Commentary

Hospital in Home (HIH) is the delivery of acute care services in a patient’s home as an alternative to hospitalization.¹ Compared with traditional inpatient care, HIH programs have been associated with reduced costs, as well as patient and caregiver satisfaction, diseasespecific outcomes, and mortality rates that were similar or improved compared with inpatient admissions.^1-4

The US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) and other hospital systems are increasingly adopting HIH models.^2-4 At the time of this writing, there were 12 HIH programs in VHA (personal communication, D. Cooper, 2/28/2022). In addition to physicians and nurses, the interdisciplinary HIH team may include a pharmacist, social worker, and registered dietitian nutritionist (RDN).^2,5 HIH programs have been shown to improve nutritional status as measured by the Mini Nutritional Assessment Score, but overall, there is a paucity of published information regarding the provision of nutrition care in HIH.⁶ The role of the RDN has varied within VHA. Some sites, such as the Sacramento VA Medical Center in California, include a distinct RDN position on the HIH team, whereas others, such as the Spark M. Matsunaga VA Medical Center in Honolulu, Hawaii, and the James A. Haley Veterans’ Hospital in Tampa, Florida, consult clinic RDNs.

Since HIH programs typically treat conditions for which diet is an inherent part of the treatment (eg, congestive heart failure [CHF]), there is a need to precisely define the role of the RDN within the HIH model.^2,3,7 Drawing from my experience as an HIH RDN, I will describe how the inclusion of an RDN position within the HIH team is optimal for health care delivery and how HIH practitioners can best utilize RDN services.

RDN Role in HIH Team

Delegating nutrition services to an RDN enhances patient care by empowering HIH team members to function at the highest level of their scope of practice. RDNs have been recognized by physicians as the most qualified health care professionals to help patients with diet-related conditions, such as obesity, and physicians also have reported a desire for additional training in nutrition.⁸ Although home-health nurses have frequently performed nutrition assessments and interventions, survey results have indicated that many nurses do not feel confident in teaching complex nutritional information^.9 In my experience, many HIH patients are nutritionally complex, with more than one condition requiring nutrition intervention. For example, patients may be admitted to HIH for management of CHF, but they may also have diabetes mellitus (DM), obesity, and low socioeconomic status. The HIH RDN can address the nutrition aspects of these conditions, freeing time for physicians and nurses to focus on their respective areas of expertise.^9,10 Moreover, the RDN can also provide dietary education to the HIH team to increase their knowledge of nutritional topics and promote consistent messaging to patients.

Including an RDN on the HIH team enables patients to have comprehensive, personalized nutrition care. Rather than merely offering generalized nutrition education, RDNs are trained to provide medical nutrition therapy (MNT), which has been shown to improve health outcomes and be cost-effective for conditions such as type 2 DM, chronic kidney disease, hypertension, and obesity.^10,11 In MNT, RDNs use the standardized 4-stepnutrition care process (NCP).¹² The Table shows examples of how the NCP can be applied in HIH settings. Furthermore, in my experience, MNT from an RDN also contributes to patient satisfaction. Subjective observations from my team have indicated that patients often express more confidence in managing their diets by the time of HIH discharge.

RDNs can guide physicians and pharmacists in ordering oral nutrition supplements (ONS). Within the VHA, a “food first” approach is preferred to increase caloric intake, and patients must meet specific criteria for prescription of an ONS.¹³ Furthermore, ONS designed for specific medical conditions (eg, chronic kidney disease) are considered nonformulary and require an RDN evaluation.¹³ Including an RDN on the HIH team allows this evaluation process to begin early in the patient’s admission to the program and ensures that provision of ONS is clinically appropriate and cost-effective.

Care Coordination

HIH is highly interdisciplinary. Team members perform their respective roles and communicate with the team throughout the day. RDNs can help monitor patients and alert physicians for changes in blood glucose, gastrointestinal concerns, and weight. This is especially helpful for patients who do not have a planned nursing visit on the day of an RDN evaluation. The HIH RDN can also collaborate with other team members to address patient needs. For example, for patients with limited financial resources, the HIH RDN can provide nutrition education regarding cooking on a budget, and the HIH social worker can arrange free or low-cost meal services.

Tips

When hiring an HIH RDN, seek candidates with experience in inpatient, outpatient, and home care settings. As a hybrid of these 3 areas, the HIH RDN position requires a unique combination of acute care skills and health coaching. Additionally, in my experience, the HIH RDN interacts more frequently with the HIH team than other RDN colleagues, so it is important that candidates can work independently and take initiative. This type of position would not be suitable for entry-level RDNs.

Stagger HIH team visits to prevent overwhelming the patient and caregivers. Early in our program, my team quickly learned that patients and caregivers can feel overwhelmed with too many home visits upon admission to HIH. After seeing multiple HIH team members the same day, they were often too tired to focus well on diet education during my visit. Staggering visits (eg, completing the initial nutrition assessment 1 day to 1 week after the initial medical and pharmacy visits) has been an effective strategy to address this problem. Furthermore, some patients prefer that the initial RDN appointment is conducted by telephone, with an inperson reassessment the following week. In my experience, HIH workflow is dynamic by nature, so it is crucial to remain flexible and accommodate individual patient needs as much as possible.

Dietary behavior change is a long-term process, and restrictive hospital diets can be challenging to replicate at home. In a hospital setting, clinicians can order a specialized diet (eg, low sodium with fluid restriction for CHF patients), whereas efforts to implement these restrictions in the home setting can be cumbersome and negatively impact quality of life.^7,14 Nevertheless, the effectiveness of medical treatment is compromised when patients do not adhere to dietary recommendations. Meal delivery services that offer specialized diets can be a useful resource for patients and caregivers who are unable to cook, and the HIH RDN can assist patients in ordering these services.

HIH patients may vary in terms of readiness to make dietary changes, and in addition to nutrition education, nutrition counseling is usually needed to effect behavior change. My team has found that consideration of the transtheoretical/ stages of change model can be a helpful approach. ¹⁵ The HIH RDN can tailor nutrition interventions to the patient’s stage of change. For example, for patients in the precontemplation stage, the HIH RDN would focus on providing information and addressing emotional aspects of dietary change. In contrast, for patients in the action stage of change, the HIH RDN might emphasize behavioral skill training and social support.¹⁵ Particularly for patients in the early stages of change, it may be unrealistic to expect full adoption of the recommended diet within the 30 days of the HIH program. However, by acknowledging the reality of the patient’s stage of change, the HIH RDN and team can then collaborate to support the patient in moving toward the next stage. Patients who are not ready for dietary behavior change during the 30 days of HIH may benefit from longer-term support, and the HIH RDN can arrange followup care with an outpatient RDN.

Conclusions

As the HIH model continues to be adopted across the VHA and other health care systems, it is crucial to consider the value and expertise of an RDN for guiding nutrition care in the HIH setting. The HIH RDN contributes to optimal health care delivery by leading nutritional aspects of patient care, offering personalized MNT, and coordinating and collaborating with team members to meet individual patient needs. An RDN can serve as a valuable resource for nutrition information and enhance the team’s overall services, with the potential to impact clinical outcomes and patient satisfaction.

Hospital in Home (HIH) is the delivery of acute care services in a patient’s home as an alternative to hospitalization.¹ Compared with traditional inpatient care, HIH programs have been associated with reduced costs, as well as patient and caregiver satisfaction, diseasespecific outcomes, and mortality rates that were similar or improved compared with inpatient admissions.^1-4

The US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) and other hospital systems are increasingly adopting HIH models.^2-4 At the time of this writing, there were 12 HIH programs in VHA (personal communication, D. Cooper, 2/28/2022). In addition to physicians and nurses, the interdisciplinary HIH team may include a pharmacist, social worker, and registered dietitian nutritionist (RDN).^2,5 HIH programs have been shown to improve nutritional status as measured by the Mini Nutritional Assessment Score, but overall, there is a paucity of published information regarding the provision of nutrition care in HIH.⁶ The role of the RDN has varied within VHA. Some sites, such as the Sacramento VA Medical Center in California, include a distinct RDN position on the HIH team, whereas others, such as the Spark M. Matsunaga VA Medical Center in Honolulu, Hawaii, and the James A. Haley Veterans’ Hospital in Tampa, Florida, consult clinic RDNs.

Since HIH programs typically treat conditions for which diet is an inherent part of the treatment (eg, congestive heart failure [CHF]), there is a need to precisely define the role of the RDN within the HIH model.^2,3,7 Drawing from my experience as an HIH RDN, I will describe how the inclusion of an RDN position within the HIH team is optimal for health care delivery and how HIH practitioners can best utilize RDN services.

RDN Role in HIH Team

Delegating nutrition services to an RDN enhances patient care by empowering HIH team members to function at the highest level of their scope of practice. RDNs have been recognized by physicians as the most qualified health care professionals to help patients with diet-related conditions, such as obesity, and physicians also have reported a desire for additional training in nutrition.⁸ Although home-health nurses have frequently performed nutrition assessments and interventions, survey results have indicated that many nurses do not feel confident in teaching complex nutritional information^.9 In my experience, many HIH patients are nutritionally complex, with more than one condition requiring nutrition intervention. For example, patients may be admitted to HIH for management of CHF, but they may also have diabetes mellitus (DM), obesity, and low socioeconomic status. The HIH RDN can address the nutrition aspects of these conditions, freeing time for physicians and nurses to focus on their respective areas of expertise.^9,10 Moreover, the RDN can also provide dietary education to the HIH team to increase their knowledge of nutritional topics and promote consistent messaging to patients.

Including an RDN on the HIH team enables patients to have comprehensive, personalized nutrition care. Rather than merely offering generalized nutrition education, RDNs are trained to provide medical nutrition therapy (MNT), which has been shown to improve health outcomes and be cost-effective for conditions such as type 2 DM, chronic kidney disease, hypertension, and obesity.^10,11 In MNT, RDNs use the standardized 4-stepnutrition care process (NCP).¹² The Table shows examples of how the NCP can be applied in HIH settings. Furthermore, in my experience, MNT from an RDN also contributes to patient satisfaction. Subjective observations from my team have indicated that patients often express more confidence in managing their diets by the time of HIH discharge.

RDNs can guide physicians and pharmacists in ordering oral nutrition supplements (ONS). Within the VHA, a “food first” approach is preferred to increase caloric intake, and patients must meet specific criteria for prescription of an ONS.¹³ Furthermore, ONS designed for specific medical conditions (eg, chronic kidney disease) are considered nonformulary and require an RDN evaluation.¹³ Including an RDN on the HIH team allows this evaluation process to begin early in the patient’s admission to the program and ensures that provision of ONS is clinically appropriate and cost-effective.

Care Coordination

HIH is highly interdisciplinary. Team members perform their respective roles and communicate with the team throughout the day. RDNs can help monitor patients and alert physicians for changes in blood glucose, gastrointestinal concerns, and weight. This is especially helpful for patients who do not have a planned nursing visit on the day of an RDN evaluation. The HIH RDN can also collaborate with other team members to address patient needs. For example, for patients with limited financial resources, the HIH RDN can provide nutrition education regarding cooking on a budget, and the HIH social worker can arrange free or low-cost meal services.

Tips

When hiring an HIH RDN, seek candidates with experience in inpatient, outpatient, and home care settings. As a hybrid of these 3 areas, the HIH RDN position requires a unique combination of acute care skills and health coaching. Additionally, in my experience, the HIH RDN interacts more frequently with the HIH team than other RDN colleagues, so it is important that candidates can work independently and take initiative. This type of position would not be suitable for entry-level RDNs.

Stagger HIH team visits to prevent overwhelming the patient and caregivers. Early in our program, my team quickly learned that patients and caregivers can feel overwhelmed with too many home visits upon admission to HIH. After seeing multiple HIH team members the same day, they were often too tired to focus well on diet education during my visit. Staggering visits (eg, completing the initial nutrition assessment 1 day to 1 week after the initial medical and pharmacy visits) has been an effective strategy to address this problem. Furthermore, some patients prefer that the initial RDN appointment is conducted by telephone, with an inperson reassessment the following week. In my experience, HIH workflow is dynamic by nature, so it is crucial to remain flexible and accommodate individual patient needs as much as possible.

Dietary behavior change is a long-term process, and restrictive hospital diets can be challenging to replicate at home. In a hospital setting, clinicians can order a specialized diet (eg, low sodium with fluid restriction for CHF patients), whereas efforts to implement these restrictions in the home setting can be cumbersome and negatively impact quality of life.^7,14 Nevertheless, the effectiveness of medical treatment is compromised when patients do not adhere to dietary recommendations. Meal delivery services that offer specialized diets can be a useful resource for patients and caregivers who are unable to cook, and the HIH RDN can assist patients in ordering these services.

HIH patients may vary in terms of readiness to make dietary changes, and in addition to nutrition education, nutrition counseling is usually needed to effect behavior change. My team has found that consideration of the transtheoretical/ stages of change model can be a helpful approach. ¹⁵ The HIH RDN can tailor nutrition interventions to the patient’s stage of change. For example, for patients in the precontemplation stage, the HIH RDN would focus on providing information and addressing emotional aspects of dietary change. In contrast, for patients in the action stage of change, the HIH RDN might emphasize behavioral skill training and social support.¹⁵ Particularly for patients in the early stages of change, it may be unrealistic to expect full adoption of the recommended diet within the 30 days of the HIH program. However, by acknowledging the reality of the patient’s stage of change, the HIH RDN and team can then collaborate to support the patient in moving toward the next stage. Patients who are not ready for dietary behavior change during the 30 days of HIH may benefit from longer-term support, and the HIH RDN can arrange followup care with an outpatient RDN.

Conclusions

As the HIH model continues to be adopted across the VHA and other health care systems, it is crucial to consider the value and expertise of an RDN for guiding nutrition care in the HIH setting. The HIH RDN contributes to optimal health care delivery by leading nutritional aspects of patient care, offering personalized MNT, and coordinating and collaborating with team members to meet individual patient needs. An RDN can serve as a valuable resource for nutrition information and enhance the team’s overall services, with the potential to impact clinical outcomes and patient satisfaction.

Hospital in Home (HIH) is the delivery of acute care services in a patient’s home as an alternative to hospitalization.¹ Compared with traditional inpatient care, HIH programs have been associated with reduced costs, as well as patient and caregiver satisfaction, diseasespecific outcomes, and mortality rates that were similar or improved compared with inpatient admissions.^1-4

The US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) and other hospital systems are increasingly adopting HIH models.^2-4 At the time of this writing, there were 12 HIH programs in VHA (personal communication, D. Cooper, 2/28/2022). In addition to physicians and nurses, the interdisciplinary HIH team may include a pharmacist, social worker, and registered dietitian nutritionist (RDN).^2,5 HIH programs have been shown to improve nutritional status as measured by the Mini Nutritional Assessment Score, but overall, there is a paucity of published information regarding the provision of nutrition care in HIH.⁶ The role of the RDN has varied within VHA. Some sites, such as the Sacramento VA Medical Center in California, include a distinct RDN position on the HIH team, whereas others, such as the Spark M. Matsunaga VA Medical Center in Honolulu, Hawaii, and the James A. Haley Veterans’ Hospital in Tampa, Florida, consult clinic RDNs.

Since HIH programs typically treat conditions for which diet is an inherent part of the treatment (eg, congestive heart failure [CHF]), there is a need to precisely define the role of the RDN within the HIH model.^2,3,7 Drawing from my experience as an HIH RDN, I will describe how the inclusion of an RDN position within the HIH team is optimal for health care delivery and how HIH practitioners can best utilize RDN services.

