include (but are not limited to) current and past urges to engage in NSSI, past NSSI and suicide attempts, access to lethal means, and ability to follow a safety plan.

Avoid exaggerating the danger and importance of NSSI. Treating a patient who engages in NSSI who is motivated by a true suicidal desire and/or has underlying psychiatric conditions may prompt you to consider hospitalization and/or prescribing psychotropic medications.³ However, because most NSSI is not due to a true suicidal desire, overreacting may unwittingly communicate to the patient that self-harm is a way to sustain someone’s attention, thus reinforcing that such behaviors can help them obtain support when distressed.³ Further, overreacting will not help patients comprehend and better cope with the reasons for their self-injurious behaviors.³

Restrict your patient’s access to lethal means. Restricting access to items such as firearms, sharp objects (eg, knives and razors), medications, implements for suffocation/hanging (eg, belts), and household poisons has been empirically proven to reduce suicide rates.⁷ Such restrictions can also potentially reduce the likelihood of NSSI. It is important to repeatedly ask your patient if they have acquired any new means, and to listen for information that indicates they possess means that they did not previously disclose. It is also important to ask if the patient has moved existing means to an area for easier access to use them.

Create a safety plan. Written safety plans can include a list of warning signs (thoughts, images, mood, situations, behaviors) that a crisis is developing, coping strategies (eg, going for a walk, exercising, engaging in a hobby, socializing with friends or family), and contact information for 24-hour crisis hotlines, emergency rooms, and mental health clinicians.⁸ The Suicide Prevention Resource Center offers a safety plan template at www.sprc.org/sites/default/files/resource-program/Brown_StanleySafetyPlanTemplate.pdf.⁸ 

Offer empathy. Individuals who engage in NSSI are making a desperate call for help that requires concerned and supportive responses.³ One such response is to provide empathy. In addition to expressing concern and compassion, empathy involves recognizing and sharing your patients’ emotions. Empathy also can help you avoid any resistance during the visit by considering what is appropriate to say to patients.

Manage countertransference. You may have negative feelings toward a patient who engages in NSSI, or may even view self-harm as a willful act designed to gain attention. However, such feelings could lead you to minimize or dismiss the importance of your patient’s behaviors, which may push them to engage in more dangerous self-harm.³ Acknowledging any feelings of derision for a patient who engages in NSSI and understanding why you have these emotions will help you better understand your patient, improve rapport, and ensure that you are not impeding the delivery of appropriate clinical care.

In this Career Choices, Siddhi Bhivandkar, MD, spoke with Captain Paulette T. Cazares, MD, MPH. Dr. Cazares is Director for Mental Health at U.S. Navy Medicine Readiness and Training Command Okinawa, Japan. She also is Assistant Professor, Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, and serves as Secretary of the American Medical Women’s Association, Schaumburg, Illinois.

Dr. Bhivandkar: What made you choose the Navy psychiatry track, and how did your training lead you towards this path?

Dr. Cazares: I had considered a career in the Navy early on in my education, and when I was ready to apply to medical school, I saw Uniformed Services University (USU) as one of my top choices. I wasn’t 100% sure, but after a tour and my interview, I was sold on serving those who serve.

During my clinical rotations at USU, I had great experiences in inpatient and emergency psychiatry. I became fascinated with understanding all I could about brain circuitry and chemistry, and how that interacts with the environment to create or protect individuals from disease. Once I talked with some mentors, it became clear to me that I would love a career in psychiatry, and that remains true today.

Dr. Bhivandkar: What are some of the pros and cons of working in Navy psychiatry?

Dr. Cazares: As a Navy psychiatrist, I have found great reward in caring for our nation’s volunteer force. I have had wonderful colleagues with whom I have deployed, and with whom I have served in both small military hospitals and large military training and academic centers. I have been able to work in research in military mental health, and feel I have specifically advanced the field of women’s mental health in the Navy.

I had 4 children while I have been on active duty, and had paid maternity leave for all of them, as well as practices that protected my choice to breastfeed and pump, even after returning to work. I have moved to areas of the country I didn’t expect to with the Navy, and my husband’s career took unexpected turns as a result. While this can be seen as a challenge, it can also be a surprisingly rewarding experience, seeing areas of our nation and world that I otherwise would not have seen. I have deployed and been away from family. While that was a challenge, my family came through it very strong, and I found myself a more humble human and a better clinician as a result of that time.

Dr. Bhivandkar: Based on your personal experience, what should one consider when choosing a Navy psychiatry program?

Dr. Cazares: In considering a Navy training program, one should consider that in the military, our patient population is generally young and healthy, yet also exposed to unique occupational stressors. This means that we generally see routine mental health diagnoses, and some early-break severe cases. We do not typically follow long-term patients with chronic mental illness, because those patients tend to be medically retired from active duty service.

Continue to: We see many unique populations...

We see many unique populations that have specific health care needs, including service members who work on submarines, who are pilots or military police members, and those who handle and manage weapons. We get to learn the unique balance between serving our patients, and the units they work for and in. We see the impact of occupational stress on individuals, and are part of the multidisciplinary team that helps to build resilience in our young service members.

Dr. Bhivandkar: What are some of the career options and work settings for Navy psychiatrists?

Dr. Cazares: My peers and I have worked across both operational and multiple hospital settings, with both the US Marine Corps, as well as the US Navy. Psychiatrists can apply for fellowship, as the Navy regularly trains child and adolescent psychiatrists, as well as those who want to specialize in addiction psychiatry.

We can work in large Navy medical centers on faculty, in community-style Navy hospitals both in the United States and overseas, as well as on ships, with the Marines, or in headquarters jobs, advising on policy and the future of the military health system.

Dr. Bhivandkar: What are some of the challenges of working in this field?

Dr. Cazares: Health care and the military are both demanding career fields. Like many areas of medicine, work-life harmony is an important part of a career in Navy psychiatry. I work hard to balance my own needs, and model this for those I lead.

Dr. Bhivandkar: What advice do you have for those contemplating a career in Navy psychiatry?

Dr. Cazares: Consider joining a team that offers incredible purpose. I have served wonderful patients and had incredibly impressive colleagues, and I am grateful for the choice I made to take an oath and wear the uniform.

In this Career Choices, Siddhi Bhivandkar, MD, spoke with Captain Paulette T. Cazares, MD, MPH. Dr. Cazares is Director for Mental Health at U.S. Navy Medicine Readiness and Training Command Okinawa, Japan. She also is Assistant Professor, Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, and serves as Secretary of the American Medical Women’s Association, Schaumburg, Illinois.

