Commentary

The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.

On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years. This is an important conversation for those interested in involuntary care.

Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”

Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.

In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.

“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”

The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.

Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”

She then discussed concerns by her manager that she was not complying with her medication regimen.

“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”

She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.

“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”

Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.

Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.


 

Reasoning behind such actions

Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.

Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”

Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”

Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?

Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.

Dr. Miller is 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, both in Baltimore. She has no disclosures.

The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.

On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years. This is an important conversation for those interested in involuntary care.

Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”

Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.

In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.

“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”

The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.

Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”

She then discussed concerns by her manager that she was not complying with her medication regimen.

“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”

She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.

“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”

Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.

Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.


 

Reasoning behind such actions

Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.

Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”

Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”

Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?

Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.

Dr. Miller is 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, both in Baltimore. She has no disclosures.

The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.

On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years. This is an important conversation for those interested in involuntary care.

Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”

Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.

In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.

“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”

The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.

Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”

She then discussed concerns by her manager that she was not complying with her medication regimen.

“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”

She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.

“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”

Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.

Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.


 

Reasoning behind such actions

Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.

Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”

Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”

Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?

Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.

Dr. Miller is 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, both in Baltimore. She has no disclosures.

Hypochondria has been useful to my patients. I mean my own hypochondria. It may not take one to know one, but we hypochondriacs understand each other.

Hypochondriacs worry that we are sick, worry that our fears are foolish and that we will be mocked for worrying about nothing, and worry even more that this time, we finally worried about something after all. Reassurance leaves us sheepish, then elated. Elation soon fades, and a new worry appears. Worry, rinse, repeat. Hypochondriasis presents one kind of patient need that doctors have to deal with. Patients have many needs, some common, others all their own. Some folks are just needy. Soothing the needs of the needy can feel like trying to drain the seven seas with a teaspoon. Those who work with people must either find ways to cope with the spectrum of neediness, or find another kind of work to do.

Some patient needs call for diagnosis and treatment. Other needs go beyond the strictly medical. Beyond knowing whether they are ill, patients have questions like, “Will this get worse?” “Will I be ashamed to go out in public?” “Can I visit my grandchildren, or will my daughter-in-law throw me out as contagious?” “Is this the beginning of the end?” or, worst of all, “Am I losing my hair?”

The list of possible patient needs is long, though not endless. Lining them up one after the other can make them sound melodramatic, even silly. (Other people’s worries often sound silly; your own never do.) Can a small growth or slight itch really cause existential agitation? Anyone who deals with complaints like these knows that the answer is yes.

Hypochondriacs with medical degrees cannot reassure themselves, but we can bring useful experience to help other members of the worry club. Doing so means paying attention not just to what doctors worry about but what patients do.

Sometimes a patient is terrified, the doctor not at all. Gentle sympathy may be enough. But the reverse can also be true: The doctor is concerned, but the patient thinks there is no problem. Sometimes I am worried enough to ask a patient to call or email an update. Patients who have already stopped worrying may not bother to answer the phone or shoot back an email. Failure to respond may mean they are fine, or in intensive care. Silence is hard to interpret.

Skin doctors have one advantageous disadvantage: Few tests help us beyond a skin scraping, the odd blood test, or a biopsy. Otherwise, most of the time all we can do is look, and perhaps apply “tincture of time,” watching the clinical course. We cannot send patients for the complex and expensive tests our colleagues use “just to be sure,” because we have no such tests to send them for.

Practice and experience help us recognize needs and worries that patients might not express. For instance, a man may show up with pimples on his back. His concerns seem intense. “What worries you?” we ask. The patient whispers, “It couldn’t be ... shingles, could it?” No, it couldn’t be shingles, because it is bilateral and for many other reasons.

The question is not whether he has shingles but why he thinks he does. Maybe his aunt suggested it. Or an article told him to watch out for it. Or his pharmacy is promoting zoster vaccination by showing huge, full-color photos of shingles cases worthy of horror movies. (Shingles the 13th!) Because he wants to visit his grandkids and his daughter is in her fourth month of pregnancy. In other words, along with the fear of cancer, fear of shingles is just out there. There are other such public concerns. Over time, we come to recognize them.

Anyone can worry, but anxiety paralyzes some to such an extent that referral to a mental health professional seems reasonable. The problem with advising it is that patients who somaticize may take exception to suggestions, however delicately put, that make us sound dismissive, locating their concern “all in the head.” Over the years, my attempts to make such referrals have met with limited success.

Dealing with needs – and neediness – can take up more of a doctor’s day than making specific diagnoses and prescribing helpful treatments. Besides, addressing needs and neediness demands skills not always stressed at school.

Practice at noting neediness makes you better at it, but no doctor nails the true wellsprings of worry all the time. We hypochondriacs can be devilishly inventive.


Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His latest book, “Doctoring from the Outside In,” was recently published. Write to him at dermnews@mdedge.com.

Hypochondria has been useful to my patients. I mean my own hypochondria. It may not take one to know one, but we hypochondriacs understand each other.