RDN Role in HIH Team

Delegating nutrition services to an RDN enhances patient care by empowering HIH team members to function at the highest level of their scope of practice. RDNs have been recognized by physicians as the most qualified health care professionals to help patients with diet-related conditions, such as obesity, and physicians also have reported a desire for additional training in nutrition.⁸ Although home-health nurses have frequently performed nutrition assessments and interventions, survey results have indicated that many nurses do not feel confident in teaching complex nutritional information^.9 In my experience, many HIH patients are nutritionally complex, with more than one condition requiring nutrition intervention. For example, patients may be admitted to HIH for management of CHF, but they may also have diabetes mellitus (DM), obesity, and low socioeconomic status. The HIH RDN can address the nutrition aspects of these conditions, freeing time for physicians and nurses to focus on their respective areas of expertise.^9,10 Moreover, the RDN can also provide dietary education to the HIH team to increase their knowledge of nutritional topics and promote consistent messaging to patients.

Including an RDN on the HIH team enables patients to have comprehensive, personalized nutrition care. Rather than merely offering generalized nutrition education, RDNs are trained to provide medical nutrition therapy (MNT), which has been shown to improve health outcomes and be cost-effective for conditions such as type 2 DM, chronic kidney disease, hypertension, and obesity.^10,11 In MNT, RDNs use the standardized 4-stepnutrition care process (NCP).¹² The Table shows examples of how the NCP can be applied in HIH settings. Furthermore, in my experience, MNT from an RDN also contributes to patient satisfaction. Subjective observations from my team have indicated that patients often express more confidence in managing their diets by the time of HIH discharge.

RDNs can guide physicians and pharmacists in ordering oral nutrition supplements (ONS). Within the VHA, a “food first” approach is preferred to increase caloric intake, and patients must meet specific criteria for prescription of an ONS.¹³ Furthermore, ONS designed for specific medical conditions (eg, chronic kidney disease) are considered nonformulary and require an RDN evaluation.¹³ Including an RDN on the HIH team allows this evaluation process to begin early in the patient’s admission to the program and ensures that provision of ONS is clinically appropriate and cost-effective.

Care Coordination

HIH is highly interdisciplinary. Team members perform their respective roles and communicate with the team throughout the day. RDNs can help monitor patients and alert physicians for changes in blood glucose, gastrointestinal concerns, and weight. This is especially helpful for patients who do not have a planned nursing visit on the day of an RDN evaluation. The HIH RDN can also collaborate with other team members to address patient needs. For example, for patients with limited financial resources, the HIH RDN can provide nutrition education regarding cooking on a budget, and the HIH social worker can arrange free or low-cost meal services.

Tips

When hiring an HIH RDN, seek candidates with experience in inpatient, outpatient, and home care settings. As a hybrid of these 3 areas, the HIH RDN position requires a unique combination of acute care skills and health coaching. Additionally, in my experience, the HIH RDN interacts more frequently with the HIH team than other RDN colleagues, so it is important that candidates can work independently and take initiative. This type of position would not be suitable for entry-level RDNs.

Stagger HIH team visits to prevent overwhelming the patient and caregivers. Early in our program, my team quickly learned that patients and caregivers can feel overwhelmed with too many home visits upon admission to HIH. After seeing multiple HIH team members the same day, they were often too tired to focus well on diet education during my visit. Staggering visits (eg, completing the initial nutrition assessment 1 day to 1 week after the initial medical and pharmacy visits) has been an effective strategy to address this problem. Furthermore, some patients prefer that the initial RDN appointment is conducted by telephone, with an inperson reassessment the following week. In my experience, HIH workflow is dynamic by nature, so it is crucial to remain flexible and accommodate individual patient needs as much as possible.

Dietary behavior change is a long-term process, and restrictive hospital diets can be challenging to replicate at home. In a hospital setting, clinicians can order a specialized diet (eg, low sodium with fluid restriction for CHF patients), whereas efforts to implement these restrictions in the home setting can be cumbersome and negatively impact quality of life.^7,14 Nevertheless, the effectiveness of medical treatment is compromised when patients do not adhere to dietary recommendations. Meal delivery services that offer specialized diets can be a useful resource for patients and caregivers who are unable to cook, and the HIH RDN can assist patients in ordering these services.

HIH patients may vary in terms of readiness to make dietary changes, and in addition to nutrition education, nutrition counseling is usually needed to effect behavior change. My team has found that consideration of the transtheoretical/ stages of change model can be a helpful approach. ¹⁵ The HIH RDN can tailor nutrition interventions to the patient’s stage of change. For example, for patients in the precontemplation stage, the HIH RDN would focus on providing information and addressing emotional aspects of dietary change. In contrast, for patients in the action stage of change, the HIH RDN might emphasize behavioral skill training and social support.¹⁵ Particularly for patients in the early stages of change, it may be unrealistic to expect full adoption of the recommended diet within the 30 days of the HIH program. However, by acknowledging the reality of the patient’s stage of change, the HIH RDN and team can then collaborate to support the patient in moving toward the next stage. Patients who are not ready for dietary behavior change during the 30 days of HIH may benefit from longer-term support, and the HIH RDN can arrange followup care with an outpatient RDN.

Conclusions

As the HIH model continues to be adopted across the VHA and other health care systems, it is crucial to consider the value and expertise of an RDN for guiding nutrition care in the HIH setting. The HIH RDN contributes to optimal health care delivery by leading nutritional aspects of patient care, offering personalized MNT, and coordinating and collaborating with team members to meet individual patient needs. An RDN can serve as a valuable resource for nutrition information and enhance the team’s overall services, with the potential to impact clinical outcomes and patient satisfaction.

I enjoyed reading “How to identify balance disorders and reduce fall risk” (J Fam Pract. 2022;71:20-30) from the January/February issue. I was, however, disappointed to see that normal pressure hydrocephalus (NPH) was not discussed in the article or tables.

Recently, I took care of a 72-year-old patient who presented after multiple falls. In conjunction with Neurology, the presumptive diagnosis of Parkinson disease was made. However, the patient continued to experience a health decline that included cognitive changes, nocturia, and the classic “magnetic gait” of NPH (mnemonic for diagnosing this triad of symptoms: weird, wet, wobbly). The presumptive diagnosis was then changed when the results of a fluorodopa F18 positron emission tomography scan (also known as a DaT scan) returned as normal, essentially excluding the diagnosis of Parkinson disease.

The patient has since seen a dramatic improvement in gait and cognitive and urinary symptoms following a high-volume lumbar puncture and placement of a ventriculoperitoneal shunt. 

This case demonstrates the importance of considering NPH in the differential diagnosis for patients with balance disorders. Prompt diagnosis and management can result in a variable, but at times dramatic, reversal of symptoms. 

Ernestine Lee, MD, MPH
Austin, TX

I enjoyed reading “How to identify balance disorders and reduce fall risk” (J Fam Pract. 2022;71:20-30) from the January/February issue. I was, however, disappointed to see that normal pressure hydrocephalus (NPH) was not discussed in the article or tables.

Recently, I took care of a 72-year-old patient who presented after multiple falls. In conjunction with Neurology, the presumptive diagnosis of Parkinson disease was made. However, the patient continued to experience a health decline that included cognitive changes, nocturia, and the classic “magnetic gait” of NPH (mnemonic for diagnosing this triad of symptoms: weird, wet, wobbly). The presumptive diagnosis was then changed when the results of a fluorodopa F18 positron emission tomography scan (also known as a DaT scan) returned as normal, essentially excluding the diagnosis of Parkinson disease.

The patient has since seen a dramatic improvement in gait and cognitive and urinary symptoms following a high-volume lumbar puncture and placement of a ventriculoperitoneal shunt. 

This case demonstrates the importance of considering NPH in the differential diagnosis for patients with balance disorders. Prompt diagnosis and management can result in a variable, but at times dramatic, reversal of symptoms. 

Ernestine Lee, MD, MPH
Austin, TX

I enjoyed reading “How to identify balance disorders and reduce fall risk” (J Fam Pract. 2022;71:20-30) from the January/February issue. I was, however, disappointed to see that normal pressure hydrocephalus (NPH) was not discussed in the article or tables.

Recently, I took care of a 72-year-old patient who presented after multiple falls. In conjunction with Neurology, the presumptive diagnosis of Parkinson disease was made. However, the patient continued to experience a health decline that included cognitive changes, nocturia, and the classic “magnetic gait” of NPH (mnemonic for diagnosing this triad of symptoms: weird, wet, wobbly). The presumptive diagnosis was then changed when the results of a fluorodopa F18 positron emission tomography scan (also known as a DaT scan) returned as normal, essentially excluding the diagnosis of Parkinson disease.

The patient has since seen a dramatic improvement in gait and cognitive and urinary symptoms following a high-volume lumbar puncture and placement of a ventriculoperitoneal shunt. 

This case demonstrates the importance of considering NPH in the differential diagnosis for patients with balance disorders. Prompt diagnosis and management can result in a variable, but at times dramatic, reversal of symptoms. 

Ernestine Lee, MD, MPH
Austin, TX

I cannot agree more with Dr. Hickner’s editorial, “The power of the pause to prevent diagnostic error” (J Fam Pract. 2022;71:102). In 1974, when I started at the Medical College of Virginia, I thought I was going to be a medical researcher. By mid-1978, I had completely changed my focus to family medicine. Fortunately, my drive for detail and accuracy remained, albeit at odds with a whirlwind residency and solo practice. I drove my staff (and wife) crazy because I frequently spent more than the “allotted” time with a patient. The time was not wasted; it was most important for me to gain the trust of the patient and then to get it right—or find a path to the answer.

Jeff Ginther, MD
Bristol, VA

I cannot agree more with Dr. Hickner’s editorial, “The power of the pause to prevent diagnostic error” (J Fam Pract. 2022;71:102). In 1974, when I started at the Medical College of Virginia, I thought I was going to be a medical researcher. By mid-1978, I had completely changed my focus to family medicine. Fortunately, my drive for detail and accuracy remained, albeit at odds with a whirlwind residency and solo practice. I drove my staff (and wife) crazy because I frequently spent more than the “allotted” time with a patient. The time was not wasted; it was most important for me to gain the trust of the patient and then to get it right—or find a path to the answer.

Jeff Ginther, MD
Bristol, VA

I cannot agree more with Dr. Hickner’s editorial, “The power of the pause to prevent diagnostic error” (J Fam Pract. 2022;71:102). In 1974, when I started at the Medical College of Virginia, I thought I was going to be a medical researcher. By mid-1978, I had completely changed my focus to family medicine. Fortunately, my drive for detail and accuracy remained, albeit at odds with a whirlwind residency and solo practice. I drove my staff (and wife) crazy because I frequently spent more than the “allotted” time with a patient. The time was not wasted; it was most important for me to gain the trust of the patient and then to get it right—or find a path to the answer.

Jeff Ginther, MD
Bristol, VA

Schools are intended to be a safe place to acquire knowledge, try out ideas, practice socializing, and build a foundation for adulthood. Many schools fulfill this mission for most children, but for children at both extremes of ability their school experience does not suffice.

When asked, “If you had the choice, would you rather stay home or go to school?” my patients almost universally prefer school. They all know that school is where they should be; they want to be normal, accepted by peers, getting ready for the world’s coming demands, and validation that they will make it as adults. Endorsement otherwise is a warning sign.

When such important tasks of childhood are thwarted children may despair, withdraw, give up, or a small number become furious. These may profoundly resent the children who are experiencing success when they could not. They may hate the teachers and the place where they experienced failure and humiliation. Lack of a positive connection to school characterizes children who are violent toward schools as well as those who drop out.

Schools may fail to support the basic needs of children for many reasons. Schools may avoid physical violence but fail to protect the children’s self-esteem. I have heard stories of teachers calling on children to perform who are clearly struggling or shy, insulting incorrect answers, calling names, putting names on the board, reading out failed grades, posting grades publicly, even allowing peers to mock students. Teachers may deny or disregard parent complaints, or even worsen treatment of the child. Although children may at times falsify complaints, children’s and parents’ reports must be taken seriously and remain anonymous. When we hear of such toxic situations for our patients, we can get details and contact school administrators without naming the child, as often the family feels they can’t. Repeated humiliation may require not only remediation, but consequences. We can advocate for a change in classroom or request a 504 Plan if emotional health is affected.

All children learn best and experience success and even joy when the tasks they face are at or slightly beyond their skill level. But with the wide range of abilities, especially for boys, education may need to be individualized. This is very difficult in larger classrooms with fewer resources, too few adult helpers, inexperienced teachers, or high levels of student misbehavior. Basing teacher promotion mainly on standardized test results makes individualizing instruction even less likely. Smaller class size is better; even the recommended (less than 20) or regulated (less than 30) class sizes are associated with suboptimal achievement, compared with smaller ones. Some ways to attain smaller class size include split days or alternate-day sessions, although these also have disadvantages.

While we can advocate for these changes, we can also encourage parents to promote academic skills by talking to and reading to their children of all ages, trying Reach Out and Read for young children, providing counting games, board games, and math songs! Besides screening for attention-deficit/hyperactivity disorder, we can use standard paragraphs and math problems (for example, WRAT, Einstein) to check skills when performance is low or behavior is a problem the school denies. When concerned, we can write letters for parents to sign requesting testing and an individualized education plan to determine need for tutoring or special education.

While Federal legislation requiring the “least restrictive environment” for education was intended to avoid sidelining differently able children, some can’t learn in a regular class. Conversely, if instruction in a special class is adjusted to the child with the lowest skills, minimal learning may occur for others. Although we can speak with the teacher about “this child’s abilities among those in his class” we can first suggest that the parent visit class to observe. Outside tutoring or home schooling may help a child move up to a regular class.

Sometimes a child’s learning is hampered by classrooms with numerous children misbehaving; this is also a reason for resentment. We can inform school administrators about methods such as The Good Behavior Game (paxis.org) that can improve behavior and connection for the whole class.

While a social “pecking order” is universal, it is unacceptable for children to be allowed to humiliate or hurt a peer, or damage their reputation. While this moral teaching should occur at home, it needs to continue at school where peers are forced into groups they did not choose. Screening for bullying at pediatric visits is now a universal recommendation as 30% report being bullied. We need to ask all children about “mean kids in school” or gang involvement for older children.

Parents can support their children experiencing cyberbullying and switch them to a “dumb phone” with no texting option, limited phone time, or no phone at all. Policies against bullying coming from school administrators are most effective but we can inform schools about the STOPit app for children to report bullying anonymously as well as education for students to stand together against a bully (stopbullying.gov). A Lunch Bunch for younger children or a buddy system for older ones can be requested to help them make friends.

With diverse child aptitudes, schools need to offer students alternative opportunities for self-expression and contribution. We can ask about a child’s strengths and suggest related extracurriculars activities in school or outside, including volunteering. Participation on teams or in clubs must not be blocked for those with poor grades. Perhaps tying participation to tutoring would satisfy the school’s desire to motivate instead. Parents can be encouraged to advocate for music, art, and drama classes – programs that are often victims of budget cuts – that can create the essential school connection.

Students in many areas lack access to classes in trades early enough in their education. The requirements for English or math may be out of reach and result in students dropping out before trade classes are an option. We may identify our patients who may do better with a trade education and advise families to request transfer to a high school offering this.

The best connection a child can have to a school is an adult who values them. The child may identify a preferred teacher to us so that we, or the parent, can call to ask them to provide special attention. Facilitating times for students to get to know teachers may require alteration in bus schedules, lunch times, study halls, or breaks, or keeping the school open longer outside class hours. While more mental health providers are clearly needed, sometimes it is the groundskeeper, the secretary, or the lunch helper who can make the best connection with a child.

As pediatricians, we must listen to struggling youth, acknowledge their pain, and model this empathy for their parents who may be obsessing over grades. Problem-solving about how to get accommodations, informal or formal, can inspire hope. We can coach parents and youth to meet respectfully with the school about issues to avoid labeling the child as a problem.

As pediatricians, our recommendations for school funding and policies may carry extra weight. We may share ideas through talks at PTA meetings, serve on school boards, or endorse leaders planning greater resources for schools to optimize each child’s experience and connection to school.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Schools are intended to be a safe place to acquire knowledge, try out ideas, practice socializing, and build a foundation for adulthood. Many schools fulfill this mission for most children, but for children at both extremes of ability their school experience does not suffice.