Dr. Bhivandkar: What made you choose the Navy psychiatry track, and how did your training lead you towards this path?

Dr. Cazares: I had considered a career in the Navy early on in my education, and when I was ready to apply to medical school, I saw Uniformed Services University (USU) as one of my top choices. I wasn’t 100% sure, but after a tour and my interview, I was sold on serving those who serve.

During my clinical rotations at USU, I had great experiences in inpatient and emergency psychiatry. I became fascinated with understanding all I could about brain circuitry and chemistry, and how that interacts with the environment to create or protect individuals from disease. Once I talked with some mentors, it became clear to me that I would love a career in psychiatry, and that remains true today.

Dr. Bhivandkar: What are some of the pros and cons of working in Navy psychiatry?

Dr. Cazares: As a Navy psychiatrist, I have found great reward in caring for our nation’s volunteer force. I have had wonderful colleagues with whom I have deployed, and with whom I have served in both small military hospitals and large military training and academic centers. I have been able to work in research in military mental health, and feel I have specifically advanced the field of women’s mental health in the Navy.

I had 4 children while I have been on active duty, and had paid maternity leave for all of them, as well as practices that protected my choice to breastfeed and pump, even after returning to work. I have moved to areas of the country I didn’t expect to with the Navy, and my husband’s career took unexpected turns as a result. While this can be seen as a challenge, it can also be a surprisingly rewarding experience, seeing areas of our nation and world that I otherwise would not have seen. I have deployed and been away from family. While that was a challenge, my family came through it very strong, and I found myself a more humble human and a better clinician as a result of that time.

Dr. Bhivandkar: Based on your personal experience, what should one consider when choosing a Navy psychiatry program?

Dr. Cazares: In considering a Navy training program, one should consider that in the military, our patient population is generally young and healthy, yet also exposed to unique occupational stressors. This means that we generally see routine mental health diagnoses, and some early-break severe cases. We do not typically follow long-term patients with chronic mental illness, because those patients tend to be medically retired from active duty service.

Continue to: We see many unique populations...

We see many unique populations that have specific health care needs, including service members who work on submarines, who are pilots or military police members, and those who handle and manage weapons. We get to learn the unique balance between serving our patients, and the units they work for and in. We see the impact of occupational stress on individuals, and are part of the multidisciplinary team that helps to build resilience in our young service members.

Dr. Bhivandkar: What are some of the career options and work settings for Navy psychiatrists?

Dr. Cazares: My peers and I have worked across both operational and multiple hospital settings, with both the US Marine Corps, as well as the US Navy. Psychiatrists can apply for fellowship, as the Navy regularly trains child and adolescent psychiatrists, as well as those who want to specialize in addiction psychiatry.

We can work in large Navy medical centers on faculty, in community-style Navy hospitals both in the United States and overseas, as well as on ships, with the Marines, or in headquarters jobs, advising on policy and the future of the military health system.

Dr. Bhivandkar: What are some of the challenges of working in this field?

Dr. Cazares: Health care and the military are both demanding career fields. Like many areas of medicine, work-life harmony is an important part of a career in Navy psychiatry. I work hard to balance my own needs, and model this for those I lead.

Dr. Bhivandkar: What advice do you have for those contemplating a career in Navy psychiatry?

Dr. Cazares: Consider joining a team that offers incredible purpose. I have served wonderful patients and had incredibly impressive colleagues, and I am grateful for the choice I made to take an oath and wear the uniform.

In this Career Choices, Siddhi Bhivandkar, MD, spoke with Captain Paulette T. Cazares, MD, MPH. Dr. Cazares is Director for Mental Health at U.S. Navy Medicine Readiness and Training Command Okinawa, Japan. She also is Assistant Professor, Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, and serves as Secretary of the American Medical Women’s Association, Schaumburg, Illinois.

Dr. Bhivandkar: What made you choose the Navy psychiatry track, and how did your training lead you towards this path?

Dr. Cazares: I had considered a career in the Navy early on in my education, and when I was ready to apply to medical school, I saw Uniformed Services University (USU) as one of my top choices. I wasn’t 100% sure, but after a tour and my interview, I was sold on serving those who serve.

During my clinical rotations at USU, I had great experiences in inpatient and emergency psychiatry. I became fascinated with understanding all I could about brain circuitry and chemistry, and how that interacts with the environment to create or protect individuals from disease. Once I talked with some mentors, it became clear to me that I would love a career in psychiatry, and that remains true today.

Dr. Bhivandkar: What are some of the pros and cons of working in Navy psychiatry?

Dr. Cazares: As a Navy psychiatrist, I have found great reward in caring for our nation’s volunteer force. I have had wonderful colleagues with whom I have deployed, and with whom I have served in both small military hospitals and large military training and academic centers. I have been able to work in research in military mental health, and feel I have specifically advanced the field of women’s mental health in the Navy.

I had 4 children while I have been on active duty, and had paid maternity leave for all of them, as well as practices that protected my choice to breastfeed and pump, even after returning to work. I have moved to areas of the country I didn’t expect to with the Navy, and my husband’s career took unexpected turns as a result. While this can be seen as a challenge, it can also be a surprisingly rewarding experience, seeing areas of our nation and world that I otherwise would not have seen. I have deployed and been away from family. While that was a challenge, my family came through it very strong, and I found myself a more humble human and a better clinician as a result of that time.

Dr. Bhivandkar: Based on your personal experience, what should one consider when choosing a Navy psychiatry program?

Dr. Cazares: In considering a Navy training program, one should consider that in the military, our patient population is generally young and healthy, yet also exposed to unique occupational stressors. This means that we generally see routine mental health diagnoses, and some early-break severe cases. We do not typically follow long-term patients with chronic mental illness, because those patients tend to be medically retired from active duty service.

Continue to: We see many unique populations...

We see many unique populations that have specific health care needs, including service members who work on submarines, who are pilots or military police members, and those who handle and manage weapons. We get to learn the unique balance between serving our patients, and the units they work for and in. We see the impact of occupational stress on individuals, and are part of the multidisciplinary team that helps to build resilience in our young service members.

Dr. Bhivandkar: What are some of the career options and work settings for Navy psychiatrists?