Hypochondriacs worry that we are sick, worry that our fears are foolish and that we will be mocked for worrying about nothing, and worry even more that this time, we finally worried about something after all. Reassurance leaves us sheepish, then elated. Elation soon fades, and a new worry appears. Worry, rinse, repeat. Hypochondriasis presents one kind of patient need that doctors have to deal with. Patients have many needs, some common, others all their own. Some folks are just needy. Soothing the needs of the needy can feel like trying to drain the seven seas with a teaspoon. Those who work with people must either find ways to cope with the spectrum of neediness, or find another kind of work to do.

Some patient needs call for diagnosis and treatment. Other needs go beyond the strictly medical. Beyond knowing whether they are ill, patients have questions like, “Will this get worse?” “Will I be ashamed to go out in public?” “Can I visit my grandchildren, or will my daughter-in-law throw me out as contagious?” “Is this the beginning of the end?” or, worst of all, “Am I losing my hair?”

The list of possible patient needs is long, though not endless. Lining them up one after the other can make them sound melodramatic, even silly. (Other people’s worries often sound silly; your own never do.) Can a small growth or slight itch really cause existential agitation? Anyone who deals with complaints like these knows that the answer is yes.

Hypochondriacs with medical degrees cannot reassure themselves, but we can bring useful experience to help other members of the worry club. Doing so means paying attention not just to what doctors worry about but what patients do.

Sometimes a patient is terrified, the doctor not at all. Gentle sympathy may be enough. But the reverse can also be true: The doctor is concerned, but the patient thinks there is no problem. Sometimes I am worried enough to ask a patient to call or email an update. Patients who have already stopped worrying may not bother to answer the phone or shoot back an email. Failure to respond may mean they are fine, or in intensive care. Silence is hard to interpret.

Skin doctors have one advantageous disadvantage: Few tests help us beyond a skin scraping, the odd blood test, or a biopsy. Otherwise, most of the time all we can do is look, and perhaps apply “tincture of time,” watching the clinical course. We cannot send patients for the complex and expensive tests our colleagues use “just to be sure,” because we have no such tests to send them for.

Practice and experience help us recognize needs and worries that patients might not express. For instance, a man may show up with pimples on his back. His concerns seem intense. “What worries you?” we ask. The patient whispers, “It couldn’t be ... shingles, could it?” No, it couldn’t be shingles, because it is bilateral and for many other reasons.

The question is not whether he has shingles but why he thinks he does. Maybe his aunt suggested it. Or an article told him to watch out for it. Or his pharmacy is promoting zoster vaccination by showing huge, full-color photos of shingles cases worthy of horror movies. (Shingles the 13th!) Because he wants to visit his grandkids and his daughter is in her fourth month of pregnancy. In other words, along with the fear of cancer, fear of shingles is just out there. There are other such public concerns. Over time, we come to recognize them.

Anyone can worry, but anxiety paralyzes some to such an extent that referral to a mental health professional seems reasonable. The problem with advising it is that patients who somaticize may take exception to suggestions, however delicately put, that make us sound dismissive, locating their concern “all in the head.” Over the years, my attempts to make such referrals have met with limited success.

Dealing with needs – and neediness – can take up more of a doctor’s day than making specific diagnoses and prescribing helpful treatments. Besides, addressing needs and neediness demands skills not always stressed at school.

Practice at noting neediness makes you better at it, but no doctor nails the true wellsprings of worry all the time. We hypochondriacs can be devilishly inventive.


Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His latest book, “Doctoring from the Outside In,” was recently published. Write to him at dermnews@mdedge.com.

Hypochondria has been useful to my patients. I mean my own hypochondria. It may not take one to know one, but we hypochondriacs understand each other.

Hypochondriacs worry that we are sick, worry that our fears are foolish and that we will be mocked for worrying about nothing, and worry even more that this time, we finally worried about something after all. Reassurance leaves us sheepish, then elated. Elation soon fades, and a new worry appears. Worry, rinse, repeat. Hypochondriasis presents one kind of patient need that doctors have to deal with. Patients have many needs, some common, others all their own. Some folks are just needy. Soothing the needs of the needy can feel like trying to drain the seven seas with a teaspoon. Those who work with people must either find ways to cope with the spectrum of neediness, or find another kind of work to do.

Some patient needs call for diagnosis and treatment. Other needs go beyond the strictly medical. Beyond knowing whether they are ill, patients have questions like, “Will this get worse?” “Will I be ashamed to go out in public?” “Can I visit my grandchildren, or will my daughter-in-law throw me out as contagious?” “Is this the beginning of the end?” or, worst of all, “Am I losing my hair?”

The list of possible patient needs is long, though not endless. Lining them up one after the other can make them sound melodramatic, even silly. (Other people’s worries often sound silly; your own never do.) Can a small growth or slight itch really cause existential agitation? Anyone who deals with complaints like these knows that the answer is yes.

Hypochondriacs with medical degrees cannot reassure themselves, but we can bring useful experience to help other members of the worry club. Doing so means paying attention not just to what doctors worry about but what patients do.

Sometimes a patient is terrified, the doctor not at all. Gentle sympathy may be enough. But the reverse can also be true: The doctor is concerned, but the patient thinks there is no problem. Sometimes I am worried enough to ask a patient to call or email an update. Patients who have already stopped worrying may not bother to answer the phone or shoot back an email. Failure to respond may mean they are fine, or in intensive care. Silence is hard to interpret.