When asked, “If you had the choice, would you rather stay home or go to school?” my patients almost universally prefer school. They all know that school is where they should be; they want to be normal, accepted by peers, getting ready for the world’s coming demands, and validation that they will make it as adults. Endorsement otherwise is a warning sign.

When such important tasks of childhood are thwarted children may despair, withdraw, give up, or a small number become furious. These may profoundly resent the children who are experiencing success when they could not. They may hate the teachers and the place where they experienced failure and humiliation. Lack of a positive connection to school characterizes children who are violent toward schools as well as those who drop out.

Schools may fail to support the basic needs of children for many reasons. Schools may avoid physical violence but fail to protect the children’s self-esteem. I have heard stories of teachers calling on children to perform who are clearly struggling or shy, insulting incorrect answers, calling names, putting names on the board, reading out failed grades, posting grades publicly, even allowing peers to mock students. Teachers may deny or disregard parent complaints, or even worsen treatment of the child. Although children may at times falsify complaints, children’s and parents’ reports must be taken seriously and remain anonymous. When we hear of such toxic situations for our patients, we can get details and contact school administrators without naming the child, as often the family feels they can’t. Repeated humiliation may require not only remediation, but consequences. We can advocate for a change in classroom or request a 504 Plan if emotional health is affected.

All children learn best and experience success and even joy when the tasks they face are at or slightly beyond their skill level. But with the wide range of abilities, especially for boys, education may need to be individualized. This is very difficult in larger classrooms with fewer resources, too few adult helpers, inexperienced teachers, or high levels of student misbehavior. Basing teacher promotion mainly on standardized test results makes individualizing instruction even less likely. Smaller class size is better; even the recommended (less than 20) or regulated (less than 30) class sizes are associated with suboptimal achievement, compared with smaller ones. Some ways to attain smaller class size include split days or alternate-day sessions, although these also have disadvantages.

While we can advocate for these changes, we can also encourage parents to promote academic skills by talking to and reading to their children of all ages, trying Reach Out and Read for young children, providing counting games, board games, and math songs! Besides screening for attention-deficit/hyperactivity disorder, we can use standard paragraphs and math problems (for example, WRAT, Einstein) to check skills when performance is low or behavior is a problem the school denies. When concerned, we can write letters for parents to sign requesting testing and an individualized education plan to determine need for tutoring or special education.

While Federal legislation requiring the “least restrictive environment” for education was intended to avoid sidelining differently able children, some can’t learn in a regular class. Conversely, if instruction in a special class is adjusted to the child with the lowest skills, minimal learning may occur for others. Although we can speak with the teacher about “this child’s abilities among those in his class” we can first suggest that the parent visit class to observe. Outside tutoring or home schooling may help a child move up to a regular class.

Sometimes a child’s learning is hampered by classrooms with numerous children misbehaving; this is also a reason for resentment. We can inform school administrators about methods such as The Good Behavior Game (paxis.org) that can improve behavior and connection for the whole class.

While a social “pecking order” is universal, it is unacceptable for children to be allowed to humiliate or hurt a peer, or damage their reputation. While this moral teaching should occur at home, it needs to continue at school where peers are forced into groups they did not choose. Screening for bullying at pediatric visits is now a universal recommendation as 30% report being bullied. We need to ask all children about “mean kids in school” or gang involvement for older children.

Parents can support their children experiencing cyberbullying and switch them to a “dumb phone” with no texting option, limited phone time, or no phone at all. Policies against bullying coming from school administrators are most effective but we can inform schools about the STOPit app for children to report bullying anonymously as well as education for students to stand together against a bully (stopbullying.gov). A Lunch Bunch for younger children or a buddy system for older ones can be requested to help them make friends.

With diverse child aptitudes, schools need to offer students alternative opportunities for self-expression and contribution. We can ask about a child’s strengths and suggest related extracurriculars activities in school or outside, including volunteering. Participation on teams or in clubs must not be blocked for those with poor grades. Perhaps tying participation to tutoring would satisfy the school’s desire to motivate instead. Parents can be encouraged to advocate for music, art, and drama classes – programs that are often victims of budget cuts – that can create the essential school connection.

Students in many areas lack access to classes in trades early enough in their education. The requirements for English or math may be out of reach and result in students dropping out before trade classes are an option. We may identify our patients who may do better with a trade education and advise families to request transfer to a high school offering this.

The best connection a child can have to a school is an adult who values them. The child may identify a preferred teacher to us so that we, or the parent, can call to ask them to provide special attention. Facilitating times for students to get to know teachers may require alteration in bus schedules, lunch times, study halls, or breaks, or keeping the school open longer outside class hours. While more mental health providers are clearly needed, sometimes it is the groundskeeper, the secretary, or the lunch helper who can make the best connection with a child.

As pediatricians, we must listen to struggling youth, acknowledge their pain, and model this empathy for their parents who may be obsessing over grades. Problem-solving about how to get accommodations, informal or formal, can inspire hope. We can coach parents and youth to meet respectfully with the school about issues to avoid labeling the child as a problem.

As pediatricians, our recommendations for school funding and policies may carry extra weight. We may share ideas through talks at PTA meetings, serve on school boards, or endorse leaders planning greater resources for schools to optimize each child’s experience and connection to school.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Schools are intended to be a safe place to acquire knowledge, try out ideas, practice socializing, and build a foundation for adulthood. Many schools fulfill this mission for most children, but for children at both extremes of ability their school experience does not suffice.

When asked, “If you had the choice, would you rather stay home or go to school?” my patients almost universally prefer school. They all know that school is where they should be; they want to be normal, accepted by peers, getting ready for the world’s coming demands, and validation that they will make it as adults. Endorsement otherwise is a warning sign.

When such important tasks of childhood are thwarted children may despair, withdraw, give up, or a small number become furious. These may profoundly resent the children who are experiencing success when they could not. They may hate the teachers and the place where they experienced failure and humiliation. Lack of a positive connection to school characterizes children who are violent toward schools as well as those who drop out.

Schools may fail to support the basic needs of children for many reasons. Schools may avoid physical violence but fail to protect the children’s self-esteem. I have heard stories of teachers calling on children to perform who are clearly struggling or shy, insulting incorrect answers, calling names, putting names on the board, reading out failed grades, posting grades publicly, even allowing peers to mock students. Teachers may deny or disregard parent complaints, or even worsen treatment of the child. Although children may at times falsify complaints, children’s and parents’ reports must be taken seriously and remain anonymous. When we hear of such toxic situations for our patients, we can get details and contact school administrators without naming the child, as often the family feels they can’t. Repeated humiliation may require not only remediation, but consequences. We can advocate for a change in classroom or request a 504 Plan if emotional health is affected.

All children learn best and experience success and even joy when the tasks they face are at or slightly beyond their skill level. But with the wide range of abilities, especially for boys, education may need to be individualized. This is very difficult in larger classrooms with fewer resources, too few adult helpers, inexperienced teachers, or high levels of student misbehavior. Basing teacher promotion mainly on standardized test results makes individualizing instruction even less likely. Smaller class size is better; even the recommended (less than 20) or regulated (less than 30) class sizes are associated with suboptimal achievement, compared with smaller ones. Some ways to attain smaller class size include split days or alternate-day sessions, although these also have disadvantages.

While we can advocate for these changes, we can also encourage parents to promote academic skills by talking to and reading to their children of all ages, trying Reach Out and Read for young children, providing counting games, board games, and math songs! Besides screening for attention-deficit/hyperactivity disorder, we can use standard paragraphs and math problems (for example, WRAT, Einstein) to check skills when performance is low or behavior is a problem the school denies. When concerned, we can write letters for parents to sign requesting testing and an individualized education plan to determine need for tutoring or special education.

While Federal legislation requiring the “least restrictive environment” for education was intended to avoid sidelining differently able children, some can’t learn in a regular class. Conversely, if instruction in a special class is adjusted to the child with the lowest skills, minimal learning may occur for others. Although we can speak with the teacher about “this child’s abilities among those in his class” we can first suggest that the parent visit class to observe. Outside tutoring or home schooling may help a child move up to a regular class.

Sometimes a child’s learning is hampered by classrooms with numerous children misbehaving; this is also a reason for resentment. We can inform school administrators about methods such as The Good Behavior Game (paxis.org) that can improve behavior and connection for the whole class.

While a social “pecking order” is universal, it is unacceptable for children to be allowed to humiliate or hurt a peer, or damage their reputation. While this moral teaching should occur at home, it needs to continue at school where peers are forced into groups they did not choose. Screening for bullying at pediatric visits is now a universal recommendation as 30% report being bullied. We need to ask all children about “mean kids in school” or gang involvement for older children.

Parents can support their children experiencing cyberbullying and switch them to a “dumb phone” with no texting option, limited phone time, or no phone at all. Policies against bullying coming from school administrators are most effective but we can inform schools about the STOPit app for children to report bullying anonymously as well as education for students to stand together against a bully (stopbullying.gov). A Lunch Bunch for younger children or a buddy system for older ones can be requested to help them make friends.

With diverse child aptitudes, schools need to offer students alternative opportunities for self-expression and contribution. We can ask about a child’s strengths and suggest related extracurriculars activities in school or outside, including volunteering. Participation on teams or in clubs must not be blocked for those with poor grades. Perhaps tying participation to tutoring would satisfy the school’s desire to motivate instead. Parents can be encouraged to advocate for music, art, and drama classes – programs that are often victims of budget cuts – that can create the essential school connection.

Students in many areas lack access to classes in trades early enough in their education. The requirements for English or math may be out of reach and result in students dropping out before trade classes are an option. We may identify our patients who may do better with a trade education and advise families to request transfer to a high school offering this.

The best connection a child can have to a school is an adult who values them. The child may identify a preferred teacher to us so that we, or the parent, can call to ask them to provide special attention. Facilitating times for students to get to know teachers may require alteration in bus schedules, lunch times, study halls, or breaks, or keeping the school open longer outside class hours. While more mental health providers are clearly needed, sometimes it is the groundskeeper, the secretary, or the lunch helper who can make the best connection with a child.

As pediatricians, we must listen to struggling youth, acknowledge their pain, and model this empathy for their parents who may be obsessing over grades. Problem-solving about how to get accommodations, informal or formal, can inspire hope. We can coach parents and youth to meet respectfully with the school about issues to avoid labeling the child as a problem.

As pediatricians, our recommendations for school funding and policies may carry extra weight. We may share ideas through talks at PTA meetings, serve on school boards, or endorse leaders planning greater resources for schools to optimize each child’s experience and connection to school.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

I still remember the woman who came to my office that day, years ago. She was struggling and uncomfortable, and she wanted “something” for stress. She described her life, and to me, it sounded stressful. She lived in a blended family and she described the chaos that one might expect to find in a household with four teens, their friends, their activities, and all it took to keep the household going. I spent 2 hours evaluating the patient, and I could not find a diagnosis that fit this problem nor – I believed – a pill that would fix it. She didn’t “meet criteria” for a psychiatric disorder, but she insisted she was uncomfortable and she wanted to try medication. I admit, I relented and I gave her a prescription for fluoxetine.

When she returned a few weeks later, my patient said she felt better, and what I remember decades later was her statement: “Now I can see dishes in the sink and be okay with it.” Perhaps she had downplayed her anxiety during our first meeting, but what I took from this was that some people are uncomfortable in ways that our lexicon does not capture, and sometimes medication helps with this discomfort.

The APA’s Diagnostic and Statistical Manual of Mental Disorders attempts to capture the problems of emotional and behavioral distress and classify them into discrete syndromes that can be validated and reliably diagnosed by different evaluators. Our disorders are syndromic; they are defined by clusters of symptoms that occur together, and not by a single symptom, lab value, or radiologic finding. The DSM is rewritten periodically so that what is or is not a disorder can bend with new discoveries and with a changing culture. And for better or for worse, when there is an available medication that can alleviate a problem, this may influence what once was a variant of normal into becoming a disorder.

Our illnesses often lie along a spectrum, so there is no precise point where someone who is easily distracted is a person with attention deficit disorder as opposed to being a mentally healthy person who is easily distracted, or a shy person is someone with social anxiety disorder. At the extremes, pathology and dysfunction are obvious, but sometimes we are left to let patients define whether they are suffering, whether they want to address this with medications, and whether their distress warrants taking a chance that they might have side effects or an adverse reaction to a medication.

When we look at our criteria, sometimes we fall short. One needs to have at least five symptoms out of nine options, to be present for 2 weeks to be diagnosed with major depression, yet I don’t know a single psychiatrist who would not offer medication to a patient who ascribed to feeling profoundly sad with thoughts of suicide in the absence of other symptoms of depression. These issues have come to the forefront with the recent inclusion of prolonged grief in the DSM, as a disorder that is distinct from both normal grieving and from major depression.

In recent weeks, mass murder has been on everyone’s mind as we mourn those lost in Uvalde, Buffalo, and unfortunately, in so many other places. Absolutely no one thinks that someone who shoots strangers is “normal” or emotionally well. Yet psychiatry is often tasked with figuring out if someone is mad (mentally ill), bad (evil), or both. We don’t have a clear path for how to treat and manage people who commit horrendous acts of violence unless they meet criteria for another illness. Yet no one would argue that a person who informs others that he is thinking of killing strangers is in need of some type of intervention, regardless of his motive. We struggle too, with how to manage people who have more regular angry outbursts or emotional dysregulation. Perhaps we diagnose intermittent explosive disorder, or irritability caused by a mood disorder, but we don’t always know how to help people to control their tempers and modulate their emotions. And our semantics to describe psychic pain and anguish are surprisingly limited – sometimes we can only assume that someone who lashes out must be in turmoil.

Psychiatry continues to struggle with our relationship with human suffering. Suffering is part of life, not necessarily a sign of illness, and in his iconic memoir, “Man’s Search for Meaning,” psychiatrist Viktor Frankl, MD, wrote of the atrocities he endured in a Nazi concentration camp. It was through his suffering that Dr. Frankl found meaning and he used these harrowing experiences to fuel positive emotions later in life. Dr. Frankl wrote: “If there is a meaning in life at all, then there must be a meaning in suffering. Suffering is an ineradicable part of life, even as fate and death. Without suffering and death, human life cannot be complete.”

Suffering may be the kindling for acts of violence, or for profound creativity. Would we have music, art, cinema, poetry, or fiction if no one ever suffered? Yet suffering and emotional torment are often what leads people to seek treatment, and what leads us, as healers, to offer any range of therapies. For years, suicide rates have been rising, as have overdose death. And now, in addition to these “deaths of despair,” we are hearing about skyrocketing rates of depression and anxiety in our world that is so full of reasons to be sad and anxious. Access to treatment is limited by so many things, and it is not always clear when one needs psychiatric interventions or when problems will heal on their own, leaving scars or not.

I wrote this article in response to the hundreds of comments that were placed on an article I wrote after the horrors at Uvalde and Buffalo: “Don’t Equate Mass Shootings with Mental Illness.” Many of the commenters suggested I believe the shooter was perfectly sane, and that I am naive (or worse). Many wrote in with their own thoughts about what causes people to become mass murderers. One commenter wrote: “To suggest that random killers do not have mental health issues and their behavior is normal is ridiculous.” I don’t believe that I ever suggested that such behavior was normal, but – for many of these crimes – we as a society have decided to treat the behavior as criminal and not as the product of our current concept of mental disorders. Obviously, people who are well, who are emotionally at peace and comfortable in their own skin, don’t kill strangers.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore.

I still remember the woman who came to my office that day, years ago. She was struggling and uncomfortable, and she wanted “something” for stress. She described her life, and to me, it sounded stressful. She lived in a blended family and she described the chaos that one might expect to find in a household with four teens, their friends, their activities, and all it took to keep the household going. I spent 2 hours evaluating the patient, and I could not find a diagnosis that fit this problem nor – I believed – a pill that would fix it. She didn’t “meet criteria” for a psychiatric disorder, but she insisted she was uncomfortable and she wanted to try medication. I admit, I relented and I gave her a prescription for fluoxetine.