Dr. Cazares: My peers and I have worked across both operational and multiple hospital settings, with both the US Marine Corps, as well as the US Navy. Psychiatrists can apply for fellowship, as the Navy regularly trains child and adolescent psychiatrists, as well as those who want to specialize in addiction psychiatry.

We can work in large Navy medical centers on faculty, in community-style Navy hospitals both in the United States and overseas, as well as on ships, with the Marines, or in headquarters jobs, advising on policy and the future of the military health system.

Dr. Bhivandkar: What are some of the challenges of working in this field?

Dr. Cazares: Health care and the military are both demanding career fields. Like many areas of medicine, work-life harmony is an important part of a career in Navy psychiatry. I work hard to balance my own needs, and model this for those I lead.

Dr. Bhivandkar: What advice do you have for those contemplating a career in Navy psychiatry?

Dr. Cazares: Consider joining a team that offers incredible purpose. I have served wonderful patients and had incredibly impressive colleagues, and I am grateful for the choice I made to take an oath and wear the uniform.

COVID-19 and decision-making capacity

Dr. Ryznar’s article “Evaluating patients’ decision-making capacity during COVID-19” (Evidence-Based Reviews, Current Psychiatry. October 2020, p. 34-40) provides a cogent overview of the “threshold” or “gradient” approach to capacity evaluations, wherein the assessment of a patient’s decisional capacity hinges on the risks and benefits of the specific clinical intervention. From a medico­legal perspective, however, I am concerned that Dr. Ryznar makes a consequential category error in framing sociopolitically-driven noncompliance with infectious disease control measures as a capacity problem. In the United States, public health powers—including the use of isolation and quarantine—fall to properly constituted public health authorities, predominantly at the state and local levels. An infectious patient with suspect ideas about coronavirus disease 2019 (COVID-19) whose decision-making process is not directly compromised by neurocognitive illness does not present a capacity issue, but rather a potential public health issue.

For example, in a controversial 2007 case in Atlanta, Georgia, an attorney with active tuberculosis failed to heed medical advice to refrain from traveling.¹ The patient’s uncooperativeness did not implicate concerns over his decisional capacity.¹ However, his international and interstate travel triggered the Centers for Disease Control and Prevention’s legal authority under the Public Health Service Act to prevent the entry and spread of communicable disease.^1-3 An authorized order from a duly constituted public health authority is issued and enforceable without regard to clinical determinations of capacity (and is generally subject to challenge via judicial or other due process mechanisms as a government-sanctioned deprivation of liberty to protect public welfare). State laws and local ordinances require physicians to notify the appropriate public health department when patients test positive for certain contagious diseases.

The difficulty with involuntarily detaining a cognitively intact patient due to concern over their contagion risk and erroneous beliefs runs considerably deeper than eliciting a “political backlash” or managing the qualms of hospital security officers. It is a fundamental matter of proper legal authority. Psychiatrists and other physicians assess patients’ decision-making capacity for specific treatment decisions on a case-by-case basis, seeking to preserve autonomy while practicing beneficence. Public health officers are agents of the state with designated authorities to control the spread of disease. A capacity determination in the absence of neurocognitive deficits implies the psychiatrist is evaluating the soundness of the patient’s ideas as opposed to their cognition, overlooking the reality that fully capable individuals can possess dubious—and even unsalutary—beliefs. While physicians educate patients about the risks of contracting and communicating infection, they are thankfully not tasked with arbitrating sociopolitical disputes at the bedside. Such controversies regarding pandemic response do not belong under the rubric of medical decision-making capacity. Conflating psychosomatic medicine consultations with public health orders risks unmooring capacity determinations from their medicolegal and bioethical foundations.

Charles G. Kels, JD
S Army Medical Center of Excellence
San Antonio, Texas  

Disclaimer: The views expressed here are those of the author and do not necessarily reflect those of any government agency.

References

1. Tanne JH. Tuberculosis case exposes flaws in international public health systems. BMJ. 2007;334(7605):1187.
2. Public Health Service Act, 42 USC § 264-272 (1944).
3. Interstate and Foreign Quarantine, 42 CFR Parts 70-71 (2017).

The author responds

I appreciate Mr. Kels’s letter and explicit discussion of the limits of decision-making capacity. I agree that physicians should not overstep their legal authority and ethical mandate. The specific case discussed in my article was a patient who was symptomatic from COVID-19 who wanted to leave the hospital against medical advice. The contagious nature of this virus certainly falls under the risk/benefit analysis of the clinical situation because it is an important aspect of understanding the nature of the illness and treatment/recovery process (as a thought example, consider that such a patient lives with their elderly mother who has heart disease and chronic obstructive pulmonary disease, and the patient does not want their mother to die). From a medico­legal perspective, the risk of infection to others may not necessarily outweigh the benefit of autonomy, especially because decision-making capacity assessments are made with the purpose of balancing autonomy and beneficence of the patient, not others. I highlighted the relative importance of autonomy using the weight of the arrows in Figure 2 of my article. I did not task physicians with arbitrating sociopolitical disputes, but merely highlighted how the current climate can impact people’s personal views on COVID-19, which sometimes can run counter to scientific evidence. If a patient has an erroneous view about an illness, it is our duty to try to help them understand if it directly impacts their health or affects their decision-making process, especially in a high-stakes clinical scenario.

Elizabeth Ryznar, MD, MSc
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins School of Medicine
Baltimore, Maryland

Continue to: Olanzapine for treatment-resistant anxiety

Olanzapine for treatment-resistant anxiety

Ms. A, age 62, was a retired high school teacher. Her primary care physician referred her to me for persistent, disabling anxiety. Her condition was recently worsened by a trial of escitalopram, 5 mg/d, which led her to visit the emergency department (ED). There she was prescribed lorazepam, 0.5 mg as needed, which helped her somewhat. Her medical conditions included prominent gastrointestinal (GI) symptoms, with nausea and a restricted diet; tinnitus; and chronic bilateral hand tremors. Her initial Patient Health Questionnaire-9 (PHQ-9) score was 11, and her Generalized Anxiety Disorder-7 (GAD-7) score was 10.

Initially, I encouraged Ms. A to exercise regularly, and I changed her lorazepam from 0.5 mg as-needed to 0.5 mg twice a day. I also referred her to a psychologist for psychotherapy. She showed limited improvement. I increased her lorazepam to 1 mg 3 times a day and started sertraline, 12.5 mg/d, but she soon experienced chest tightness and was admitted to the ED for observation and a cardiac workup. After she visited the ED, Ms. A stopped taking sertraline.