Skin doctors have one advantageous disadvantage: Few tests help us beyond a skin scraping, the odd blood test, or a biopsy. Otherwise, most of the time all we can do is look, and perhaps apply “tincture of time,” watching the clinical course. We cannot send patients for the complex and expensive tests our colleagues use “just to be sure,” because we have no such tests to send them for.

Practice and experience help us recognize needs and worries that patients might not express. For instance, a man may show up with pimples on his back. His concerns seem intense. “What worries you?” we ask. The patient whispers, “It couldn’t be ... shingles, could it?” No, it couldn’t be shingles, because it is bilateral and for many other reasons.

The question is not whether he has shingles but why he thinks he does. Maybe his aunt suggested it. Or an article told him to watch out for it. Or his pharmacy is promoting zoster vaccination by showing huge, full-color photos of shingles cases worthy of horror movies. (Shingles the 13th!) Because he wants to visit his grandkids and his daughter is in her fourth month of pregnancy. In other words, along with the fear of cancer, fear of shingles is just out there. There are other such public concerns. Over time, we come to recognize them.

Anyone can worry, but anxiety paralyzes some to such an extent that referral to a mental health professional seems reasonable. The problem with advising it is that patients who somaticize may take exception to suggestions, however delicately put, that make us sound dismissive, locating their concern “all in the head.” Over the years, my attempts to make such referrals have met with limited success.

Dealing with needs – and neediness – can take up more of a doctor’s day than making specific diagnoses and prescribing helpful treatments. Besides, addressing needs and neediness demands skills not always stressed at school.

Practice at noting neediness makes you better at it, but no doctor nails the true wellsprings of worry all the time. We hypochondriacs can be devilishly inventive.


Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His latest book, “Doctoring from the Outside In,” was recently published. Write to him at dermnews@mdedge.com.

“What’s my number?” When I hear this from my financial planning clients, I know they mean: “What investment net worth do I need to be financially independent and make practicing medicine optional?” In my 20-year career, this “magic number” is by far the most common thing physicians want to know.

Wiroj Sidhisoradej/EyeEm/Getty Images

If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.

There’s no magic number your portfolio should be – just your number.

It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.

By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.

Form a guesstimate based on savings and anticipated expenses

The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.

In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.

Let’s see how it works.
 

Early to mid-career: Focus on building up retirement savings

We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.

With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.

What is a ‘reasonable’ savings goal for retirement?

As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.

For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.

This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
 

Later-career docs: Calculate your spending level in retirement

Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.

A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:

• Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
• Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.

As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.

Are you ready for retirement?

During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.

Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.

In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.

Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.

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

“What’s my number?” When I hear this from my financial planning clients, I know they mean: “What investment net worth do I need to be financially independent and make practicing medicine optional?” In my 20-year career, this “magic number” is by far the most common thing physicians want to know.

Wiroj Sidhisoradej/EyeEm/Getty Images

If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.

There’s no magic number your portfolio should be – just your number.

It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.

By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.

Form a guesstimate based on savings and anticipated expenses

The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.

In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.

Let’s see how it works.
 

Early to mid-career: Focus on building up retirement savings

We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.

With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.

What is a ‘reasonable’ savings goal for retirement?

As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.

For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.

This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
 

Later-career docs: Calculate your spending level in retirement

Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.

A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:

• Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
• Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.

As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.

Are you ready for retirement?

During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.

Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.

In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.

Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.

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

“What’s my number?” When I hear this from my financial planning clients, I know they mean: “What investment net worth do I need to be financially independent and make practicing medicine optional?” In my 20-year career, this “magic number” is by far the most common thing physicians want to know.

Wiroj Sidhisoradej/EyeEm/Getty Images

If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.

There’s no magic number your portfolio should be – just your number.

It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.

By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.

Form a guesstimate based on savings and anticipated expenses

The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.

In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.

Let’s see how it works.
 

Early to mid-career: Focus on building up retirement savings

We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.

With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.

What is a ‘reasonable’ savings goal for retirement?

As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.

For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.

This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
 

Later-career docs: Calculate your spending level in retirement

Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.

A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:

• Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
• Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.

As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.

Are you ready for retirement?

During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.

Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.

In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.

Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.

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

Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.

Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.

Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.

On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.

I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).

I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*

Let’s hope she is correct.

* This story was updated on July 6, 2021. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.

Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.

Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.

On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.

I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).

I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*

Let’s hope she is correct.

* This story was updated on July 6, 2021. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.

Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.

Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.

On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.

I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).

I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*

Let’s hope she is correct.

* This story was updated on July 6, 2021. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

As COVID-related restrictions are lifting and the streets, restaurants, and events are filling back up, we must encourage our patients to take inventory. It is time to help them create posttraumatic growth.

As we help them navigate this part of the pandemic, encourage them to ask what they learned over the last year and how they plan to integrate what they’ve been through to successfully create the “new normal.”