When she returned a few weeks later, my patient said she felt better, and what I remember decades later was her statement: “Now I can see dishes in the sink and be okay with it.” Perhaps she had downplayed her anxiety during our first meeting, but what I took from this was that some people are uncomfortable in ways that our lexicon does not capture, and sometimes medication helps with this discomfort.

The APA’s Diagnostic and Statistical Manual of Mental Disorders attempts to capture the problems of emotional and behavioral distress and classify them into discrete syndromes that can be validated and reliably diagnosed by different evaluators. Our disorders are syndromic; they are defined by clusters of symptoms that occur together, and not by a single symptom, lab value, or radiologic finding. The DSM is rewritten periodically so that what is or is not a disorder can bend with new discoveries and with a changing culture. And for better or for worse, when there is an available medication that can alleviate a problem, this may influence what once was a variant of normal into becoming a disorder.

Our illnesses often lie along a spectrum, so there is no precise point where someone who is easily distracted is a person with attention deficit disorder as opposed to being a mentally healthy person who is easily distracted, or a shy person is someone with social anxiety disorder. At the extremes, pathology and dysfunction are obvious, but sometimes we are left to let patients define whether they are suffering, whether they want to address this with medications, and whether their distress warrants taking a chance that they might have side effects or an adverse reaction to a medication.

When we look at our criteria, sometimes we fall short. One needs to have at least five symptoms out of nine options, to be present for 2 weeks to be diagnosed with major depression, yet I don’t know a single psychiatrist who would not offer medication to a patient who ascribed to feeling profoundly sad with thoughts of suicide in the absence of other symptoms of depression. These issues have come to the forefront with the recent inclusion of prolonged grief in the DSM, as a disorder that is distinct from both normal grieving and from major depression.

In recent weeks, mass murder has been on everyone’s mind as we mourn those lost in Uvalde, Buffalo, and unfortunately, in so many other places. Absolutely no one thinks that someone who shoots strangers is “normal” or emotionally well. Yet psychiatry is often tasked with figuring out if someone is mad (mentally ill), bad (evil), or both. We don’t have a clear path for how to treat and manage people who commit horrendous acts of violence unless they meet criteria for another illness. Yet no one would argue that a person who informs others that he is thinking of killing strangers is in need of some type of intervention, regardless of his motive. We struggle too, with how to manage people who have more regular angry outbursts or emotional dysregulation. Perhaps we diagnose intermittent explosive disorder, or irritability caused by a mood disorder, but we don’t always know how to help people to control their tempers and modulate their emotions. And our semantics to describe psychic pain and anguish are surprisingly limited – sometimes we can only assume that someone who lashes out must be in turmoil.

Psychiatry continues to struggle with our relationship with human suffering. Suffering is part of life, not necessarily a sign of illness, and in his iconic memoir, “Man’s Search for Meaning,” psychiatrist Viktor Frankl, MD, wrote of the atrocities he endured in a Nazi concentration camp. It was through his suffering that Dr. Frankl found meaning and he used these harrowing experiences to fuel positive emotions later in life. Dr. Frankl wrote: “If there is a meaning in life at all, then there must be a meaning in suffering. Suffering is an ineradicable part of life, even as fate and death. Without suffering and death, human life cannot be complete.”

Suffering may be the kindling for acts of violence, or for profound creativity. Would we have music, art, cinema, poetry, or fiction if no one ever suffered? Yet suffering and emotional torment are often what leads people to seek treatment, and what leads us, as healers, to offer any range of therapies. For years, suicide rates have been rising, as have overdose death. And now, in addition to these “deaths of despair,” we are hearing about skyrocketing rates of depression and anxiety in our world that is so full of reasons to be sad and anxious. Access to treatment is limited by so many things, and it is not always clear when one needs psychiatric interventions or when problems will heal on their own, leaving scars or not.

I wrote this article in response to the hundreds of comments that were placed on an article I wrote after the horrors at Uvalde and Buffalo: “Don’t Equate Mass Shootings with Mental Illness.” Many of the commenters suggested I believe the shooter was perfectly sane, and that I am naive (or worse). Many wrote in with their own thoughts about what causes people to become mass murderers. One commenter wrote: “To suggest that random killers do not have mental health issues and their behavior is normal is ridiculous.” I don’t believe that I ever suggested that such behavior was normal, but – for many of these crimes – we as a society have decided to treat the behavior as criminal and not as the product of our current concept of mental disorders. Obviously, people who are well, who are emotionally at peace and comfortable in their own skin, don’t kill strangers.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore.

I still remember the woman who came to my office that day, years ago. She was struggling and uncomfortable, and she wanted “something” for stress. She described her life, and to me, it sounded stressful. She lived in a blended family and she described the chaos that one might expect to find in a household with four teens, their friends, their activities, and all it took to keep the household going. I spent 2 hours evaluating the patient, and I could not find a diagnosis that fit this problem nor – I believed – a pill that would fix it. She didn’t “meet criteria” for a psychiatric disorder, but she insisted she was uncomfortable and she wanted to try medication. I admit, I relented and I gave her a prescription for fluoxetine.

When she returned a few weeks later, my patient said she felt better, and what I remember decades later was her statement: “Now I can see dishes in the sink and be okay with it.” Perhaps she had downplayed her anxiety during our first meeting, but what I took from this was that some people are uncomfortable in ways that our lexicon does not capture, and sometimes medication helps with this discomfort.

The APA’s Diagnostic and Statistical Manual of Mental Disorders attempts to capture the problems of emotional and behavioral distress and classify them into discrete syndromes that can be validated and reliably diagnosed by different evaluators. Our disorders are syndromic; they are defined by clusters of symptoms that occur together, and not by a single symptom, lab value, or radiologic finding. The DSM is rewritten periodically so that what is or is not a disorder can bend with new discoveries and with a changing culture. And for better or for worse, when there is an available medication that can alleviate a problem, this may influence what once was a variant of normal into becoming a disorder.

Our illnesses often lie along a spectrum, so there is no precise point where someone who is easily distracted is a person with attention deficit disorder as opposed to being a mentally healthy person who is easily distracted, or a shy person is someone with social anxiety disorder. At the extremes, pathology and dysfunction are obvious, but sometimes we are left to let patients define whether they are suffering, whether they want to address this with medications, and whether their distress warrants taking a chance that they might have side effects or an adverse reaction to a medication.

When we look at our criteria, sometimes we fall short. One needs to have at least five symptoms out of nine options, to be present for 2 weeks to be diagnosed with major depression, yet I don’t know a single psychiatrist who would not offer medication to a patient who ascribed to feeling profoundly sad with thoughts of suicide in the absence of other symptoms of depression. These issues have come to the forefront with the recent inclusion of prolonged grief in the DSM, as a disorder that is distinct from both normal grieving and from major depression.

In recent weeks, mass murder has been on everyone’s mind as we mourn those lost in Uvalde, Buffalo, and unfortunately, in so many other places. Absolutely no one thinks that someone who shoots strangers is “normal” or emotionally well. Yet psychiatry is often tasked with figuring out if someone is mad (mentally ill), bad (evil), or both. We don’t have a clear path for how to treat and manage people who commit horrendous acts of violence unless they meet criteria for another illness. Yet no one would argue that a person who informs others that he is thinking of killing strangers is in need of some type of intervention, regardless of his motive. We struggle too, with how to manage people who have more regular angry outbursts or emotional dysregulation. Perhaps we diagnose intermittent explosive disorder, or irritability caused by a mood disorder, but we don’t always know how to help people to control their tempers and modulate their emotions. And our semantics to describe psychic pain and anguish are surprisingly limited – sometimes we can only assume that someone who lashes out must be in turmoil.

Psychiatry continues to struggle with our relationship with human suffering. Suffering is part of life, not necessarily a sign of illness, and in his iconic memoir, “Man’s Search for Meaning,” psychiatrist Viktor Frankl, MD, wrote of the atrocities he endured in a Nazi concentration camp. It was through his suffering that Dr. Frankl found meaning and he used these harrowing experiences to fuel positive emotions later in life. Dr. Frankl wrote: “If there is a meaning in life at all, then there must be a meaning in suffering. Suffering is an ineradicable part of life, even as fate and death. Without suffering and death, human life cannot be complete.”

Suffering may be the kindling for acts of violence, or for profound creativity. Would we have music, art, cinema, poetry, or fiction if no one ever suffered? Yet suffering and emotional torment are often what leads people to seek treatment, and what leads us, as healers, to offer any range of therapies. For years, suicide rates have been rising, as have overdose death. And now, in addition to these “deaths of despair,” we are hearing about skyrocketing rates of depression and anxiety in our world that is so full of reasons to be sad and anxious. Access to treatment is limited by so many things, and it is not always clear when one needs psychiatric interventions or when problems will heal on their own, leaving scars or not.

I wrote this article in response to the hundreds of comments that were placed on an article I wrote after the horrors at Uvalde and Buffalo: “Don’t Equate Mass Shootings with Mental Illness.” Many of the commenters suggested I believe the shooter was perfectly sane, and that I am naive (or worse). Many wrote in with their own thoughts about what causes people to become mass murderers. One commenter wrote: “To suggest that random killers do not have mental health issues and their behavior is normal is ridiculous.” I don’t believe that I ever suggested that such behavior was normal, but – for many of these crimes – we as a society have decided to treat the behavior as criminal and not as the product of our current concept of mental disorders. Obviously, people who are well, who are emotionally at peace and comfortable in their own skin, don’t kill strangers.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore.

In 2016, Gupta and Cahill challenged the field of psychiatry to reexamine prescribing patterns.¹ They warned against the use of polypharmacy when not attached to improved patient functioning. They were concerned with the limited evidence for polypharmacy as well as DSM diagnostic criteria. In their inspiring article, they described a process of deprescribing.

In an effort to study and practice their recommendations, we have noticed a lack of literature examining the elimination of diagnostic labels. While there have been some studies looking at comorbidity, especially with substance use disorders,² there is a paucity of scientific evidence on patients with numerous diagnoses. Yet our practices are filled with patients who have been labeled with multiple conflicting or redundant diagnoses throughout their lives depending on the setting or the orientation of the practitioner.

The DSM-5 warns against diagnosing disorders when “the occurrence … is not better explained by” another disorder.³ A mix of diagnoses creates confusion for patients as well as clinicians trying to sort through their reported psychiatric histories.

A routine example would include a patient presenting for an initial evaluation and stating “I’ve been diagnosed as manic-depressive, high anxiety, split personality, posttraumatic stress, insomnia, ADD, and depression.” A review of the medical record will reveal a list of diagnoses, including bipolar II, generalized anxiety disorder, borderline personality disorder, posttraumatic stress disorder, unspecified insomnia, attention-deficit/hyperactivity disorder, and major depressive disorder. The medication list includes lamotrigine, valproic acid, citalopram, bupropion, buspirone, prazosin, methylphenidate, clonazepam, hydroxyzine, and low-dose quetiapine at night as needed.

This is an example of polypharmacy treating multiple, and at times conflicting, diagnoses. While an extreme case, in our experience, cases like this are not uncommon. It was actually in our efforts to examine deprescribing that we noticed this quandary. When inquiring about patients on many psychotropic medications, we often receive this retort: the patient is only prescribed one medication per disorder. Some providers have the belief that multiple disorders justify multiple medications, and that this tautological thinking legitimizes polypharmacy.

A patient who has varying moods, some fears, a fluctuating temperament, past traumas, occasional difficulty sleeping, intermittent inattention, and some sadness may be given all the diagnoses listed above and the resulting medication list. The multiplication of diagnoses, “polydiagnosing,” is a convenient justification for future polypharmacy. A lack of careful assessment and thinking in the application of new diagnoses permits the use of increasing numbers of pharmacological agents. A constellation of symptoms of anxiety, concentration deficits, affective dysregulation, and psychosis may justify the combination of benzodiazepines, stimulants, mood stabilizers, and antipsychotics, while a patient with “just” schizophrenia who is sometimes sad, scared, or distracted is more likely to be kept on just one medication, likely an antipsychotic.

Contrary to most medical disorders (for example, tuberculosis) but similar to others (for example, chronic pain), psychiatric disorders are based on the opinion of a “modest number of ‘expert’ classifications.”⁴ While the broad categories of disorders are justifiable, individual diagnoses are burdened with high rates of comorbidity; lack of treatment specificity; and evidence that distinct syndromes share a genetic basis. Those concerns were exemplified in the study examining the inter-rater reliability of DSM-5 diagnoses, where many disorders were found to have questionable validity.⁵

A psychiatric diagnosis should be based on biological, psychological, and social factors, which align with our understanding of the natural course of an illness. A patient presenting with transient symptoms of sadness in the context of significant social factors like homelessness and/or significant biological factors associated with schizophrenia should not reflexively receive an additional diagnosis of a depressive disorder. A patient reporting poor concentration in the context of a manic episode should not receive an additional diagnosis of attention-deficit disorder. An older patient with depression on multiple antipsychotics for adjunctive treatment should not necessarily receive a diagnosis of cognitive disorder at the first sign of memory problems.

The cavalier and inconsistent use of diagnoses renders the patients with no clear narrative of who they are. They end up integrating the varying providers’ opinions as a cacophony of labels of unclear significance. Many patients have contradictory diagnoses like major depressive disorder and bipolar disorder, or schizophrenia and schizoaffective disorder. Those inaccurate diagnoses could not only lead to treatment mistakes, but also psychological harm.⁶

A clearer diagnostic picture is not only more scientifically sound but also more coherent to the patient. This in turn can lead to an improved treatment alliance and buy-in from the patient. Assisting a patient in sorting out and understanding the vast arrays of diagnostic labels they may hear throughout their treatment can serve as a tool for psychoeducation, empowerment, and control over their own care and themselves.

How should a provider practice de-diagnosing? Based on the work of Reeve, et al.,⁷ on the principles crucial to deprescribing, and subsequent research by Gupta and Cahill,⁸ we compiled a list of considerations for practitioners wishing to engage in this type of work with their patients.
 

Choose the right time. While insurance companies require diagnostic findings from the first visit, abrupt de-diagnosing for the sake of simplifying the record from that first visit could be detrimental. Patients can become attached to and find meaning in their diagnostic labels. This was exemplified with the removal of Asperger’s syndrome from the DSM-5.⁹ Acute symptomatology may be an opportune time to revisit the core pathology of a patient, or a poor time for a patient to have this discussion.

Compile a list of all the patient’s diagnoses. Our initial visits are often illuminated when patients enumerate the vast number of diagnoses they have been given by different providers. Patients will often list half a dozen diagnoses. The patterns often follow life courses with ADHD, conduct disorder, and learning disability in childhood; with anxiety, depression, and/or bipolar disorder in early adulthood; to complicated grief, depression with pseudodementia, and neurocognitive disorders in older adults. Yet patients rarely appreciate the temporary or episodic nature of mental disorders and instead accumulate diagnoses at each change of provider.

Initiate discussion with the patient. It is meaningful to see if patients resonate with the question, “Do you ever feel like every psychiatrist you have seen has given you a different diagnosis?” In our experience, patients’ reactions to this question usually exemplify the problematic nature of the vast array of diagnoses our patients are given. The majority of them are unable to confidently explain the meaning of those diagnoses, the context in which they were given, or their significance. This simple exercise has a powerful effect on raising awareness to patients of the problematic nature of polydiagnosing.

Introduce de-diagnosing. The engagement of patients in the diagnostic process has a significant effect. Reviewing not only diagnostic criteria but also nosology and debates in our understanding of diagnoses can provide patients with further engagement in their care. A simple review of the debate of the bereavement exclusion may permit a patient to not only understand the complexity, but also the changing nature of diagnoses. Suddenly, they are no longer bystanders, but informed participants in their care.

Identify diagnoses most appropriate for removal. Contradictory diagnoses are common in the clinical settings we work in. We routinely see patients carrying multiple mood diagnoses, despite our diagnostic systems not permitting one to have both unipolar and bipolar depression. Superfluous diagnoses are also frequent, with patients receiving depressive, or anxious labels when in an acute state of psychosis or mania. This is exemplified by patients suffering from thought blocking and receiving cognitive or attention-related diagnoses. Concurrent yet different diagnoses are also common in patients with a different list of diagnoses by their primary care provider, their therapist, and their psychiatrist. This is particularly problematic as it forces the patient to alternate their thinking or choose between their providers.