When I next saw Ms. A, she agreed to a trial of olanzapine, 2.5 mg/d at bedtime. Three weeks later, she told me, “I feel so much better.” Her scores on the PHQ-9 and GAD-7 were 0 and 1, respectively. Her GI complaints decreased, she had gained a little weight, and her tinnitus bothered her less. Lorazepam was gradually decreased and stopped.

After approximately 2 years, Ms. A had experienced no long-term adverse effects. We agreed to gradually discontinue olanzapine. Over the next 4 months, Ms. A decreased and stopped taking olanzapine at her own discretion.Three weeks after she stopped taking olanzapine, Ms. A reported that her psychiatric and GI symptoms had returned. She still maintained weekly visits with her psychotherapist. Her GI specialist asked if I could prescribe her olanzapine again. I restarted Ms. A on olanzapine, 2.5 mg/d at bedtime. By the next month, she said she felt much better (PHQ-9: 0; GAD-7: 1). I last saw Ms. A approximately 1 year ago.

Over the years, I have usually prescribed low-dose olanzapine alone or with other medications for patients with treatment-resistance who had no overt psychotic symptoms, I have used this medication for patients with “soft” psychotic thinking marked by severe anxiety, obsessions, compulsivity, perfectionism, and/or rumination.¹ Evidence suggests olanzapine also may be effective for anorexia nervosa.² There is good evidence for its use in the DSM-5 diagnosis of avoidant/restrictive food intake disorder (“a food avoidance emotional disorder”).^3,4 In retrospect, Ms. A also likely met the criteria for the diagnosis of unspecified eating disorder. Despite extensive GI workup and follow-up, physical signs of GI pathology were equivocal.

Among antipsychotics, olanzapine most closely resembles clozapine, the only antipsychotic that has been proved more efficacious than others for psychotic symptoms.⁵ There is also some research suggesting that olanzapine may be more efficacious.⁶ Obsessions and perfectionism are associated with dopamine D4 receptor activity, and D1, D2, and D3 receptors are involved in normalizing cognition and reward.⁷ There are appropriate concerns about adverse effects, especially metabolic syndrome and obesity, with olanzapine, but patients can have different profiles of receptor sensitivity. In my conversations with Ms. A’s primary care physician and GI specialist, metabolic syndrome was not an issue. Clearly, low-dose olanzapine was very helpful in her treatment.

Daniel Storch, MD
Key Point Health Services
Catonsville, Maryland

References

1. Goodnick PJ, Barrios CA. Use of olanzapine in non-psychotic psychiatric disorders. Expert Opin Pharmacother. 2001;2(4):667-680.
2. Brewerton TD. Psychopharmacologic management of eating disorders. Presented at: 25th Annual National Psychopharmacology Update; February 2020; Las Vegas, Nevada. Accessed December 8, 2020. https://legacy.audio-digest.org/pages/htmlos/pastissues.html?sub1=psychiatry&sub2=2020
3. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association; 2013.
4. Brewerton TD, D’Agostino M. Adjunctive use of olanzapine in the treatment of avoidant restrictive food intake disorder in children and adolescents in an eating disorders program. J Child Adolesc Psychopharmacol. 2017;27(10):920-922.
5. Lobos CA, Komossa K, Rummel-Kluge C, et al. Clozapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010;(11):CD006633.
6. Komossa K, Rummel-Kluge C, Hunger H, et al. Olanzapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010;(3):CD006654.
7. Bachner-Melman R, Lerer E, Zohar AH, et al. Anorexia nervosa, perfectionism, and dopamine D4 receptor (DRD4). Am J Med Genet B Neuropsychiatr Genet. 2007;144B(6):748-756.

Continue to: Neuro-politics and academic paralysis...

Neuro-politics and academic paralysis

I commend Dr. Nasrallah for his brief, precisely defined, scientific editorial “Neuro-politics: Will you vote with your cortex or limbic system?” (From the Editor, Current Psychiatry. October 2020, p. 14-15,63). Furthermore, he has demonstrated an admirable intellectual juggling ability to discuss politics while staying off it. This is no easy task when we witness stress, fear, and loathing from the media in the streets and academic institutes.

I would like to see Current Psychiatry and the academic psychiatric community dig deeper into what I will term as the emerging academic paralysis. Psychiatric forums and publications have been sheepish about addressing, probing, and analyzing the bitter divisions in the United States and in other nations. It appears apropos to Dr. Nasrallah’s editorial that the limbic system has trumped the prefrontal cortex. As in adolescence, this process has risks, because brain regions governing reward, impulsivity, and sensation-seeking have become—due to the choice of the “Bon Ton” political-correctness church—more influential than higher-order cognitive regions regulating behavioral inhibition, decision-making, and planning,

Similar to a hurricane or tsunami that pushes water into a river, this retro­grade shift of feedback pathways is demonstrated by emotional narratives that have flooded the public and drowned facts and evidence-based practice. Furthermore, the science of convenience has emerged, where facts are eligible only if they justify the narrative. Any discussion, debate, or questioning of the rationale of the approach is met with hostility, naming, shaming, and even loss of employment at universities. I have sadly learned from frightened colleagues and from reading reports by academicians whose publications have been either rejected or coerced for revision following acceptance by a peer-reviewed journal or even retracted post-publication due to complaints, harassment, and threats by the politically correct “thought police.” Diversity of thinking and freedom of speech—core values and principles in academic dialogue—have been violated. Academicians are as perplexed as laboratory rats that need to learn which lever to push in order to receive a reward and avoid punishment in an ever-shifting environment. People have been pondering, “Is it time for flight, fright, or fight?” As Buffalo Springfield’s legendary Vietnam 1960s–era song “For What it’s Worth” states: “There’s battle lines being drawn and nobody’s right if everybody’s wrong.”

What we have learned from history is that the majority of people exercise passivity and hope as bystanders in order to avoid becoming victims of “collateral damage.” Are there no modern Giordano Bruno (the martyr of science), Copernicus, or Michelangelo who would challenge the “Church of the People” that has created new language, terminology, and culture and is on the verge of creating nouveau scientific principles that could lead to a monopoly of one segment of society that threatens pluralism of thought. Do we need dystopic books such as 1984 or Fahrenheit 451, or the experience of the French and Russian revolution (epitomized by the guillotine and the gulag) to remind us that we are a step away from education and reprogramming camps that used to be called universities? The American Association of University Professors’ most recent announcement on academic freedom ominously avoids using terms such as freedom of speech, diversity of opinions, or even pluralism.