The Biden administration had set a goal of getting at least one shot to 70% of American adults by July 4, and that goal will not be reached. That shortfall, combined with the increase of the highly transmissible Delta variant of SARS-CoV-2 means that we and our patients must not let our guards completely down. At the same time, we can encourage our vaccinated patients to get back to their prepandemic lives – to the extent that they feel comfortable doing so.

Ultimately, this is about respecting physical and emotional boundaries. How do we greet vaccinated people now? Is it okay to shake hands, hug, or kiss to greet a friend or family member – or should we continue to elbow bump – or perhaps wave? Should we confront family members who have opted not to get vaccinated for reasons not related to health? Is it safe to visit with older relatives who are vaccinated? What about children under 12 who are not?

We psychiatrists also need to ask our fellow health care workers how they’re doing. Those who were on the front lines of the pandemic faced unfathomable pain and suffering – and mental and physical exhaustion. And we know that the nightmare is not over. Several areas of the country with large numbers of unvaccinated people could face “very dense outbreaks,” in large part because of the Delta variant.

As we sort through the remaining challenges, I urge us all to reflect. We have been in this together and will emerge together. We know that the closer we were to the trauma, the longer recovery will take.

Ask patients to consider what is most important to resume and what can still wait. Some are eager to jump back into the deep end of the pool; others prefer to continue to wait cautiously. Families need to be on the same page as they assess risks and opportunities going forward, because household spread continues to be at the highest risk. Remind patients that the health of one of us affects the health of all of us.

Urge patients to take time to explore the following questions as they process the pandemic. We can also ask ourselves these same questions and share them with colleagues who are also rebuilding.

• Did you prioritize your family more? How can you continue to spend quality time them as other opportunities emerge?
• Did you have to withdraw from friends/coworkers and family members because of the pandemic? If so, how can you reincorporate them in our lives?
• Did you send more time caring for yourself with exercise and meditation? Can those new habits remain in place as life presents more options? How can you continue to make time for self-care while adding back other responsibilities?
• Did you eat better or worse in quarantine? Can you maintain the positive habits you developed as you venture back to restaurants, parties, and gatherings?
• What habits did you break that you are now better off without?
• What new habits or hobbies did you create that you want to continue?
• What hobbies should you resume that you missed during the last year?
• What new coping skills have you gained?
• Has your alcohol consumption declined or increased during the pandemic?
• Did you neglect/decide to forgo your medical and dental care? How quickly can you safely resume that care?
• How did your value system shift this year?
• Did the people you feel closest to change?
• How can you use this trauma to appreciate life more?

Life might get very busy this summer, so encourage patients to find time to answer these questions. Journaling can be a great way to think through all that we have experienced. Our brains will need to change again to adapt. Many of us have felt sad or anxious for a quite a while, and we want to move toward more positive feelings of safety, happiness, optimism, and joy. This will take effort. After all, we have lost more than 600,000 people to COVID, and much of the world is still in the middle of the pandemic. But this will get much easier as the threat of COVID-19 continues to recede. We must now work toward creating better times ahead.

Dr. Ritvo has almost 30 years’ experience in psychiatry and is currently practicing telemedicine. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). She has no conflicts of interest.
 

As COVID-related restrictions are lifting and the streets, restaurants, and events are filling back up, we must encourage our patients to take inventory. It is time to help them create posttraumatic growth.

As we help them navigate this part of the pandemic, encourage them to ask what they learned over the last year and how they plan to integrate what they’ve been through to successfully create the “new normal.”

The Biden administration had set a goal of getting at least one shot to 70% of American adults by July 4, and that goal will not be reached. That shortfall, combined with the increase of the highly transmissible Delta variant of SARS-CoV-2 means that we and our patients must not let our guards completely down. At the same time, we can encourage our vaccinated patients to get back to their prepandemic lives – to the extent that they feel comfortable doing so.

Ultimately, this is about respecting physical and emotional boundaries. How do we greet vaccinated people now? Is it okay to shake hands, hug, or kiss to greet a friend or family member – or should we continue to elbow bump – or perhaps wave? Should we confront family members who have opted not to get vaccinated for reasons not related to health? Is it safe to visit with older relatives who are vaccinated? What about children under 12 who are not?

We psychiatrists also need to ask our fellow health care workers how they’re doing. Those who were on the front lines of the pandemic faced unfathomable pain and suffering – and mental and physical exhaustion. And we know that the nightmare is not over. Several areas of the country with large numbers of unvaccinated people could face “very dense outbreaks,” in large part because of the Delta variant.

As we sort through the remaining challenges, I urge us all to reflect. We have been in this together and will emerge together. We know that the closer we were to the trauma, the longer recovery will take.

Ask patients to consider what is most important to resume and what can still wait. Some are eager to jump back into the deep end of the pool; others prefer to continue to wait cautiously. Families need to be on the same page as they assess risks and opportunities going forward, because household spread continues to be at the highest risk. Remind patients that the health of one of us affects the health of all of us.

Urge patients to take time to explore the following questions as they process the pandemic. We can also ask ourselves these same questions and share them with colleagues who are also rebuilding.