Create a new narrative for the patient. Once diagnoses are explained, clarified, and understood, patients with the help of their providers can reexamine their life story under a new and simplified construct. This process often leads to a less confusing sense of self, an increased dedication to the treatment process, whether behavioral, social, psychological, or pharmacologic.

Consider deprescribing. With a more straightforward and more grounded list of diagnoses (or simply one diagnosis), we find the process of deprescribing to be simpler and more engaging for patients. For example, patients can clearly understand the lack of necessity of an antipsychotic prescription for a resolved substance-induced psychosis. Patients are more engaged in their care, leading to improved medication compliance and less attachment to discontinued medications.

Monitor and adapt. One should of course reevaluate diagnoses as the course of illness provides us with additional information. However, we suggest waiting for a manic episode to emerge prior to diagnosing bipolar rather than suggesting the diagnosis because a patient was wearing red shoes, spoke multiple languages, had multiple degrees and was creative.¹⁰ The contextual basis and progression of the symptoms should lead to continual reassessment of diagnoses.

Physicians are aware of the balance between Occam’s razor, which promotes the simplest single explanation for a problem, versus Hickam’s dictum that reminds us that patients can have as many diseases as they please. However, similarly to polypharmacy, “polydiagnosing” has negative effects. While the field of psychiatry’s advancing knowledge may encourage providers to diagnose their patients with the growing number of diagnoses, patients still need and benefit from a coherent and clear medical narrative. Psychiatry would be wise to recognize this concerning trend, in its attempt at rectifying polypharmacy.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest. Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He has no conflicts of interest.

References

1. Gupta S & Cahill JD. A prescription for “deprescribing” in psychiatry. Psychiatr Serv. 2016 Aug 1;67(8):904-7. doi: 10.1176/appi.ps.201500359.

2. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006 Sep;101 Suppl 1:76-88. doi: 10.1111/j.1360-0443.2006.01592.x.

3. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association, 2022. https://psychiatry.org/psychiatrists/practice/dsm.

4. Kendler KS. An historical framework for psychiatric nosology. Psychol Med. 2009 Dec;39(12):1935-41. doi: 10.1017/S0033291709005753.

5. Regier DA et al. DSM-5 field trials in the United States and Canada. Am J Psychiatry. 2013 Jan;170(1):59-70. doi: 10.1176/appi.ajp.2012.12070999.

6. Bhattacharya R et al. When good news is bad news: psychological impact of false-positive diagnosis of HIV. AIDS Care. 2008 May;20(5):560-4. doi: 10.1080/09540120701867206.

7. Reeve E et al. Review of deprescribing processes and development of an evidence‐based, patient‐centred deprescribing process. Br J Clin Pharmacol. 2014 Oct;78(4):738-47. doi: 10.1111/bcp.12386.

8. Gupta S and Cahill JD. A prescription for “deprescribing” in psychiatry.

9. Solomon M. “On the appearance and disappearance of Asperger’s syndrome” in Kendler and Parnas (eds.) Philosophical Issues in Psychiatry IV: Classification of Psychiatric Illness. Oxford University Press, 2017. doi: 10.1093/med/9780198796022.003.0023.

10. Akiskal HS. Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: The “red sign,” the “rule of three,” and other biographic signs of temperamental extravagance, activation, and hypomania. J Affect Disord. 2005 Feb;84(2-3):279-90. doi: 10.1016/j.jad.2004.06.002.

In 2016, Gupta and Cahill challenged the field of psychiatry to reexamine prescribing patterns.¹ They warned against the use of polypharmacy when not attached to improved patient functioning. They were concerned with the limited evidence for polypharmacy as well as DSM diagnostic criteria. In their inspiring article, they described a process of deprescribing.

In an effort to study and practice their recommendations, we have noticed a lack of literature examining the elimination of diagnostic labels. While there have been some studies looking at comorbidity, especially with substance use disorders,² there is a paucity of scientific evidence on patients with numerous diagnoses. Yet our practices are filled with patients who have been labeled with multiple conflicting or redundant diagnoses throughout their lives depending on the setting or the orientation of the practitioner.

The DSM-5 warns against diagnosing disorders when “the occurrence … is not better explained by” another disorder.³ A mix of diagnoses creates confusion for patients as well as clinicians trying to sort through their reported psychiatric histories.

A routine example would include a patient presenting for an initial evaluation and stating “I’ve been diagnosed as manic-depressive, high anxiety, split personality, posttraumatic stress, insomnia, ADD, and depression.” A review of the medical record will reveal a list of diagnoses, including bipolar II, generalized anxiety disorder, borderline personality disorder, posttraumatic stress disorder, unspecified insomnia, attention-deficit/hyperactivity disorder, and major depressive disorder. The medication list includes lamotrigine, valproic acid, citalopram, bupropion, buspirone, prazosin, methylphenidate, clonazepam, hydroxyzine, and low-dose quetiapine at night as needed.

This is an example of polypharmacy treating multiple, and at times conflicting, diagnoses. While an extreme case, in our experience, cases like this are not uncommon. It was actually in our efforts to examine deprescribing that we noticed this quandary. When inquiring about patients on many psychotropic medications, we often receive this retort: the patient is only prescribed one medication per disorder. Some providers have the belief that multiple disorders justify multiple medications, and that this tautological thinking legitimizes polypharmacy.

A patient who has varying moods, some fears, a fluctuating temperament, past traumas, occasional difficulty sleeping, intermittent inattention, and some sadness may be given all the diagnoses listed above and the resulting medication list. The multiplication of diagnoses, “polydiagnosing,” is a convenient justification for future polypharmacy. A lack of careful assessment and thinking in the application of new diagnoses permits the use of increasing numbers of pharmacological agents. A constellation of symptoms of anxiety, concentration deficits, affective dysregulation, and psychosis may justify the combination of benzodiazepines, stimulants, mood stabilizers, and antipsychotics, while a patient with “just” schizophrenia who is sometimes sad, scared, or distracted is more likely to be kept on just one medication, likely an antipsychotic.

Contrary to most medical disorders (for example, tuberculosis) but similar to others (for example, chronic pain), psychiatric disorders are based on the opinion of a “modest number of ‘expert’ classifications.”⁴ While the broad categories of disorders are justifiable, individual diagnoses are burdened with high rates of comorbidity; lack of treatment specificity; and evidence that distinct syndromes share a genetic basis. Those concerns were exemplified in the study examining the inter-rater reliability of DSM-5 diagnoses, where many disorders were found to have questionable validity.⁵

A psychiatric diagnosis should be based on biological, psychological, and social factors, which align with our understanding of the natural course of an illness. A patient presenting with transient symptoms of sadness in the context of significant social factors like homelessness and/or significant biological factors associated with schizophrenia should not reflexively receive an additional diagnosis of a depressive disorder. A patient reporting poor concentration in the context of a manic episode should not receive an additional diagnosis of attention-deficit disorder. An older patient with depression on multiple antipsychotics for adjunctive treatment should not necessarily receive a diagnosis of cognitive disorder at the first sign of memory problems.

The cavalier and inconsistent use of diagnoses renders the patients with no clear narrative of who they are. They end up integrating the varying providers’ opinions as a cacophony of labels of unclear significance. Many patients have contradictory diagnoses like major depressive disorder and bipolar disorder, or schizophrenia and schizoaffective disorder. Those inaccurate diagnoses could not only lead to treatment mistakes, but also psychological harm.⁶

A clearer diagnostic picture is not only more scientifically sound but also more coherent to the patient. This in turn can lead to an improved treatment alliance and buy-in from the patient. Assisting a patient in sorting out and understanding the vast arrays of diagnostic labels they may hear throughout their treatment can serve as a tool for psychoeducation, empowerment, and control over their own care and themselves.

How should a provider practice de-diagnosing? Based on the work of Reeve, et al.,⁷ on the principles crucial to deprescribing, and subsequent research by Gupta and Cahill,⁸ we compiled a list of considerations for practitioners wishing to engage in this type of work with their patients.
 

Choose the right time. While insurance companies require diagnostic findings from the first visit, abrupt de-diagnosing for the sake of simplifying the record from that first visit could be detrimental. Patients can become attached to and find meaning in their diagnostic labels. This was exemplified with the removal of Asperger’s syndrome from the DSM-5.⁹ Acute symptomatology may be an opportune time to revisit the core pathology of a patient, or a poor time for a patient to have this discussion.

Compile a list of all the patient’s diagnoses. Our initial visits are often illuminated when patients enumerate the vast number of diagnoses they have been given by different providers. Patients will often list half a dozen diagnoses. The patterns often follow life courses with ADHD, conduct disorder, and learning disability in childhood; with anxiety, depression, and/or bipolar disorder in early adulthood; to complicated grief, depression with pseudodementia, and neurocognitive disorders in older adults. Yet patients rarely appreciate the temporary or episodic nature of mental disorders and instead accumulate diagnoses at each change of provider.

Initiate discussion with the patient. It is meaningful to see if patients resonate with the question, “Do you ever feel like every psychiatrist you have seen has given you a different diagnosis?” In our experience, patients’ reactions to this question usually exemplify the problematic nature of the vast array of diagnoses our patients are given. The majority of them are unable to confidently explain the meaning of those diagnoses, the context in which they were given, or their significance. This simple exercise has a powerful effect on raising awareness to patients of the problematic nature of polydiagnosing.

Introduce de-diagnosing. The engagement of patients in the diagnostic process has a significant effect. Reviewing not only diagnostic criteria but also nosology and debates in our understanding of diagnoses can provide patients with further engagement in their care. A simple review of the debate of the bereavement exclusion may permit a patient to not only understand the complexity, but also the changing nature of diagnoses. Suddenly, they are no longer bystanders, but informed participants in their care.

Identify diagnoses most appropriate for removal. Contradictory diagnoses are common in the clinical settings we work in. We routinely see patients carrying multiple mood diagnoses, despite our diagnostic systems not permitting one to have both unipolar and bipolar depression. Superfluous diagnoses are also frequent, with patients receiving depressive, or anxious labels when in an acute state of psychosis or mania. This is exemplified by patients suffering from thought blocking and receiving cognitive or attention-related diagnoses. Concurrent yet different diagnoses are also common in patients with a different list of diagnoses by their primary care provider, their therapist, and their psychiatrist. This is particularly problematic as it forces the patient to alternate their thinking or choose between their providers.

Create a new narrative for the patient. Once diagnoses are explained, clarified, and understood, patients with the help of their providers can reexamine their life story under a new and simplified construct. This process often leads to a less confusing sense of self, an increased dedication to the treatment process, whether behavioral, social, psychological, or pharmacologic.

Consider deprescribing. With a more straightforward and more grounded list of diagnoses (or simply one diagnosis), we find the process of deprescribing to be simpler and more engaging for patients. For example, patients can clearly understand the lack of necessity of an antipsychotic prescription for a resolved substance-induced psychosis. Patients are more engaged in their care, leading to improved medication compliance and less attachment to discontinued medications.

Monitor and adapt. One should of course reevaluate diagnoses as the course of illness provides us with additional information. However, we suggest waiting for a manic episode to emerge prior to diagnosing bipolar rather than suggesting the diagnosis because a patient was wearing red shoes, spoke multiple languages, had multiple degrees and was creative.¹⁰ The contextual basis and progression of the symptoms should lead to continual reassessment of diagnoses.

Physicians are aware of the balance between Occam’s razor, which promotes the simplest single explanation for a problem, versus Hickam’s dictum that reminds us that patients can have as many diseases as they please. However, similarly to polypharmacy, “polydiagnosing” has negative effects. While the field of psychiatry’s advancing knowledge may encourage providers to diagnose their patients with the growing number of diagnoses, patients still need and benefit from a coherent and clear medical narrative. Psychiatry would be wise to recognize this concerning trend, in its attempt at rectifying polypharmacy.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest. Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He has no conflicts of interest.

References

1. Gupta S & Cahill JD. A prescription for “deprescribing” in psychiatry. Psychiatr Serv. 2016 Aug 1;67(8):904-7. doi: 10.1176/appi.ps.201500359.

2. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006 Sep;101 Suppl 1:76-88. doi: 10.1111/j.1360-0443.2006.01592.x.

3. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association, 2022. https://psychiatry.org/psychiatrists/practice/dsm.

4. Kendler KS. An historical framework for psychiatric nosology. Psychol Med. 2009 Dec;39(12):1935-41. doi: 10.1017/S0033291709005753.

5. Regier DA et al. DSM-5 field trials in the United States and Canada. Am J Psychiatry. 2013 Jan;170(1):59-70. doi: 10.1176/appi.ajp.2012.12070999.

6. Bhattacharya R et al. When good news is bad news: psychological impact of false-positive diagnosis of HIV. AIDS Care. 2008 May;20(5):560-4. doi: 10.1080/09540120701867206.

7. Reeve E et al. Review of deprescribing processes and development of an evidence‐based, patient‐centred deprescribing process. Br J Clin Pharmacol. 2014 Oct;78(4):738-47. doi: 10.1111/bcp.12386.

8. Gupta S and Cahill JD. A prescription for “deprescribing” in psychiatry.

9. Solomon M. “On the appearance and disappearance of Asperger’s syndrome” in Kendler and Parnas (eds.) Philosophical Issues in Psychiatry IV: Classification of Psychiatric Illness. Oxford University Press, 2017. doi: 10.1093/med/9780198796022.003.0023.

10. Akiskal HS. Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: The “red sign,” the “rule of three,” and other biographic signs of temperamental extravagance, activation, and hypomania. J Affect Disord. 2005 Feb;84(2-3):279-90. doi: 10.1016/j.jad.2004.06.002.

In 2016, Gupta and Cahill challenged the field of psychiatry to reexamine prescribing patterns.¹ They warned against the use of polypharmacy when not attached to improved patient functioning. They were concerned with the limited evidence for polypharmacy as well as DSM diagnostic criteria. In their inspiring article, they described a process of deprescribing.

In an effort to study and practice their recommendations, we have noticed a lack of literature examining the elimination of diagnostic labels. While there have been some studies looking at comorbidity, especially with substance use disorders,² there is a paucity of scientific evidence on patients with numerous diagnoses. Yet our practices are filled with patients who have been labeled with multiple conflicting or redundant diagnoses throughout their lives depending on the setting or the orientation of the practitioner.

The DSM-5 warns against diagnosing disorders when “the occurrence … is not better explained by” another disorder.³ A mix of diagnoses creates confusion for patients as well as clinicians trying to sort through their reported psychiatric histories.

A routine example would include a patient presenting for an initial evaluation and stating “I’ve been diagnosed as manic-depressive, high anxiety, split personality, posttraumatic stress, insomnia, ADD, and depression.” A review of the medical record will reveal a list of diagnoses, including bipolar II, generalized anxiety disorder, borderline personality disorder, posttraumatic stress disorder, unspecified insomnia, attention-deficit/hyperactivity disorder, and major depressive disorder. The medication list includes lamotrigine, valproic acid, citalopram, bupropion, buspirone, prazosin, methylphenidate, clonazepam, hydroxyzine, and low-dose quetiapine at night as needed.

This is an example of polypharmacy treating multiple, and at times conflicting, diagnoses. While an extreme case, in our experience, cases like this are not uncommon. It was actually in our efforts to examine deprescribing that we noticed this quandary. When inquiring about patients on many psychotropic medications, we often receive this retort: the patient is only prescribed one medication per disorder. Some providers have the belief that multiple disorders justify multiple medications, and that this tautological thinking legitimizes polypharmacy.