I hope that psychiatrists will lead the way back to sanity, starting with focus groups and forums. It would amount to a group cognitive-behavioral therapy of immense proportion following a paradigm of “Problem Solving,” according to Albert Bandura’s social learning model. There is simply no other constructive way to get to the cheese at the end of the maze.

Yifrah Kaminer, MD

Professor Emeritus of Psychiatry & Pediatrics
University of Connecticut School of Medicine
Farmington, Connecticut

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

COVID-19 and decision-making capacity

Dr. Ryznar’s article “Evaluating patients’ decision-making capacity during COVID-19” (Evidence-Based Reviews, Current Psychiatry. October 2020, p. 34-40) provides a cogent overview of the “threshold” or “gradient” approach to capacity evaluations, wherein the assessment of a patient’s decisional capacity hinges on the risks and benefits of the specific clinical intervention. From a medico­legal perspective, however, I am concerned that Dr. Ryznar makes a consequential category error in framing sociopolitically-driven noncompliance with infectious disease control measures as a capacity problem. In the United States, public health powers—including the use of isolation and quarantine—fall to properly constituted public health authorities, predominantly at the state and local levels. An infectious patient with suspect ideas about coronavirus disease 2019 (COVID-19) whose decision-making process is not directly compromised by neurocognitive illness does not present a capacity issue, but rather a potential public health issue.

For example, in a controversial 2007 case in Atlanta, Georgia, an attorney with active tuberculosis failed to heed medical advice to refrain from traveling.¹ The patient’s uncooperativeness did not implicate concerns over his decisional capacity.¹ However, his international and interstate travel triggered the Centers for Disease Control and Prevention’s legal authority under the Public Health Service Act to prevent the entry and spread of communicable disease.^1-3 An authorized order from a duly constituted public health authority is issued and enforceable without regard to clinical determinations of capacity (and is generally subject to challenge via judicial or other due process mechanisms as a government-sanctioned deprivation of liberty to protect public welfare). State laws and local ordinances require physicians to notify the appropriate public health department when patients test positive for certain contagious diseases.

The difficulty with involuntarily detaining a cognitively intact patient due to concern over their contagion risk and erroneous beliefs runs considerably deeper than eliciting a “political backlash” or managing the qualms of hospital security officers. It is a fundamental matter of proper legal authority. Psychiatrists and other physicians assess patients’ decision-making capacity for specific treatment decisions on a case-by-case basis, seeking to preserve autonomy while practicing beneficence. Public health officers are agents of the state with designated authorities to control the spread of disease. A capacity determination in the absence of neurocognitive deficits implies the psychiatrist is evaluating the soundness of the patient’s ideas as opposed to their cognition, overlooking the reality that fully capable individuals can possess dubious—and even unsalutary—beliefs. While physicians educate patients about the risks of contracting and communicating infection, they are thankfully not tasked with arbitrating sociopolitical disputes at the bedside. Such controversies regarding pandemic response do not belong under the rubric of medical decision-making capacity. Conflating psychosomatic medicine consultations with public health orders risks unmooring capacity determinations from their medicolegal and bioethical foundations.

Charles G. Kels, JD
S Army Medical Center of Excellence
San Antonio, Texas  

Disclaimer: The views expressed here are those of the author and do not necessarily reflect those of any government agency.

References

1. Tanne JH. Tuberculosis case exposes flaws in international public health systems. BMJ. 2007;334(7605):1187.
2. Public Health Service Act, 42 USC § 264-272 (1944).
3. Interstate and Foreign Quarantine, 42 CFR Parts 70-71 (2017).

The author responds

I appreciate Mr. Kels’s letter and explicit discussion of the limits of decision-making capacity. I agree that physicians should not overstep their legal authority and ethical mandate. The specific case discussed in my article was a patient who was symptomatic from COVID-19 who wanted to leave the hospital against medical advice. The contagious nature of this virus certainly falls under the risk/benefit analysis of the clinical situation because it is an important aspect of understanding the nature of the illness and treatment/recovery process (as a thought example, consider that such a patient lives with their elderly mother who has heart disease and chronic obstructive pulmonary disease, and the patient does not want their mother to die). From a medico­legal perspective, the risk of infection to others may not necessarily outweigh the benefit of autonomy, especially because decision-making capacity assessments are made with the purpose of balancing autonomy and beneficence of the patient, not others. I highlighted the relative importance of autonomy using the weight of the arrows in Figure 2 of my article. I did not task physicians with arbitrating sociopolitical disputes, but merely highlighted how the current climate can impact people’s personal views on COVID-19, which sometimes can run counter to scientific evidence. If a patient has an erroneous view about an illness, it is our duty to try to help them understand if it directly impacts their health or affects their decision-making process, especially in a high-stakes clinical scenario.

Elizabeth Ryznar, MD, MSc
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins School of Medicine
Baltimore, Maryland

Continue to: Olanzapine for treatment-resistant anxiety

Olanzapine for treatment-resistant anxiety

Ms. A, age 62, was a retired high school teacher. Her primary care physician referred her to me for persistent, disabling anxiety. Her condition was recently worsened by a trial of escitalopram, 5 mg/d, which led her to visit the emergency department (ED). There she was prescribed lorazepam, 0.5 mg as needed, which helped her somewhat. Her medical conditions included prominent gastrointestinal (GI) symptoms, with nausea and a restricted diet; tinnitus; and chronic bilateral hand tremors. Her initial Patient Health Questionnaire-9 (PHQ-9) score was 11, and her Generalized Anxiety Disorder-7 (GAD-7) score was 10.

Initially, I encouraged Ms. A to exercise regularly, and I changed her lorazepam from 0.5 mg as-needed to 0.5 mg twice a day. I also referred her to a psychologist for psychotherapy. She showed limited improvement. I increased her lorazepam to 1 mg 3 times a day and started sertraline, 12.5 mg/d, but she soon experienced chest tightness and was admitted to the ED for observation and a cardiac workup. After she visited the ED, Ms. A stopped taking sertraline.

When I next saw Ms. A, she agreed to a trial of olanzapine, 2.5 mg/d at bedtime. Three weeks later, she told me, “I feel so much better.” Her scores on the PHQ-9 and GAD-7 were 0 and 1, respectively. Her GI complaints decreased, she had gained a little weight, and her tinnitus bothered her less. Lorazepam was gradually decreased and stopped.