• Did you prioritize your family more? How can you continue to spend quality time them as other opportunities emerge?
• Did you have to withdraw from friends/coworkers and family members because of the pandemic? If so, how can you reincorporate them in our lives?
• Did you send more time caring for yourself with exercise and meditation? Can those new habits remain in place as life presents more options? How can you continue to make time for self-care while adding back other responsibilities?
• Did you eat better or worse in quarantine? Can you maintain the positive habits you developed as you venture back to restaurants, parties, and gatherings?
• What habits did you break that you are now better off without?
• What new habits or hobbies did you create that you want to continue?
• What hobbies should you resume that you missed during the last year?
• What new coping skills have you gained?
• Has your alcohol consumption declined or increased during the pandemic?
• Did you neglect/decide to forgo your medical and dental care? How quickly can you safely resume that care?
• How did your value system shift this year?
• Did the people you feel closest to change?
• How can you use this trauma to appreciate life more?

Life might get very busy this summer, so encourage patients to find time to answer these questions. Journaling can be a great way to think through all that we have experienced. Our brains will need to change again to adapt. Many of us have felt sad or anxious for a quite a while, and we want to move toward more positive feelings of safety, happiness, optimism, and joy. This will take effort. After all, we have lost more than 600,000 people to COVID, and much of the world is still in the middle of the pandemic. But this will get much easier as the threat of COVID-19 continues to recede. We must now work toward creating better times ahead.

Dr. Ritvo has almost 30 years’ experience in psychiatry and is currently practicing telemedicine. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). She has no conflicts of interest.
 

As COVID-related restrictions are lifting and the streets, restaurants, and events are filling back up, we must encourage our patients to take inventory. It is time to help them create posttraumatic growth.

As we help them navigate this part of the pandemic, encourage them to ask what they learned over the last year and how they plan to integrate what they’ve been through to successfully create the “new normal.”

The Biden administration had set a goal of getting at least one shot to 70% of American adults by July 4, and that goal will not be reached. That shortfall, combined with the increase of the highly transmissible Delta variant of SARS-CoV-2 means that we and our patients must not let our guards completely down. At the same time, we can encourage our vaccinated patients to get back to their prepandemic lives – to the extent that they feel comfortable doing so.

Ultimately, this is about respecting physical and emotional boundaries. How do we greet vaccinated people now? Is it okay to shake hands, hug, or kiss to greet a friend or family member – or should we continue to elbow bump – or perhaps wave? Should we confront family members who have opted not to get vaccinated for reasons not related to health? Is it safe to visit with older relatives who are vaccinated? What about children under 12 who are not?

We psychiatrists also need to ask our fellow health care workers how they’re doing. Those who were on the front lines of the pandemic faced unfathomable pain and suffering – and mental and physical exhaustion. And we know that the nightmare is not over. Several areas of the country with large numbers of unvaccinated people could face “very dense outbreaks,” in large part because of the Delta variant.

As we sort through the remaining challenges, I urge us all to reflect. We have been in this together and will emerge together. We know that the closer we were to the trauma, the longer recovery will take.

Ask patients to consider what is most important to resume and what can still wait. Some are eager to jump back into the deep end of the pool; others prefer to continue to wait cautiously. Families need to be on the same page as they assess risks and opportunities going forward, because household spread continues to be at the highest risk. Remind patients that the health of one of us affects the health of all of us.

Urge patients to take time to explore the following questions as they process the pandemic. We can also ask ourselves these same questions and share them with colleagues who are also rebuilding.

• Did you prioritize your family more? How can you continue to spend quality time them as other opportunities emerge?
• Did you have to withdraw from friends/coworkers and family members because of the pandemic? If so, how can you reincorporate them in our lives?
• Did you send more time caring for yourself with exercise and meditation? Can those new habits remain in place as life presents more options? How can you continue to make time for self-care while adding back other responsibilities?
• Did you eat better or worse in quarantine? Can you maintain the positive habits you developed as you venture back to restaurants, parties, and gatherings?
• What habits did you break that you are now better off without?
• What new habits or hobbies did you create that you want to continue?
• What hobbies should you resume that you missed during the last year?
• What new coping skills have you gained?
• Has your alcohol consumption declined or increased during the pandemic?
• Did you neglect/decide to forgo your medical and dental care? How quickly can you safely resume that care?
• How did your value system shift this year?
• Did the people you feel closest to change?
• How can you use this trauma to appreciate life more?

Life might get very busy this summer, so encourage patients to find time to answer these questions. Journaling can be a great way to think through all that we have experienced. Our brains will need to change again to adapt. Many of us have felt sad or anxious for a quite a while, and we want to move toward more positive feelings of safety, happiness, optimism, and joy. This will take effort. After all, we have lost more than 600,000 people to COVID, and much of the world is still in the middle of the pandemic. But this will get much easier as the threat of COVID-19 continues to recede. We must now work toward creating better times ahead.

Dr. Ritvo has almost 30 years’ experience in psychiatry and is currently practicing telemedicine. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). She has no conflicts of interest.
 