A patient who has varying moods, some fears, a fluctuating temperament, past traumas, occasional difficulty sleeping, intermittent inattention, and some sadness may be given all the diagnoses listed above and the resulting medication list. The multiplication of diagnoses, “polydiagnosing,” is a convenient justification for future polypharmacy. A lack of careful assessment and thinking in the application of new diagnoses permits the use of increasing numbers of pharmacological agents. A constellation of symptoms of anxiety, concentration deficits, affective dysregulation, and psychosis may justify the combination of benzodiazepines, stimulants, mood stabilizers, and antipsychotics, while a patient with “just” schizophrenia who is sometimes sad, scared, or distracted is more likely to be kept on just one medication, likely an antipsychotic.

Contrary to most medical disorders (for example, tuberculosis) but similar to others (for example, chronic pain), psychiatric disorders are based on the opinion of a “modest number of ‘expert’ classifications.”⁴ While the broad categories of disorders are justifiable, individual diagnoses are burdened with high rates of comorbidity; lack of treatment specificity; and evidence that distinct syndromes share a genetic basis. Those concerns were exemplified in the study examining the inter-rater reliability of DSM-5 diagnoses, where many disorders were found to have questionable validity.⁵

A psychiatric diagnosis should be based on biological, psychological, and social factors, which align with our understanding of the natural course of an illness. A patient presenting with transient symptoms of sadness in the context of significant social factors like homelessness and/or significant biological factors associated with schizophrenia should not reflexively receive an additional diagnosis of a depressive disorder. A patient reporting poor concentration in the context of a manic episode should not receive an additional diagnosis of attention-deficit disorder. An older patient with depression on multiple antipsychotics for adjunctive treatment should not necessarily receive a diagnosis of cognitive disorder at the first sign of memory problems.

The cavalier and inconsistent use of diagnoses renders the patients with no clear narrative of who they are. They end up integrating the varying providers’ opinions as a cacophony of labels of unclear significance. Many patients have contradictory diagnoses like major depressive disorder and bipolar disorder, or schizophrenia and schizoaffective disorder. Those inaccurate diagnoses could not only lead to treatment mistakes, but also psychological harm.⁶

A clearer diagnostic picture is not only more scientifically sound but also more coherent to the patient. This in turn can lead to an improved treatment alliance and buy-in from the patient. Assisting a patient in sorting out and understanding the vast arrays of diagnostic labels they may hear throughout their treatment can serve as a tool for psychoeducation, empowerment, and control over their own care and themselves.

How should a provider practice de-diagnosing? Based on the work of Reeve, et al.,⁷ on the principles crucial to deprescribing, and subsequent research by Gupta and Cahill,⁸ we compiled a list of considerations for practitioners wishing to engage in this type of work with their patients.
 

Choose the right time. While insurance companies require diagnostic findings from the first visit, abrupt de-diagnosing for the sake of simplifying the record from that first visit could be detrimental. Patients can become attached to and find meaning in their diagnostic labels. This was exemplified with the removal of Asperger’s syndrome from the DSM-5.⁹ Acute symptomatology may be an opportune time to revisit the core pathology of a patient, or a poor time for a patient to have this discussion.

Compile a list of all the patient’s diagnoses. Our initial visits are often illuminated when patients enumerate the vast number of diagnoses they have been given by different providers. Patients will often list half a dozen diagnoses. The patterns often follow life courses with ADHD, conduct disorder, and learning disability in childhood; with anxiety, depression, and/or bipolar disorder in early adulthood; to complicated grief, depression with pseudodementia, and neurocognitive disorders in older adults. Yet patients rarely appreciate the temporary or episodic nature of mental disorders and instead accumulate diagnoses at each change of provider.

Initiate discussion with the patient. It is meaningful to see if patients resonate with the question, “Do you ever feel like every psychiatrist you have seen has given you a different diagnosis?” In our experience, patients’ reactions to this question usually exemplify the problematic nature of the vast array of diagnoses our patients are given. The majority of them are unable to confidently explain the meaning of those diagnoses, the context in which they were given, or their significance. This simple exercise has a powerful effect on raising awareness to patients of the problematic nature of polydiagnosing.

Introduce de-diagnosing. The engagement of patients in the diagnostic process has a significant effect. Reviewing not only diagnostic criteria but also nosology and debates in our understanding of diagnoses can provide patients with further engagement in their care. A simple review of the debate of the bereavement exclusion may permit a patient to not only understand the complexity, but also the changing nature of diagnoses. Suddenly, they are no longer bystanders, but informed participants in their care.

Identify diagnoses most appropriate for removal. Contradictory diagnoses are common in the clinical settings we work in. We routinely see patients carrying multiple mood diagnoses, despite our diagnostic systems not permitting one to have both unipolar and bipolar depression. Superfluous diagnoses are also frequent, with patients receiving depressive, or anxious labels when in an acute state of psychosis or mania. This is exemplified by patients suffering from thought blocking and receiving cognitive or attention-related diagnoses. Concurrent yet different diagnoses are also common in patients with a different list of diagnoses by their primary care provider, their therapist, and their psychiatrist. This is particularly problematic as it forces the patient to alternate their thinking or choose between their providers.

Create a new narrative for the patient. Once diagnoses are explained, clarified, and understood, patients with the help of their providers can reexamine their life story under a new and simplified construct. This process often leads to a less confusing sense of self, an increased dedication to the treatment process, whether behavioral, social, psychological, or pharmacologic.

Consider deprescribing. With a more straightforward and more grounded list of diagnoses (or simply one diagnosis), we find the process of deprescribing to be simpler and more engaging for patients. For example, patients can clearly understand the lack of necessity of an antipsychotic prescription for a resolved substance-induced psychosis. Patients are more engaged in their care, leading to improved medication compliance and less attachment to discontinued medications.

Monitor and adapt. One should of course reevaluate diagnoses as the course of illness provides us with additional information. However, we suggest waiting for a manic episode to emerge prior to diagnosing bipolar rather than suggesting the diagnosis because a patient was wearing red shoes, spoke multiple languages, had multiple degrees and was creative.¹⁰ The contextual basis and progression of the symptoms should lead to continual reassessment of diagnoses.

Physicians are aware of the balance between Occam’s razor, which promotes the simplest single explanation for a problem, versus Hickam’s dictum that reminds us that patients can have as many diseases as they please. However, similarly to polypharmacy, “polydiagnosing” has negative effects. While the field of psychiatry’s advancing knowledge may encourage providers to diagnose their patients with the growing number of diagnoses, patients still need and benefit from a coherent and clear medical narrative. Psychiatry would be wise to recognize this concerning trend, in its attempt at rectifying polypharmacy.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest. Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He has no conflicts of interest.

References

1. Gupta S & Cahill JD. A prescription for “deprescribing” in psychiatry. Psychiatr Serv. 2016 Aug 1;67(8):904-7. doi: 10.1176/appi.ps.201500359.

2. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006 Sep;101 Suppl 1:76-88. doi: 10.1111/j.1360-0443.2006.01592.x.

3. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association, 2022. https://psychiatry.org/psychiatrists/practice/dsm.

4. Kendler KS. An historical framework for psychiatric nosology. Psychol Med. 2009 Dec;39(12):1935-41. doi: 10.1017/S0033291709005753.

5. Regier DA et al. DSM-5 field trials in the United States and Canada. Am J Psychiatry. 2013 Jan;170(1):59-70. doi: 10.1176/appi.ajp.2012.12070999.

6. Bhattacharya R et al. When good news is bad news: psychological impact of false-positive diagnosis of HIV. AIDS Care. 2008 May;20(5):560-4. doi: 10.1080/09540120701867206.

7. Reeve E et al. Review of deprescribing processes and development of an evidence‐based, patient‐centred deprescribing process. Br J Clin Pharmacol. 2014 Oct;78(4):738-47. doi: 10.1111/bcp.12386.

8. Gupta S and Cahill JD. A prescription for “deprescribing” in psychiatry.

9. Solomon M. “On the appearance and disappearance of Asperger’s syndrome” in Kendler and Parnas (eds.) Philosophical Issues in Psychiatry IV: Classification of Psychiatric Illness. Oxford University Press, 2017. doi: 10.1093/med/9780198796022.003.0023.

10. Akiskal HS. Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: The “red sign,” the “rule of three,” and other biographic signs of temperamental extravagance, activation, and hypomania. J Affect Disord. 2005 Feb;84(2-3):279-90. doi: 10.1016/j.jad.2004.06.002.

Migraine headaches pose a challenge for many patients and their physicians, so new, effective approaches are always welcome. Sometimes new treatments come as total surprises. For example, who would have guessed that timolol eyedrops could be effective for acute migraine?¹ Granted, the results (discussed in this issue's PURLs) are from a single randomized trial, but they look very promising.

This is not the only new and innovative treatment for migraine. Everyone knows about the heavily marketed calcium gene-related peptide antagonists, which include monoclonal antibodies and the so-called “gepants.” The monoclonal antibodies and atogepant are approved for migraine prevention, and they do a decent job (although at a high price). In randomized trials, these agents reduced migraine days per month by an average of about 1.5 to 2.5 days compared to placebo.^2-5

Who would have guessed that timolol eyedrops could be effective for acute migraine?

Ubrogepant and rimegepant are approved for acute migraine treatment. In clinical trials, about 20% of patients taking ubrogepant or rimegepant were pain free at 2 hours post dose, compared to 12% to 14% taking placebo.^6,7 Unfortunately, that means 80% of patients still have some pain at 2 hours. By comparison, zolmitriptan performs a bit better, with 34% of patients pain free at 2 hours.⁸ However, for those who can’t tolerate zolmitriptan, these newer options provide an alternative.

We also now have nonpharmacologic options. The caloric vestibular stimulation device is essentially a headset with ear probes that change temperature, alternating warm and cold. In a randomized controlled trial, it reduced monthly migraine days by 1.1 compared to placebo, from a baseline of 7.7 to 3.9 days.⁹ It can also be used to treat acute migraine. There is also a vagus nerve–stimulating device that reduced migraine headache severity by 20% on average in 32.2% of patients in 30 minutes. Sham treatment was as effective for 18.5% of patients, giving a number needed to treat of 6 compared to sham.¹⁰

And finally, there are complementary and alternative medicine options. Two recent randomized trials demonstrated that ≥ 2000 IU/d of vitamin D reduced monthly migraine days an average of 2 days, which is comparable to the effectiveness of the calcium gene-related peptide antagonists at a fraction of the cost.^11,12 In another randomized trial, intranasal 1.5% peppermint oil was as effective as topical 4% lidocaine in providing substantial pain relief for acute migraine; about 42% of patients achieved significant relief with either treatment.¹³

While we may not have a perfect treatment for our patients with migraine headache, we certainly have many options to choose from.

Migraine headaches pose a challenge for many patients and their physicians, so new, effective approaches are always welcome. Sometimes new treatments come as total surprises. For example, who would have guessed that timolol eyedrops could be effective for acute migraine?¹ Granted, the results (discussed in this issue's PURLs) are from a single randomized trial, but they look very promising.

This is not the only new and innovative treatment for migraine. Everyone knows about the heavily marketed calcium gene-related peptide antagonists, which include monoclonal antibodies and the so-called “gepants.” The monoclonal antibodies and atogepant are approved for migraine prevention, and they do a decent job (although at a high price). In randomized trials, these agents reduced migraine days per month by an average of about 1.5 to 2.5 days compared to placebo.^2-5

Who would have guessed that timolol eyedrops could be effective for acute migraine?

Ubrogepant and rimegepant are approved for acute migraine treatment. In clinical trials, about 20% of patients taking ubrogepant or rimegepant were pain free at 2 hours post dose, compared to 12% to 14% taking placebo.^6,7 Unfortunately, that means 80% of patients still have some pain at 2 hours. By comparison, zolmitriptan performs a bit better, with 34% of patients pain free at 2 hours.⁸ However, for those who can’t tolerate zolmitriptan, these newer options provide an alternative.

We also now have nonpharmacologic options. The caloric vestibular stimulation device is essentially a headset with ear probes that change temperature, alternating warm and cold. In a randomized controlled trial, it reduced monthly migraine days by 1.1 compared to placebo, from a baseline of 7.7 to 3.9 days.⁹ It can also be used to treat acute migraine. There is also a vagus nerve–stimulating device that reduced migraine headache severity by 20% on average in 32.2% of patients in 30 minutes. Sham treatment was as effective for 18.5% of patients, giving a number needed to treat of 6 compared to sham.¹⁰

And finally, there are complementary and alternative medicine options. Two recent randomized trials demonstrated that ≥ 2000 IU/d of vitamin D reduced monthly migraine days an average of 2 days, which is comparable to the effectiveness of the calcium gene-related peptide antagonists at a fraction of the cost.^11,12 In another randomized trial, intranasal 1.5% peppermint oil was as effective as topical 4% lidocaine in providing substantial pain relief for acute migraine; about 42% of patients achieved significant relief with either treatment.¹³

While we may not have a perfect treatment for our patients with migraine headache, we certainly have many options to choose from.

Migraine headaches pose a challenge for many patients and their physicians, so new, effective approaches are always welcome. Sometimes new treatments come as total surprises. For example, who would have guessed that timolol eyedrops could be effective for acute migraine?¹ Granted, the results (discussed in this issue's PURLs) are from a single randomized trial, but they look very promising.

This is not the only new and innovative treatment for migraine. Everyone knows about the heavily marketed calcium gene-related peptide antagonists, which include monoclonal antibodies and the so-called “gepants.” The monoclonal antibodies and atogepant are approved for migraine prevention, and they do a decent job (although at a high price). In randomized trials, these agents reduced migraine days per month by an average of about 1.5 to 2.5 days compared to placebo.^2-5

Who would have guessed that timolol eyedrops could be effective for acute migraine?

Ubrogepant and rimegepant are approved for acute migraine treatment. In clinical trials, about 20% of patients taking ubrogepant or rimegepant were pain free at 2 hours post dose, compared to 12% to 14% taking placebo.^6,7 Unfortunately, that means 80% of patients still have some pain at 2 hours. By comparison, zolmitriptan performs a bit better, with 34% of patients pain free at 2 hours.⁸ However, for those who can’t tolerate zolmitriptan, these newer options provide an alternative.

We also now have nonpharmacologic options. The caloric vestibular stimulation device is essentially a headset with ear probes that change temperature, alternating warm and cold. In a randomized controlled trial, it reduced monthly migraine days by 1.1 compared to placebo, from a baseline of 7.7 to 3.9 days.⁹ It can also be used to treat acute migraine. There is also a vagus nerve–stimulating device that reduced migraine headache severity by 20% on average in 32.2% of patients in 30 minutes. Sham treatment was as effective for 18.5% of patients, giving a number needed to treat of 6 compared to sham.¹⁰

And finally, there are complementary and alternative medicine options. Two recent randomized trials demonstrated that ≥ 2000 IU/d of vitamin D reduced monthly migraine days an average of 2 days, which is comparable to the effectiveness of the calcium gene-related peptide antagonists at a fraction of the cost.^11,12 In another randomized trial, intranasal 1.5% peppermint oil was as effective as topical 4% lidocaine in providing substantial pain relief for acute migraine; about 42% of patients achieved significant relief with either treatment.¹³

While we may not have a perfect treatment for our patients with migraine headache, we certainly have many options to choose from.

The 1973 Supreme Court of the United States (SCOTUS) decision in Roe v Wade was a landmark ruling,¹ establishing that the United States Constitution provides a fundamental “right to privacy,” protecting pregnant people’s freedom to access all available reproductive health care options. Recognizing that the right to abortion was not absolute, the majority of justices supported a trimester system. In the first trimester, decisions about abortion care are fully controlled by patients and clinicians, and no government could place restrictions on access to abortion. In the second trimester, SCOTUS ruled that states may choose to regulate abortion to protect maternal health. (As an example of such state restrictions, in Massachusetts, for many years, but no longer, the state required that abortions occur in a hospital when the patient was between 18 and 24 weeks’ gestation in order to facilitate comprehensive emergency care for complications.) Beginning in the third trimester, a point at which a fetus could be viable, the Court ruled that a government could prohibit abortion except when an abortion was necessary to protect the life or health of the pregnant person. In 1992, the SCOTUS decision in Planned Parenthood v Casey² rejected the trimester system, reaffirming the right to an abortion before fetal viability, and adopting a new standard that states may not create an undue burden on a person seeking an abortion before fetal viability. SCOTUS ruled that an undue burden exists if the purpose of a regulation is to place substantial obstacles in the path of a person seeking an abortion.