After approximately 2 years, Ms. A had experienced no long-term adverse effects. We agreed to gradually discontinue olanzapine. Over the next 4 months, Ms. A decreased and stopped taking olanzapine at her own discretion.Three weeks after she stopped taking olanzapine, Ms. A reported that her psychiatric and GI symptoms had returned. She still maintained weekly visits with her psychotherapist. Her GI specialist asked if I could prescribe her olanzapine again. I restarted Ms. A on olanzapine, 2.5 mg/d at bedtime. By the next month, she said she felt much better (PHQ-9: 0; GAD-7: 1). I last saw Ms. A approximately 1 year ago.

Over the years, I have usually prescribed low-dose olanzapine alone or with other medications for patients with treatment-resistance who had no overt psychotic symptoms, I have used this medication for patients with “soft” psychotic thinking marked by severe anxiety, obsessions, compulsivity, perfectionism, and/or rumination.¹ Evidence suggests olanzapine also may be effective for anorexia nervosa.² There is good evidence for its use in the DSM-5 diagnosis of avoidant/restrictive food intake disorder (“a food avoidance emotional disorder”).^3,4 In retrospect, Ms. A also likely met the criteria for the diagnosis of unspecified eating disorder. Despite extensive GI workup and follow-up, physical signs of GI pathology were equivocal.

Among antipsychotics, olanzapine most closely resembles clozapine, the only antipsychotic that has been proved more efficacious than others for psychotic symptoms.⁵ There is also some research suggesting that olanzapine may be more efficacious.⁶ Obsessions and perfectionism are associated with dopamine D4 receptor activity, and D1, D2, and D3 receptors are involved in normalizing cognition and reward.⁷ There are appropriate concerns about adverse effects, especially metabolic syndrome and obesity, with olanzapine, but patients can have different profiles of receptor sensitivity. In my conversations with Ms. A’s primary care physician and GI specialist, metabolic syndrome was not an issue. Clearly, low-dose olanzapine was very helpful in her treatment.

Daniel Storch, MD
Key Point Health Services
Catonsville, Maryland

References

1. Goodnick PJ, Barrios CA. Use of olanzapine in non-psychotic psychiatric disorders. Expert Opin Pharmacother. 2001;2(4):667-680.
2. Brewerton TD. Psychopharmacologic management of eating disorders. Presented at: 25th Annual National Psychopharmacology Update; February 2020; Las Vegas, Nevada. Accessed December 8, 2020. https://legacy.audio-digest.org/pages/htmlos/pastissues.html?sub1=psychiatry&sub2=2020
3. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association; 2013.
4. Brewerton TD, D’Agostino M. Adjunctive use of olanzapine in the treatment of avoidant restrictive food intake disorder in children and adolescents in an eating disorders program. J Child Adolesc Psychopharmacol. 2017;27(10):920-922.
5. Lobos CA, Komossa K, Rummel-Kluge C, et al. Clozapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010;(11):CD006633.
6. Komossa K, Rummel-Kluge C, Hunger H, et al. Olanzapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010;(3):CD006654.
7. Bachner-Melman R, Lerer E, Zohar AH, et al. Anorexia nervosa, perfectionism, and dopamine D4 receptor (DRD4). Am J Med Genet B Neuropsychiatr Genet. 2007;144B(6):748-756.

Continue to: Neuro-politics and academic paralysis...

Neuro-politics and academic paralysis

I commend Dr. Nasrallah for his brief, precisely defined, scientific editorial “Neuro-politics: Will you vote with your cortex or limbic system?” (From the Editor, Current Psychiatry. October 2020, p. 14-15,63). Furthermore, he has demonstrated an admirable intellectual juggling ability to discuss politics while staying off it. This is no easy task when we witness stress, fear, and loathing from the media in the streets and academic institutes.

I would like to see Current Psychiatry and the academic psychiatric community dig deeper into what I will term as the emerging academic paralysis. Psychiatric forums and publications have been sheepish about addressing, probing, and analyzing the bitter divisions in the United States and in other nations. It appears apropos to Dr. Nasrallah’s editorial that the limbic system has trumped the prefrontal cortex. As in adolescence, this process has risks, because brain regions governing reward, impulsivity, and sensation-seeking have become—due to the choice of the “Bon Ton” political-correctness church—more influential than higher-order cognitive regions regulating behavioral inhibition, decision-making, and planning,

Similar to a hurricane or tsunami that pushes water into a river, this retro­grade shift of feedback pathways is demonstrated by emotional narratives that have flooded the public and drowned facts and evidence-based practice. Furthermore, the science of convenience has emerged, where facts are eligible only if they justify the narrative. Any discussion, debate, or questioning of the rationale of the approach is met with hostility, naming, shaming, and even loss of employment at universities. I have sadly learned from frightened colleagues and from reading reports by academicians whose publications have been either rejected or coerced for revision following acceptance by a peer-reviewed journal or even retracted post-publication due to complaints, harassment, and threats by the politically correct “thought police.” Diversity of thinking and freedom of speech—core values and principles in academic dialogue—have been violated. Academicians are as perplexed as laboratory rats that need to learn which lever to push in order to receive a reward and avoid punishment in an ever-shifting environment. People have been pondering, “Is it time for flight, fright, or fight?” As Buffalo Springfield’s legendary Vietnam 1960s–era song “For What it’s Worth” states: “There’s battle lines being drawn and nobody’s right if everybody’s wrong.”

What we have learned from history is that the majority of people exercise passivity and hope as bystanders in order to avoid becoming victims of “collateral damage.” Are there no modern Giordano Bruno (the martyr of science), Copernicus, or Michelangelo who would challenge the “Church of the People” that has created new language, terminology, and culture and is on the verge of creating nouveau scientific principles that could lead to a monopoly of one segment of society that threatens pluralism of thought. Do we need dystopic books such as 1984 or Fahrenheit 451, or the experience of the French and Russian revolution (epitomized by the guillotine and the gulag) to remind us that we are a step away from education and reprogramming camps that used to be called universities? The American Association of University Professors’ most recent announcement on academic freedom ominously avoids using terms such as freedom of speech, diversity of opinions, or even pluralism.