Disasters—both natural and human-caused—can strike at any time, causing severe trauma for those impacted. Disasters may create circumstances where the need for mental health resources could exceed capacity, and hospitals and clinics would be unable to meet the needs of the affected communities. As psychiatric clinicians, we may want to provide our services in such situations; however, we are still at risk for civil, criminal, or constitutional liability claims against us if we fail to meet our legal obligations related to psychiatric practice. Ideally, whether we live and work in an area affected by a disaster or volunteer from other states, we should be able to care for patients without fear of facing unreasonable liability risks. Although an exhaustive list of all relevant federal and state laws and regulations is beyond the scope of this article, here I discuss some of the federal and state laws and regulations that could provide protection from these risks, and some limitations of liability protection.

A familiar list of liability concerns

From a liability perspective, what should we be aware of when practicing during disasters? The same liability concerns we have during our day-to-day practice also exist during disasters, especially when there are suboptimal or adverse outcomes. Negligence, practicing without a proper state medical license, and abandonment are among the liability concerns that we could face when practicing during a disaster (Box^1,2).

Box

Liability protections

There are no comprehensive national liability protections for all practitioners during disasters.¹ Limited immunity is often provided through a patchwork of federal and state laws and regulations, which can be complex and are often modified. This immunity depends on several factors, such as applicable regulations, the type of services that are provided, and whether the clinicians are volunteering their services (ie, they are not being paid for providing services).² There is usually no immunity due to willful or wanton acts, gross negligence, providing care while intoxicated, or criminal acts.²

Federal laws and regulations

Most of the federal laws that provide liability protections are activated once a disaster is declared. However, some laws provide liability protections without requiring such declarations. Additional federal laws and regulations that provide additional liability protections, especially to volunteers, can be enacted after disasters occur.

Federal Tort Claims Act

The Federal Tort Claims Act (FTCA)³ protects federal government employees from tort liability by substituting the federal government as the defendant in certain types of suits brought against the federal government. These suits may involve injury, loss of personal property, personal injury, or death by the negligent or wrongful act or omission of any federal government employees while acting in the scope of their office or employment.^3,4 It does not require that an emergency be declared before immunity is conferred. FTCA covers all federal government employees, including volunteers.⁴ In the context of an emergency response, volunteers can assert the liability protections afforded to federal employees if they are designated as unpaid employees of the federal government.⁴ Federal employees are immune from suit under state tort law.⁴

Volunteer Protection Act

The Volunteer Protection Act (VPA) of 1997⁵ provides liability protections to uncompensated volunteer health professionals (VHPs) who perform services for nonprofit organizations or government entities against claims of ordinary negligence committed within the scope of their volunteer responsibilities.⁴ It does not require that an emergency be declared before immunity is conferred. Although VHPs are not liable for economic damages caused by providing medical care within the scope of their volunteer responsibilities, this exemption does not extend to non-economic damages, such as losses for suffering and mental anguish.⁵ VPA does not protect VHPs working in businesses (including for-profit hospitals) and organizational entities of any type (including nonprofit or governmental organizations) that use VHPs.⁴

VPA only protects VHPs practicing with a license as required by law in the state where the harm occurred, unless state authorities allow for licensure exceptions. VPA overrides state laws that are inconsistent with VPA, unless those state laws provide greater liability protection for VHPs.⁴ However, VPA protections are limited. VPA protects only volunteers, not clinicians working in their regular nonemergency roles and capacities.⁶ A nonprofit or government agent can still bring civil claims against VHPs.⁶ VPA does not override certain state laws that put conditions on volunteers, such as risk management requirements, vicarious liability, and a financially secure form of recovery for intended victims.⁶

Continue to: Health Insurance Portability and Accountability Act

 

 

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act (HIPAA) of 1996,⁷ specifically Section 194, extends eligibility for FTCA liability protections to VHPs at qualifying free clinics, provided the clinic sponsors the VHPs by applying to the Health Resources and Services Administration.⁸ It does not require that an emergency be declared before immunity is conferred.

Public Readiness and Emergency Preparedness Act

The Public Readiness and Emergency Preparedness (PREP) Act of 2005⁹ authorizes the US Department of Health and Human Services (HHS) Secretary to issue a declaration that provides immunity to VHPs from tort liability for claims of loss caused by the use of authorized countermeasures (eg, vaccines) against diseases or other threats of public health emergencies.⁴ A separate emergency determination under Public Health Service Act Section 319 or another statute is not required for PREP Act immunities to take effect.⁴ The PREP Act covers individual persons and entities involved in the manufacture, testing, distribution, administration, and use of covered countermeasures.⁴

PREP Act immunity is not absolute and does not protect against claims of willful misconduct, violation of the Americans with Disabilities Act (ADA), or other civil rights violations.⁴ Liability protection under the PREP Act is limited to a specific emergency and includes only the countermeasures and other conditions listed in the PREP Act declaration by the HHS Secretary.⁴

State laws and regulations

States have a variety of standing liability protections that could apply to VHPs who provide care in an emergency. Some states have crafted executive orders to be put into effect during a disaster. Most of these executive orders, which can include extending liability protections, are similar to what other states have done by adopting model acts such as Model State Emergency Health Powers Act.⁶ These orders are not actually laws; they only become effective when the governor signs them at the time of the disaster. These orders also are time-limited and must be reissued in subsequent disasters.