If, as anticipated, the 2022 SCOTUS decision in Dobbs v Jackson Women’s Health Organization³ overturns the precedents set in Roe v Wade and Planned Parenthood v Casey, decisions on abortion law will be relegated to elected legislators and state courts.⁴ It is expected that at least 26 state legislatures and governors will enact stringent new restrictions on access to abortion. This cataclysmic reversal of judicial opinion creates a historic challenge to obstetrician-gynecologists and their patients and could threaten access to other vital reproductive services beyond abortion, like contraception. We will be fighting, state by state, for people’s right to access all available reproductive health procedures. This will also significantly affect the ability for providers in women’s reproductive health to obtain appropriate and necessary education and training in a critical skills. If access to safe abortion is restricted, we fear patients may be forced to consider unsafe abortion, raising the specter of a return to the 1960s, when an epidemic of unsafe abortion caused countless injuries and deaths.^5,6

How do we best prepare for these challenges?

• We will need to be flexible and continually evolve our clinical practices to be adherent with state and local legislation and regulation.
• To reduce unintended pregnancies, we need to strengthen our efforts to ensure that every patient has ready access to all available contraceptive options with no out-of-pocket cost.
• When a contraceptive is desired, we will focus on educating people about effectiveness, and offering them highly reliable contraception, such as the implant or intrauterine devices.
• We need to ensure timely access to abortion if state-based laws permit abortion before 6 or 7 weeks’ gestation. Providing medication abortion without an in-person visit using a telehealth option would be one option to expand rapid access to early first trimester abortion.
• Clinicians in states with access to abortion services will need to collaborate with colleagues in states with restrictions on abortion services to improve patient access across state borders.

On a national level, advancing our effective advocacy in Congress may lead to national legislation passed and signed by the President. This could supersede most state laws prohibiting access to comprehensive women’s reproductive health and create a unified, national approach to abortion care, allowing for the appropriate training of all obstetrician-gynecologists. We will also need to develop teams in every state capable of advocating for laws that ensure access to all reproductive health care options. The American College of Obstetricians and Gynecologists has leaders trained and tasked with legislative advocacy in every state.⁷ This network will be a foundation upon which to build additional advocacy efforts.

As women’s health care professionals, our responsibility to our patients, is to work to ensure universal access to safe and effective comprehensive reproductive options, and to ensure that our workforce is prepared to meet the needs of our patients by defending the patient-clinician relationship. Abortion care saves lives of pregnant patients and reduces maternal morbidity.⁸ Access to safe abortion care as part of comprehensive reproductive services is an important component of health care. ●

The 1973 Supreme Court of the United States (SCOTUS) decision in Roe v Wade was a landmark ruling,¹ establishing that the United States Constitution provides a fundamental “right to privacy,” protecting pregnant people’s freedom to access all available reproductive health care options. Recognizing that the right to abortion was not absolute, the majority of justices supported a trimester system. In the first trimester, decisions about abortion care are fully controlled by patients and clinicians, and no government could place restrictions on access to abortion. In the second trimester, SCOTUS ruled that states may choose to regulate abortion to protect maternal health. (As an example of such state restrictions, in Massachusetts, for many years, but no longer, the state required that abortions occur in a hospital when the patient was between 18 and 24 weeks’ gestation in order to facilitate comprehensive emergency care for complications.) Beginning in the third trimester, a point at which a fetus could be viable, the Court ruled that a government could prohibit abortion except when an abortion was necessary to protect the life or health of the pregnant person. In 1992, the SCOTUS decision in Planned Parenthood v Casey² rejected the trimester system, reaffirming the right to an abortion before fetal viability, and adopting a new standard that states may not create an undue burden on a person seeking an abortion before fetal viability. SCOTUS ruled that an undue burden exists if the purpose of a regulation is to place substantial obstacles in the path of a person seeking an abortion.

If, as anticipated, the 2022 SCOTUS decision in Dobbs v Jackson Women’s Health Organization³ overturns the precedents set in Roe v Wade and Planned Parenthood v Casey, decisions on abortion law will be relegated to elected legislators and state courts.⁴ It is expected that at least 26 state legislatures and governors will enact stringent new restrictions on access to abortion. This cataclysmic reversal of judicial opinion creates a historic challenge to obstetrician-gynecologists and their patients and could threaten access to other vital reproductive services beyond abortion, like contraception. We will be fighting, state by state, for people’s right to access all available reproductive health procedures. This will also significantly affect the ability for providers in women’s reproductive health to obtain appropriate and necessary education and training in a critical skills. If access to safe abortion is restricted, we fear patients may be forced to consider unsafe abortion, raising the specter of a return to the 1960s, when an epidemic of unsafe abortion caused countless injuries and deaths.^5,6

How do we best prepare for these challenges?

• We will need to be flexible and continually evolve our clinical practices to be adherent with state and local legislation and regulation.
• To reduce unintended pregnancies, we need to strengthen our efforts to ensure that every patient has ready access to all available contraceptive options with no out-of-pocket cost.
• When a contraceptive is desired, we will focus on educating people about effectiveness, and offering them highly reliable contraception, such as the implant or intrauterine devices.
• We need to ensure timely access to abortion if state-based laws permit abortion before 6 or 7 weeks’ gestation. Providing medication abortion without an in-person visit using a telehealth option would be one option to expand rapid access to early first trimester abortion.
• Clinicians in states with access to abortion services will need to collaborate with colleagues in states with restrictions on abortion services to improve patient access across state borders.

On a national level, advancing our effective advocacy in Congress may lead to national legislation passed and signed by the President. This could supersede most state laws prohibiting access to comprehensive women’s reproductive health and create a unified, national approach to abortion care, allowing for the appropriate training of all obstetrician-gynecologists. We will also need to develop teams in every state capable of advocating for laws that ensure access to all reproductive health care options. The American College of Obstetricians and Gynecologists has leaders trained and tasked with legislative advocacy in every state.⁷ This network will be a foundation upon which to build additional advocacy efforts.

As women’s health care professionals, our responsibility to our patients, is to work to ensure universal access to safe and effective comprehensive reproductive options, and to ensure that our workforce is prepared to meet the needs of our patients by defending the patient-clinician relationship. Abortion care saves lives of pregnant patients and reduces maternal morbidity.⁸ Access to safe abortion care as part of comprehensive reproductive services is an important component of health care. ●

The 1973 Supreme Court of the United States (SCOTUS) decision in Roe v Wade was a landmark ruling,¹ establishing that the United States Constitution provides a fundamental “right to privacy,” protecting pregnant people’s freedom to access all available reproductive health care options. Recognizing that the right to abortion was not absolute, the majority of justices supported a trimester system. In the first trimester, decisions about abortion care are fully controlled by patients and clinicians, and no government could place restrictions on access to abortion. In the second trimester, SCOTUS ruled that states may choose to regulate abortion to protect maternal health. (As an example of such state restrictions, in Massachusetts, for many years, but no longer, the state required that abortions occur in a hospital when the patient was between 18 and 24 weeks’ gestation in order to facilitate comprehensive emergency care for complications.) Beginning in the third trimester, a point at which a fetus could be viable, the Court ruled that a government could prohibit abortion except when an abortion was necessary to protect the life or health of the pregnant person. In 1992, the SCOTUS decision in Planned Parenthood v Casey² rejected the trimester system, reaffirming the right to an abortion before fetal viability, and adopting a new standard that states may not create an undue burden on a person seeking an abortion before fetal viability. SCOTUS ruled that an undue burden exists if the purpose of a regulation is to place substantial obstacles in the path of a person seeking an abortion.

If, as anticipated, the 2022 SCOTUS decision in Dobbs v Jackson Women’s Health Organization³ overturns the precedents set in Roe v Wade and Planned Parenthood v Casey, decisions on abortion law will be relegated to elected legislators and state courts.⁴ It is expected that at least 26 state legislatures and governors will enact stringent new restrictions on access to abortion. This cataclysmic reversal of judicial opinion creates a historic challenge to obstetrician-gynecologists and their patients and could threaten access to other vital reproductive services beyond abortion, like contraception. We will be fighting, state by state, for people’s right to access all available reproductive health procedures. This will also significantly affect the ability for providers in women’s reproductive health to obtain appropriate and necessary education and training in a critical skills. If access to safe abortion is restricted, we fear patients may be forced to consider unsafe abortion, raising the specter of a return to the 1960s, when an epidemic of unsafe abortion caused countless injuries and deaths.^5,6

How do we best prepare for these challenges?

• We will need to be flexible and continually evolve our clinical practices to be adherent with state and local legislation and regulation.
• To reduce unintended pregnancies, we need to strengthen our efforts to ensure that every patient has ready access to all available contraceptive options with no out-of-pocket cost.
• When a contraceptive is desired, we will focus on educating people about effectiveness, and offering them highly reliable contraception, such as the implant or intrauterine devices.
• We need to ensure timely access to abortion if state-based laws permit abortion before 6 or 7 weeks’ gestation. Providing medication abortion without an in-person visit using a telehealth option would be one option to expand rapid access to early first trimester abortion.
• Clinicians in states with access to abortion services will need to collaborate with colleagues in states with restrictions on abortion services to improve patient access across state borders.

On a national level, advancing our effective advocacy in Congress may lead to national legislation passed and signed by the President. This could supersede most state laws prohibiting access to comprehensive women’s reproductive health and create a unified, national approach to abortion care, allowing for the appropriate training of all obstetrician-gynecologists. We will also need to develop teams in every state capable of advocating for laws that ensure access to all reproductive health care options. The American College of Obstetricians and Gynecologists has leaders trained and tasked with legislative advocacy in every state.⁷ This network will be a foundation upon which to build additional advocacy efforts.

As women’s health care professionals, our responsibility to our patients, is to work to ensure universal access to safe and effective comprehensive reproductive options, and to ensure that our workforce is prepared to meet the needs of our patients by defending the patient-clinician relationship. Abortion care saves lives of pregnant patients and reduces maternal morbidity.⁸ Access to safe abortion care as part of comprehensive reproductive services is an important component of health care. ●

Although it has been used as an ingredient in sunscreens and other personal care products since the 1980s, benzophenone-3 (BP-3) or oxybenzone has emerged in recent years as a significant environmental and health contaminant. DiNardo and Downs point out that BP-3 has been linked to contact and photocontact allergies in humans and implicated as a potential endocrine disruptor. They add that it can yield deleterious by-products when reacting with chlorine in swimming pools and wastewater treatment plants and can cause additional side effects in humans who ingest fish.¹ This column will focus on recent studies, mainly on the role of benzophenones in sunscreen agents that pose considerable risks to waterways and marine life, with concomitant effects on the food chain.

Environmental effects of BPs and legislative responses

Various UV filters, including BP-3, octinoxate, octocrylene, and ethylhexyl salicylate, are thought to pose considerable peril to the marine environment.^2,3 In particular, BP-3 has been demonstrated to provoke coral reef bleaching in vitro, leading to ossification and deforming DNA in the larval stage.^3,4

According to a 2018 report, BP-3 is believed to be present in approximately two thirds of organic sunscreens used in the United States.³ In addition, several studies have revealed that detectable levels of organic sunscreen ingredients, including BP-3, have been identified in coastal waters around the globe, including Hawaii and the U.S. Virgin Islands.^4-8

M Swiet Productions/Moment/Getty Images

A surfeit of tourists has been blamed in part, given that an estimated 25% of applied sunscreen is eliminated within 20 minutes of entering the water and thought to release about 4,000-6,000 tons/year into the surrounding coral reefs.^9,10 In Hawaii in particular, sewage contamination of the waterways has resulted from wastewater treatment facilities ill-equipped to filter out organic substances such as BP-3 and octinoxate.^10,11 In light of such circumstances, the use of sunscreens containing BP-3 and octinoxate have been restricted in Hawaii, particularly in proximity to beaches, since Jan. 1, 2021, because of their apparent environmental impact.¹⁰

The exposure of coral to these compounds is believed to result in bleaching because of impaired membrane integrity and photosynthetic pigment loss in the zooxanthellae that coral releases.^9,10 Coral and the algae zooxanthellae have a symbiotic relationship, Siller et al. explain, with the coral delivering protection and components essential for photosynthesis and the algae ultimately serving as nutrients for the coral.¹⁰ Stress endured by coral is believed to cause algae to detach, rendering coral more vulnerable to disease and less viable overall.¹⁰

In 2016, Downs et al. showed that four out of five sampled locations had detectable levels of BP-3 (100 pp trillion) with a fifth tested site measured at 19.2 pp billion.⁴

In 2019, Sirois acknowledges the problem of coral bleaching around the world but speculates that banning sunscreen ingredients for this purpose will delude people that such a measure will reverse the decline of coral and may lead to the unintended consequence of lower use of sunscreens. Sirois adds that a more comprehensive investigation of the multiple causes of coral reef bleaching is warranted, as are deeper examinations of studies using higher concentrations of sunscreen ingredients in artificial conditions.¹²

In the same year, Raffa et al. discussed the impending ban in Hawaii of the two sunscreen ingredients (BP-3 and octinoxate) to help preserve coral reefs. In so doing, they detailed the natural and human-induced harm to coral reefs, including pollution, fishing practices, overall impact of global climate change, and alterations in ocean temperature and chemistry. The implication is that sunscreen ingredients, which help prevent sun damage in users, are not the only causes of harm to coral reefs. Nevertheless, they point out that concentration estimates and mechanism studies buttress the argument that sunscreen ingredients contribute to coral bleaching. Still, the ban in Hawaii is thought to be a trend. Opponents of the ban are concerned that human skin cancers will rise in such circumstances. Alternative chemical sunscreens are being investigated, and physical sunscreens have emerged as the go-to recommendation.¹³

Notably, oxybenzone has been virtually replaced in the European Union with other UV filters with broad-spectrum action, but the majority of such filters have not yet been approved for use in the United States by the Food and Drug Administration.³

Food chain implications

BP-3 and other UV filters have been investigated for their effects on fish and mammals. Schneider and Lim illustrate that BP-3 is among the frequently used organic UV filters (along with 4-methylbenzylidene camphor, octocrylene, and octinoxate [ethylhexyl methoxycinnamate]) found in most water sources in the world, as well as multiple fish species.2 Cod liver in Norway, for instance, was found to contain octocrylene in 80% of cod, with BP-3 identified in 50% of the sample. BP-3 and octinoxate were also found in white fish.2,14 In laboratory studies, BP-3 in particular has been found in high concentrations in rainbow trout and Japanese rice fish (medaka), causing reduced egg production and hatchlings in females and increased vitellogenin protein production in males, suggesting potential feminization.^2,15

Schneider and Lim note that standard wastewater treatment approaches cannot address this issue and the presence of such contaminants in fish can pose dangerous ramifications in the food chain. They assert that, despite relatively low concentrations in the fish, bioaccumulation and biomagnification present the potential for chemicals accumulating over time and becoming more deleterious as such ingredients travel up the food chain. As higher-chain organisms absorb higher concentrations of the chemicals not broken down in the lower-chain organisms, though, there have not yet been reports of adverse effects of biomagnification in humans.²

BP-3 has been found by Brausch and Rand to have bioaccumulated in fish at higher levels than the ambient water, however.^1,2,16 Schneider and Lim present these issues as relevant to the sun protection discussion, while advocating for dermatologists to continue to counsel wise sun-protective behaviors.²

Conclusion

While calls for additional research are necessary and encouraging, I think human, and likely environmental, health would be better protected by the use of inorganic sunscreens in general and near or in coastal waterways. In light of legislative actions, in particular, it is important for dermatologists to intervene to ensure that patients do not engage in riskier behaviors in the sun in areas facing imminent organic sunscreen bans.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.