I hope that psychiatrists will lead the way back to sanity, starting with focus groups and forums. It would amount to a group cognitive-behavioral therapy of immense proportion following a paradigm of “Problem Solving,” according to Albert Bandura’s social learning model. There is simply no other constructive way to get to the cheese at the end of the maze.

Yifrah Kaminer, MD

Professor Emeritus of Psychiatry & Pediatrics
University of Connecticut School of Medicine
Farmington, Connecticut

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

COVID-19 and decision-making capacity

Dr. Ryznar’s article “Evaluating patients’ decision-making capacity during COVID-19” (Evidence-Based Reviews, Current Psychiatry. October 2020, p. 34-40) provides a cogent overview of the “threshold” or “gradient” approach to capacity evaluations, wherein the assessment of a patient’s decisional capacity hinges on the risks and benefits of the specific clinical intervention. From a medico­legal perspective, however, I am concerned that Dr. Ryznar makes a consequential category error in framing sociopolitically-driven noncompliance with infectious disease control measures as a capacity problem. In the United States, public health powers—including the use of isolation and quarantine—fall to properly constituted public health authorities, predominantly at the state and local levels. An infectious patient with suspect ideas about coronavirus disease 2019 (COVID-19) whose decision-making process is not directly compromised by neurocognitive illness does not present a capacity issue, but rather a potential public health issue.

For example, in a controversial 2007 case in Atlanta, Georgia, an attorney with active tuberculosis failed to heed medical advice to refrain from traveling.¹ The patient’s uncooperativeness did not implicate concerns over his decisional capacity.¹ However, his international and interstate travel triggered the Centers for Disease Control and Prevention’s legal authority under the Public Health Service Act to prevent the entry and spread of communicable disease.^1-3 An authorized order from a duly constituted public health authority is issued and enforceable without regard to clinical determinations of capacity (and is generally subject to challenge via judicial or other due process mechanisms as a government-sanctioned deprivation of liberty to protect public welfare). State laws and local ordinances require physicians to notify the appropriate public health department when patients test positive for certain contagious diseases.

The difficulty with involuntarily detaining a cognitively intact patient due to concern over their contagion risk and erroneous beliefs runs considerably deeper than eliciting a “political backlash” or managing the qualms of hospital security officers. It is a fundamental matter of proper legal authority. Psychiatrists and other physicians assess patients’ decision-making capacity for specific treatment decisions on a case-by-case basis, seeking to preserve autonomy while practicing beneficence. Public health officers are agents of the state with designated authorities to control the spread of disease. A capacity determination in the absence of neurocognitive deficits implies the psychiatrist is evaluating the soundness of the patient’s ideas as opposed to their cognition, overlooking the reality that fully capable individuals can possess dubious—and even unsalutary—beliefs. While physicians educate patients about the risks of contracting and communicating infection, they are thankfully not tasked with arbitrating sociopolitical disputes at the bedside. Such controversies regarding pandemic response do not belong under the rubric of medical decision-making capacity. Conflating psychosomatic medicine consultations with public health orders risks unmooring capacity determinations from their medicolegal and bioethical foundations.

Charles G. Kels, JD
S Army Medical Center of Excellence
San Antonio, Texas  

Disclaimer: The views expressed here are those of the author and do not necessarily reflect those of any government agency.

References

1. Tanne JH. Tuberculosis case exposes flaws in international public health systems. BMJ. 2007;334(7605):1187.
2. Public Health Service Act, 42 USC § 264-272 (1944).
3. Interstate and Foreign Quarantine, 42 CFR Parts 70-71 (2017).

The author responds

I appreciate Mr. Kels’s letter and explicit discussion of the limits of decision-making capacity. I agree that physicians should not overstep their legal authority and ethical mandate. The specific case discussed in my article was a patient who was symptomatic from COVID-19 who wanted to leave the hospital against medical advice. The contagious nature of this virus certainly falls under the risk/benefit analysis of the clinical situation because it is an important aspect of understanding the nature of the illness and treatment/recovery process (as a thought example, consider that such a patient lives with their elderly mother who has heart disease and chronic obstructive pulmonary disease, and the patient does not want their mother to die). From a medico­legal perspective, the risk of infection to others may not necessarily outweigh the benefit of autonomy, especially because decision-making capacity assessments are made with the purpose of balancing autonomy and beneficence of the patient, not others. I highlighted the relative importance of autonomy using the weight of the arrows in Figure 2 of my article. I did not task physicians with arbitrating sociopolitical disputes, but merely highlighted how the current climate can impact people’s personal views on COVID-19, which sometimes can run counter to scientific evidence. If a patient has an erroneous view about an illness, it is our duty to try to help them understand if it directly impacts their health or affects their decision-making process, especially in a high-stakes clinical scenario.

Elizabeth Ryznar, MD, MSc
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins School of Medicine
Baltimore, Maryland

Continue to: Olanzapine for treatment-resistant anxiety

Olanzapine for treatment-resistant anxiety

Ms. A, age 62, was a retired high school teacher. Her primary care physician referred her to me for persistent, disabling anxiety. Her condition was recently worsened by a trial of escitalopram, 5 mg/d, which led her to visit the emergency department (ED). There she was prescribed lorazepam, 0.5 mg as needed, which helped her somewhat. Her medical conditions included prominent gastrointestinal (GI) symptoms, with nausea and a restricted diet; tinnitus; and chronic bilateral hand tremors. Her initial Patient Health Questionnaire-9 (PHQ-9) score was 11, and her Generalized Anxiety Disorder-7 (GAD-7) score was 10.

Initially, I encouraged Ms. A to exercise regularly, and I changed her lorazepam from 0.5 mg as-needed to 0.5 mg twice a day. I also referred her to a psychologist for psychotherapy. She showed limited improvement. I increased her lorazepam to 1 mg 3 times a day and started sertraline, 12.5 mg/d, but she soon experienced chest tightness and was admitted to the ED for observation and a cardiac workup. After she visited the ED, Ms. A stopped taking sertraline.

When I next saw Ms. A, she agreed to a trial of olanzapine, 2.5 mg/d at bedtime. Three weeks later, she told me, “I feel so much better.” Her scores on the PHQ-9 and GAD-7 were 0 and 1, respectively. Her GI complaints decreased, she had gained a little weight, and her tinnitus bothered her less. Lorazepam was gradually decreased and stopped.