State tort claims acts and state claims acts

Similar to the federal government, some states have waived sovereign immunity in certain circumstances through state tort claims or state claims acts.

Continue to: State tort claims act

State tort claims acts either abolish state sovereign immunity generally and provide immunity only in specific circumstances, or preserve sovereign immunity generally but identify certain exceptions in which immunity is waived.⁴

State claims acts limit state sovereign immunity by establishing procedures for making claims against the state.⁴ These acts typically immunize state government employees from tort liability for acts or omissions committed within the scope of their employment.⁴ Some states extend these protections to volunteers, and some states declare volunteers to be unpaid state employees during an emergency, which allows volunteers to assert the liability protections afforded of state employees.⁴

Emergency power statutes

State emergency laws can trigger additional powers, suspend certain administrative requirements, and provide or enhance liability protections to specified groups of volunteers and other responders upon a gubernatorial declaration of emergency.⁴ These statutes can extend the rights and immunities provided to governmental employees to volunteers performing work that is eligible for coverage under governmental immunity and state tort claims acts.⁴ There is a wide range in the types and degrees of coverage provided to volunteers under emergency powers statutes, and these provisions can be broad or duplicative of other provisions in state law.⁴

State volunteer protection statutes

All states have some statutory provisions for volunteers. Similar to the VPA, these state volunteer protection statutes generally do not require that an emergency be declared, apply to uncompensated individual volunteers for nonprofit and government entities only, and apply only to individuals and not to organizations.⁴ Many states have adopted specific liability protections for VHPs in addition to or to supplement their emergency powers and general volunteer protection statutes.⁴ These statutes confer immunity from civil liability provided that certain conditions are met and are not dependent on the declaration of an emergency.⁴ Each state statute differs in regard to who receives immunity, which acts are immune from liability, and what liability protections are available.

Good Samaritan laws

All 50 states and the District of Columbia have enacted Good Samaritan laws. These laws, which do not need an official declaration of an emergency in order to be applicable, generally protect VHPs from liability when volunteering in good faith and without compensation at the scene of an emergency.² Good Samaritan protections may also apply to care provided by VHPs in a hospital if the VHP is not on duty and does not charge a fee.² However, the effect and scope of Good Samaritan laws vary dramatically from state to state. Some states include hospital settings as an emergency scene in their statutes, while others expressly exclude hospitals from their statutes.⁶ Some state statutes only include declared emergencies, while others are drawn to broadly cover all emergency situations.⁶

Continue to: Limitations

Limitations. Many Good Samaritan statutes apply only to volunteers, and not all states have statutes that allow clinicians to be designated as such,⁶ so receiving compensation would take a clinician outside the scope of the statute. Further, most states only shield action taken at the scene of an accident, and immunity would not extend to a hospital emergency department, or in the aftermath of an emergency as normal conditions slowly return.⁶ Therefore, Good Samaritan liability protection would apply to the common scenario of assisting at the scene of a car crash, but not necessarily to treating individuals in the emergency department after a hurricane or during a pandemic.⁶ State laws vary considerably on what constitutes “good faith” and “without compensation,” which would determine whether protection applies for a clinician who is otherwise salaried in a regular job.¹

Mutual aid agreements

Mutual aid agreements are mechanisms through which jurisdictions can aid other jurisdictions during emergencies.⁴ These agreements also include provisions for reimbursing expenses, providing liability protections to governmental employees and volunteers who provide aid, and awarding compensation for injuries to personnel deployed under the agreement.⁴ These protections are not automatic and are limited in their applicability.

The Emergency Management Assistance Compact (EMAC), the most widely adopted mutual aid agreement in the United States, has been adopted by all 50 states, the District of Columbia, and some territories.¹⁰ It only becomes effective once an emergency has been declared. EMAC provides immunity to officers from the state that is rendering aid to the state requesting aid, in which officers are considered agents of the requesting state for tort liability and immunity purposes.⁸ These individuals, who must be properly dispatched in response to an EMAC request, are not to be held liable for acts or omissions rendered in good faith; however, EMAC does not provide liability protection for actions constituting willful misconduct, gross negligence, or recklessness.⁶ EMAC also provides reciprocity for individuals who are properly dispatched in response to an EMAC request who hold medical licenses to practice medicine in the receiving state, subject to any limitations imposed by the receiving state.⁴ Clinicians can familiarize themselves with a state’s medical licensing requirements by reviewing that state’s medical board website. For EMAC protections to apply, a state must make a request to another/other state(s) through EMAC, and such requests must be formally accepted by the rendering state.⁸ EMAC does not require participating states to actually provide aid.¹⁰

Non-volunteer health care clinicians

Non-volunteer (salaried or paid) health care clinicians are more likely to bear the brunt of providing care during a disaster, especially in the early stages before VHPs arrive; however, most legislation does not address the associated disproportionate liability risk burden of non-volunteer health care clinicians.^1,11 As opposed to VHPs and government employees, non-volunteer health care clinicians performing their regular job duties during a disaster are generally not provided immunity from negligence by most legislation.^1,6 One exception is the PREP Act, which provides immunity for all clinicians from claims that may arise from dispensing a specific counter­measure during a declared public health emergency.^1,9 Some states have enacted the Model State Emergency Health Powers Act, which may offer immunity from negligence if the non-volunteer clinician is rendering care under contract with or at the request of a state¹; however, non-volunteer clinicians who practice from their office or a local hospital will not receive protection through these laws.¹ Good Samaritan laws may not apply unless care is provided at a scene of an emergency.