References

1. DiNardo JC and Downs CA. J Cosmet Dermatol. 2018 Feb;17(1):15-9.

2. Schneider SL and Lim HW. J Am Acad Dermatol. 2019 Jan;80(1):266-71.

3. Yeager DG and Lim HW. Dermatol Clin. 2019 Apr;37(2):149-57.

4. Downs CA et al. Arch Environ Contam Toxicol 2016 Feb;70(2):265-88.

5. Sánchez Rodríguez A et al. Chemosphere. 2015 Jul;131:85-90.

6. Tovar-Sánchez A et al. PLoS One. 2013 Jun 5;8(6):e65451.

7. Danovaro R and Corinaldesi C. Microb Ecol. 2003 Feb;45(2):109-18.

8. Daughton CG and Ternes TA. Environ Health Perspect. 1999 Dec;107 Suppl 6:907-38.

9. Danovaro R et al. Environ Health Perspect. 2008 Apr;116(4):441-7.

10. Siller A et al. Plast Surg Nur. 2019 Oct/Dec;39(4):157-60.

11. Ramos S et al. Sci Total Environ. 2015 Sep 1;526:278-311.

12. Sirois J. Sci Total Environ. 2019 Jul 15;674:211-2.

13. Raffa RB et al. J Clin Pharm Ther. 2019 Feb;44(1):134-9.

14. Langford KH et al. Environ Int. 2015 Jul;80:1-7.

15. Coronado M et al. Aquat Toxicol. 2008 Nov 21;90(3):182-7.

16. Brausch JM and Rand GM. Chemosphere. 2011 Mar;82(11):1518-32.

Although it has been used as an ingredient in sunscreens and other personal care products since the 1980s, benzophenone-3 (BP-3) or oxybenzone has emerged in recent years as a significant environmental and health contaminant. DiNardo and Downs point out that BP-3 has been linked to contact and photocontact allergies in humans and implicated as a potential endocrine disruptor. They add that it can yield deleterious by-products when reacting with chlorine in swimming pools and wastewater treatment plants and can cause additional side effects in humans who ingest fish.¹ This column will focus on recent studies, mainly on the role of benzophenones in sunscreen agents that pose considerable risks to waterways and marine life, with concomitant effects on the food chain.

Environmental effects of BPs and legislative responses

Various UV filters, including BP-3, octinoxate, octocrylene, and ethylhexyl salicylate, are thought to pose considerable peril to the marine environment.^2,3 In particular, BP-3 has been demonstrated to provoke coral reef bleaching in vitro, leading to ossification and deforming DNA in the larval stage.^3,4

According to a 2018 report, BP-3 is believed to be present in approximately two thirds of organic sunscreens used in the United States.³ In addition, several studies have revealed that detectable levels of organic sunscreen ingredients, including BP-3, have been identified in coastal waters around the globe, including Hawaii and the U.S. Virgin Islands.^4-8

M Swiet Productions/Moment/Getty Images

A surfeit of tourists has been blamed in part, given that an estimated 25% of applied sunscreen is eliminated within 20 minutes of entering the water and thought to release about 4,000-6,000 tons/year into the surrounding coral reefs.^9,10 In Hawaii in particular, sewage contamination of the waterways has resulted from wastewater treatment facilities ill-equipped to filter out organic substances such as BP-3 and octinoxate.^10,11 In light of such circumstances, the use of sunscreens containing BP-3 and octinoxate have been restricted in Hawaii, particularly in proximity to beaches, since Jan. 1, 2021, because of their apparent environmental impact.¹⁰

The exposure of coral to these compounds is believed to result in bleaching because of impaired membrane integrity and photosynthetic pigment loss in the zooxanthellae that coral releases.^9,10 Coral and the algae zooxanthellae have a symbiotic relationship, Siller et al. explain, with the coral delivering protection and components essential for photosynthesis and the algae ultimately serving as nutrients for the coral.¹⁰ Stress endured by coral is believed to cause algae to detach, rendering coral more vulnerable to disease and less viable overall.¹⁰

In 2016, Downs et al. showed that four out of five sampled locations had detectable levels of BP-3 (100 pp trillion) with a fifth tested site measured at 19.2 pp billion.⁴

In 2019, Sirois acknowledges the problem of coral bleaching around the world but speculates that banning sunscreen ingredients for this purpose will delude people that such a measure will reverse the decline of coral and may lead to the unintended consequence of lower use of sunscreens. Sirois adds that a more comprehensive investigation of the multiple causes of coral reef bleaching is warranted, as are deeper examinations of studies using higher concentrations of sunscreen ingredients in artificial conditions.¹²

In the same year, Raffa et al. discussed the impending ban in Hawaii of the two sunscreen ingredients (BP-3 and octinoxate) to help preserve coral reefs. In so doing, they detailed the natural and human-induced harm to coral reefs, including pollution, fishing practices, overall impact of global climate change, and alterations in ocean temperature and chemistry. The implication is that sunscreen ingredients, which help prevent sun damage in users, are not the only causes of harm to coral reefs. Nevertheless, they point out that concentration estimates and mechanism studies buttress the argument that sunscreen ingredients contribute to coral bleaching. Still, the ban in Hawaii is thought to be a trend. Opponents of the ban are concerned that human skin cancers will rise in such circumstances. Alternative chemical sunscreens are being investigated, and physical sunscreens have emerged as the go-to recommendation.¹³

Notably, oxybenzone has been virtually replaced in the European Union with other UV filters with broad-spectrum action, but the majority of such filters have not yet been approved for use in the United States by the Food and Drug Administration.³

Food chain implications

BP-3 and other UV filters have been investigated for their effects on fish and mammals. Schneider and Lim illustrate that BP-3 is among the frequently used organic UV filters (along with 4-methylbenzylidene camphor, octocrylene, and octinoxate [ethylhexyl methoxycinnamate]) found in most water sources in the world, as well as multiple fish species.2 Cod liver in Norway, for instance, was found to contain octocrylene in 80% of cod, with BP-3 identified in 50% of the sample. BP-3 and octinoxate were also found in white fish.2,14 In laboratory studies, BP-3 in particular has been found in high concentrations in rainbow trout and Japanese rice fish (medaka), causing reduced egg production and hatchlings in females and increased vitellogenin protein production in males, suggesting potential feminization.^2,15

Schneider and Lim note that standard wastewater treatment approaches cannot address this issue and the presence of such contaminants in fish can pose dangerous ramifications in the food chain. They assert that, despite relatively low concentrations in the fish, bioaccumulation and biomagnification present the potential for chemicals accumulating over time and becoming more deleterious as such ingredients travel up the food chain. As higher-chain organisms absorb higher concentrations of the chemicals not broken down in the lower-chain organisms, though, there have not yet been reports of adverse effects of biomagnification in humans.²

BP-3 has been found by Brausch and Rand to have bioaccumulated in fish at higher levels than the ambient water, however.^1,2,16 Schneider and Lim present these issues as relevant to the sun protection discussion, while advocating for dermatologists to continue to counsel wise sun-protective behaviors.²

Conclusion

While calls for additional research are necessary and encouraging, I think human, and likely environmental, health would be better protected by the use of inorganic sunscreens in general and near or in coastal waterways. In light of legislative actions, in particular, it is important for dermatologists to intervene to ensure that patients do not engage in riskier behaviors in the sun in areas facing imminent organic sunscreen bans.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.

References

1. DiNardo JC and Downs CA. J Cosmet Dermatol. 2018 Feb;17(1):15-9.

2. Schneider SL and Lim HW. J Am Acad Dermatol. 2019 Jan;80(1):266-71.

3. Yeager DG and Lim HW. Dermatol Clin. 2019 Apr;37(2):149-57.

4. Downs CA et al. Arch Environ Contam Toxicol 2016 Feb;70(2):265-88.

5. Sánchez Rodríguez A et al. Chemosphere. 2015 Jul;131:85-90.

6. Tovar-Sánchez A et al. PLoS One. 2013 Jun 5;8(6):e65451.

7. Danovaro R and Corinaldesi C. Microb Ecol. 2003 Feb;45(2):109-18.

8. Daughton CG and Ternes TA. Environ Health Perspect. 1999 Dec;107 Suppl 6:907-38.

9. Danovaro R et al. Environ Health Perspect. 2008 Apr;116(4):441-7.

10. Siller A et al. Plast Surg Nur. 2019 Oct/Dec;39(4):157-60.

11. Ramos S et al. Sci Total Environ. 2015 Sep 1;526:278-311.

12. Sirois J. Sci Total Environ. 2019 Jul 15;674:211-2.

13. Raffa RB et al. J Clin Pharm Ther. 2019 Feb;44(1):134-9.

14. Langford KH et al. Environ Int. 2015 Jul;80:1-7.

15. Coronado M et al. Aquat Toxicol. 2008 Nov 21;90(3):182-7.

16. Brausch JM and Rand GM. Chemosphere. 2011 Mar;82(11):1518-32.

Although it has been used as an ingredient in sunscreens and other personal care products since the 1980s, benzophenone-3 (BP-3) or oxybenzone has emerged in recent years as a significant environmental and health contaminant. DiNardo and Downs point out that BP-3 has been linked to contact and photocontact allergies in humans and implicated as a potential endocrine disruptor. They add that it can yield deleterious by-products when reacting with chlorine in swimming pools and wastewater treatment plants and can cause additional side effects in humans who ingest fish.¹ This column will focus on recent studies, mainly on the role of benzophenones in sunscreen agents that pose considerable risks to waterways and marine life, with concomitant effects on the food chain.

Environmental effects of BPs and legislative responses

Various UV filters, including BP-3, octinoxate, octocrylene, and ethylhexyl salicylate, are thought to pose considerable peril to the marine environment.^2,3 In particular, BP-3 has been demonstrated to provoke coral reef bleaching in vitro, leading to ossification and deforming DNA in the larval stage.^3,4

According to a 2018 report, BP-3 is believed to be present in approximately two thirds of organic sunscreens used in the United States.³ In addition, several studies have revealed that detectable levels of organic sunscreen ingredients, including BP-3, have been identified in coastal waters around the globe, including Hawaii and the U.S. Virgin Islands.^4-8

M Swiet Productions/Moment/Getty Images

A surfeit of tourists has been blamed in part, given that an estimated 25% of applied sunscreen is eliminated within 20 minutes of entering the water and thought to release about 4,000-6,000 tons/year into the surrounding coral reefs.^9,10 In Hawaii in particular, sewage contamination of the waterways has resulted from wastewater treatment facilities ill-equipped to filter out organic substances such as BP-3 and octinoxate.^10,11 In light of such circumstances, the use of sunscreens containing BP-3 and octinoxate have been restricted in Hawaii, particularly in proximity to beaches, since Jan. 1, 2021, because of their apparent environmental impact.¹⁰

The exposure of coral to these compounds is believed to result in bleaching because of impaired membrane integrity and photosynthetic pigment loss in the zooxanthellae that coral releases.^9,10 Coral and the algae zooxanthellae have a symbiotic relationship, Siller et al. explain, with the coral delivering protection and components essential for photosynthesis and the algae ultimately serving as nutrients for the coral.¹⁰ Stress endured by coral is believed to cause algae to detach, rendering coral more vulnerable to disease and less viable overall.¹⁰

In 2016, Downs et al. showed that four out of five sampled locations had detectable levels of BP-3 (100 pp trillion) with a fifth tested site measured at 19.2 pp billion.⁴

In 2019, Sirois acknowledges the problem of coral bleaching around the world but speculates that banning sunscreen ingredients for this purpose will delude people that such a measure will reverse the decline of coral and may lead to the unintended consequence of lower use of sunscreens. Sirois adds that a more comprehensive investigation of the multiple causes of coral reef bleaching is warranted, as are deeper examinations of studies using higher concentrations of sunscreen ingredients in artificial conditions.¹²

In the same year, Raffa et al. discussed the impending ban in Hawaii of the two sunscreen ingredients (BP-3 and octinoxate) to help preserve coral reefs. In so doing, they detailed the natural and human-induced harm to coral reefs, including pollution, fishing practices, overall impact of global climate change, and alterations in ocean temperature and chemistry. The implication is that sunscreen ingredients, which help prevent sun damage in users, are not the only causes of harm to coral reefs. Nevertheless, they point out that concentration estimates and mechanism studies buttress the argument that sunscreen ingredients contribute to coral bleaching. Still, the ban in Hawaii is thought to be a trend. Opponents of the ban are concerned that human skin cancers will rise in such circumstances. Alternative chemical sunscreens are being investigated, and physical sunscreens have emerged as the go-to recommendation.¹³

Notably, oxybenzone has been virtually replaced in the European Union with other UV filters with broad-spectrum action, but the majority of such filters have not yet been approved for use in the United States by the Food and Drug Administration.³

Food chain implications

BP-3 and other UV filters have been investigated for their effects on fish and mammals. Schneider and Lim illustrate that BP-3 is among the frequently used organic UV filters (along with 4-methylbenzylidene camphor, octocrylene, and octinoxate [ethylhexyl methoxycinnamate]) found in most water sources in the world, as well as multiple fish species.2 Cod liver in Norway, for instance, was found to contain octocrylene in 80% of cod, with BP-3 identified in 50% of the sample. BP-3 and octinoxate were also found in white fish.2,14 In laboratory studies, BP-3 in particular has been found in high concentrations in rainbow trout and Japanese rice fish (medaka), causing reduced egg production and hatchlings in females and increased vitellogenin protein production in males, suggesting potential feminization.^2,15

Schneider and Lim note that standard wastewater treatment approaches cannot address this issue and the presence of such contaminants in fish can pose dangerous ramifications in the food chain. They assert that, despite relatively low concentrations in the fish, bioaccumulation and biomagnification present the potential for chemicals accumulating over time and becoming more deleterious as such ingredients travel up the food chain. As higher-chain organisms absorb higher concentrations of the chemicals not broken down in the lower-chain organisms, though, there have not yet been reports of adverse effects of biomagnification in humans.²

BP-3 has been found by Brausch and Rand to have bioaccumulated in fish at higher levels than the ambient water, however.^1,2,16 Schneider and Lim present these issues as relevant to the sun protection discussion, while advocating for dermatologists to continue to counsel wise sun-protective behaviors.²

Conclusion

While calls for additional research are necessary and encouraging, I think human, and likely environmental, health would be better protected by the use of inorganic sunscreens in general and near or in coastal waterways. In light of legislative actions, in particular, it is important for dermatologists to intervene to ensure that patients do not engage in riskier behaviors in the sun in areas facing imminent organic sunscreen bans.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at dermnews@mdedge.com.

References

1. DiNardo JC and Downs CA. J Cosmet Dermatol. 2018 Feb;17(1):15-9.

2. Schneider SL and Lim HW. J Am Acad Dermatol. 2019 Jan;80(1):266-71.

3. Yeager DG and Lim HW. Dermatol Clin. 2019 Apr;37(2):149-57.

4. Downs CA et al. Arch Environ Contam Toxicol 2016 Feb;70(2):265-88.

5. Sánchez Rodríguez A et al. Chemosphere. 2015 Jul;131:85-90.

6. Tovar-Sánchez A et al. PLoS One. 2013 Jun 5;8(6):e65451.

7. Danovaro R and Corinaldesi C. Microb Ecol. 2003 Feb;45(2):109-18.

8. Daughton CG and Ternes TA. Environ Health Perspect. 1999 Dec;107 Suppl 6:907-38.

9. Danovaro R et al. Environ Health Perspect. 2008 Apr;116(4):441-7.

10. Siller A et al. Plast Surg Nur. 2019 Oct/Dec;39(4):157-60.

11. Ramos S et al. Sci Total Environ. 2015 Sep 1;526:278-311.

12. Sirois J. Sci Total Environ. 2019 Jul 15;674:211-2.

13. Raffa RB et al. J Clin Pharm Ther. 2019 Feb;44(1):134-9.

14. Langford KH et al. Environ Int. 2015 Jul;80:1-7.

15. Coronado M et al. Aquat Toxicol. 2008 Nov 21;90(3):182-7.

16. Brausch JM and Rand GM. Chemosphere. 2011 Mar;82(11):1518-32.