After approximately 2 years, Ms. A had experienced no long-term adverse effects. We agreed to gradually discontinue olanzapine. Over the next 4 months, Ms. A decreased and stopped taking olanzapine at her own discretion.Three weeks after she stopped taking olanzapine, Ms. A reported that her psychiatric and GI symptoms had returned. She still maintained weekly visits with her psychotherapist. Her GI specialist asked if I could prescribe her olanzapine again. I restarted Ms. A on olanzapine, 2.5 mg/d at bedtime. By the next month, she said she felt much better (PHQ-9: 0; GAD-7: 1). I last saw Ms. A approximately 1 year ago.

Over the years, I have usually prescribed low-dose olanzapine alone or with other medications for patients with treatment-resistance who had no overt psychotic symptoms, I have used this medication for patients with “soft” psychotic thinking marked by severe anxiety, obsessions, compulsivity, perfectionism, and/or rumination.¹ Evidence suggests olanzapine also may be effective for anorexia nervosa.² There is good evidence for its use in the DSM-5 diagnosis of avoidant/restrictive food intake disorder (“a food avoidance emotional disorder”).^3,4 In retrospect, Ms. A also likely met the criteria for the diagnosis of unspecified eating disorder. Despite extensive GI workup and follow-up, physical signs of GI pathology were equivocal.

Among antipsychotics, olanzapine most closely resembles clozapine, the only antipsychotic that has been proved more efficacious than others for psychotic symptoms.⁵ There is also some research suggesting that olanzapine may be more efficacious.⁶ Obsessions and perfectionism are associated with dopamine D4 receptor activity, and D1, D2, and D3 receptors are involved in normalizing cognition and reward.⁷ There are appropriate concerns about adverse effects, especially metabolic syndrome and obesity, with olanzapine, but patients can have different profiles of receptor sensitivity. In my conversations with Ms. A’s primary care physician and GI specialist, metabolic syndrome was not an issue. Clearly, low-dose olanzapine was very helpful in her treatment.

Daniel Storch, MD
Key Point Health Services
Catonsville, Maryland

References

1. Goodnick PJ, Barrios CA. Use of olanzapine in non-psychotic psychiatric disorders. Expert Opin Pharmacother. 2001;2(4):667-680.
2. Brewerton TD. Psychopharmacologic management of eating disorders. Presented at: 25th Annual National Psychopharmacology Update; February 2020; Las Vegas, Nevada. Accessed December 8, 2020. https://legacy.audio-digest.org/pages/htmlos/pastissues.html?sub1=psychiatry&sub2=2020
3. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association; 2013.
4. Brewerton TD, D’Agostino M. Adjunctive use of olanzapine in the treatment of avoidant restrictive food intake disorder in children and adolescents in an eating disorders program. J Child Adolesc Psychopharmacol. 2017;27(10):920-922.
5. Lobos CA, Komossa K, Rummel-Kluge C, et al. Clozapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010;(11):CD006633.
6. Komossa K, Rummel-Kluge C, Hunger H, et al. Olanzapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010;(3):CD006654.
7. Bachner-Melman R, Lerer E, Zohar AH, et al. Anorexia nervosa, perfectionism, and dopamine D4 receptor (DRD4). Am J Med Genet B Neuropsychiatr Genet. 2007;144B(6):748-756.

Continue to: Neuro-politics and academic paralysis...

Neuro-politics and academic paralysis

I commend Dr. Nasrallah for his brief, precisely defined, scientific editorial “Neuro-politics: Will you vote with your cortex or limbic system?” (From the Editor, Current Psychiatry. October 2020, p. 14-15,63). Furthermore, he has demonstrated an admirable intellectual juggling ability to discuss politics while staying off it. This is no easy task when we witness stress, fear, and loathing from the media in the streets and academic institutes.

I would like to see Current Psychiatry and the academic psychiatric community dig deeper into what I will term as the emerging academic paralysis. Psychiatric forums and publications have been sheepish about addressing, probing, and analyzing the bitter divisions in the United States and in other nations. It appears apropos to Dr. Nasrallah’s editorial that the limbic system has trumped the prefrontal cortex. As in adolescence, this process has risks, because brain regions governing reward, impulsivity, and sensation-seeking have become—due to the choice of the “Bon Ton” political-correctness church—more influential than higher-order cognitive regions regulating behavioral inhibition, decision-making, and planning,

Similar to a hurricane or tsunami that pushes water into a river, this retro­grade shift of feedback pathways is demonstrated by emotional narratives that have flooded the public and drowned facts and evidence-based practice. Furthermore, the science of convenience has emerged, where facts are eligible only if they justify the narrative. Any discussion, debate, or questioning of the rationale of the approach is met with hostility, naming, shaming, and even loss of employment at universities. I have sadly learned from frightened colleagues and from reading reports by academicians whose publications have been either rejected or coerced for revision following acceptance by a peer-reviewed journal or even retracted post-publication due to complaints, harassment, and threats by the politically correct “thought police.” Diversity of thinking and freedom of speech—core values and principles in academic dialogue—have been violated. Academicians are as perplexed as laboratory rats that need to learn which lever to push in order to receive a reward and avoid punishment in an ever-shifting environment. People have been pondering, “Is it time for flight, fright, or fight?” As Buffalo Springfield’s legendary Vietnam 1960s–era song “For What it’s Worth” states: “There’s battle lines being drawn and nobody’s right if everybody’s wrong.”

What we have learned from history is that the majority of people exercise passivity and hope as bystanders in order to avoid becoming victims of “collateral damage.” Are there no modern Giordano Bruno (the martyr of science), Copernicus, or Michelangelo who would challenge the “Church of the People” that has created new language, terminology, and culture and is on the verge of creating nouveau scientific principles that could lead to a monopoly of one segment of society that threatens pluralism of thought. Do we need dystopic books such as 1984 or Fahrenheit 451, or the experience of the French and Russian revolution (epitomized by the guillotine and the gulag) to remind us that we are a step away from education and reprogramming camps that used to be called universities? The American Association of University Professors’ most recent announcement on academic freedom ominously avoids using terms such as freedom of speech, diversity of opinions, or even pluralism.

I hope that psychiatrists will lead the way back to sanity, starting with focus groups and forums. It would amount to a group cognitive-behavioral therapy of immense proportion following a paradigm of “Problem Solving,” according to Albert Bandura’s social learning model. There is simply no other constructive way to get to the cheese at the end of the maze.

Yifrah Kaminer, MD

Professor Emeritus of Psychiatry & Pediatrics
University of Connecticut School of Medicine
Farmington, Connecticut

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.