A few states have attempted to narrow this legislative gap by enacting laws that provide immunity more broadly for clinicians, regardless of their volunteer or compensation status.¹ Elements of these states’ laws include acting in response to a declared emergency or disaster in which there is a recognized depletion of resources attributable to the disaster, at express or implied request of the state government, and consistent with emergency plans.¹

Continue to: Bottom Line

 

 

Bottom Line

There are potential liability risks when treating patients during a disaster. Statutory protections that limit liability may be enacted when the US President or a state Governor declares an official state of emergency. Although some federal and state laws and regulations provide liability protections during these situations, there is a discrepancy in the protections offered to non-volunteer vs volunteer clinicians.

Related Resources

• Federal Emergency Management Agency. https://www.fema.gov/
• Federation of State Medical Boards. https://www.fsmb.org

Disasters—both natural and human-caused—can strike at any time, causing severe trauma for those impacted. Disasters may create circumstances where the need for mental health resources could exceed capacity, and hospitals and clinics would be unable to meet the needs of the affected communities. As psychiatric clinicians, we may want to provide our services in such situations; however, we are still at risk for civil, criminal, or constitutional liability claims against us if we fail to meet our legal obligations related to psychiatric practice. Ideally, whether we live and work in an area affected by a disaster or volunteer from other states, we should be able to care for patients without fear of facing unreasonable liability risks. Although an exhaustive list of all relevant federal and state laws and regulations is beyond the scope of this article, here I discuss some of the federal and state laws and regulations that could provide protection from these risks, and some limitations of liability protection.

A familiar list of liability concerns

From a liability perspective, what should we be aware of when practicing during disasters? The same liability concerns we have during our day-to-day practice also exist during disasters, especially when there are suboptimal or adverse outcomes. Negligence, practicing without a proper state medical license, and abandonment are among the liability concerns that we could face when practicing during a disaster (Box^1,2).

Box

Liability protections

There are no comprehensive national liability protections for all practitioners during disasters.¹ Limited immunity is often provided through a patchwork of federal and state laws and regulations, which can be complex and are often modified. This immunity depends on several factors, such as applicable regulations, the type of services that are provided, and whether the clinicians are volunteering their services (ie, they are not being paid for providing services).² There is usually no immunity due to willful or wanton acts, gross negligence, providing care while intoxicated, or criminal acts.²

Federal laws and regulations

Most of the federal laws that provide liability protections are activated once a disaster is declared. However, some laws provide liability protections without requiring such declarations. Additional federal laws and regulations that provide additional liability protections, especially to volunteers, can be enacted after disasters occur.

Federal Tort Claims Act

The Federal Tort Claims Act (FTCA)³ protects federal government employees from tort liability by substituting the federal government as the defendant in certain types of suits brought against the federal government. These suits may involve injury, loss of personal property, personal injury, or death by the negligent or wrongful act or omission of any federal government employees while acting in the scope of their office or employment.^3,4 It does not require that an emergency be declared before immunity is conferred. FTCA covers all federal government employees, including volunteers.⁴ In the context of an emergency response, volunteers can assert the liability protections afforded to federal employees if they are designated as unpaid employees of the federal government.⁴ Federal employees are immune from suit under state tort law.⁴

Volunteer Protection Act

The Volunteer Protection Act (VPA) of 1997⁵ provides liability protections to uncompensated volunteer health professionals (VHPs) who perform services for nonprofit organizations or government entities against claims of ordinary negligence committed within the scope of their volunteer responsibilities.⁴ It does not require that an emergency be declared before immunity is conferred. Although VHPs are not liable for economic damages caused by providing medical care within the scope of their volunteer responsibilities, this exemption does not extend to non-economic damages, such as losses for suffering and mental anguish.⁵ VPA does not protect VHPs working in businesses (including for-profit hospitals) and organizational entities of any type (including nonprofit or governmental organizations) that use VHPs.⁴

VPA only protects VHPs practicing with a license as required by law in the state where the harm occurred, unless state authorities allow for licensure exceptions. VPA overrides state laws that are inconsistent with VPA, unless those state laws provide greater liability protection for VHPs.⁴ However, VPA protections are limited. VPA protects only volunteers, not clinicians working in their regular nonemergency roles and capacities.⁶ A nonprofit or government agent can still bring civil claims against VHPs.⁶ VPA does not override certain state laws that put conditions on volunteers, such as risk management requirements, vicarious liability, and a financially secure form of recovery for intended victims.⁶

Continue to: Health Insurance Portability and Accountability Act

 

 

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act (HIPAA) of 1996,⁷ specifically Section 194, extends eligibility for FTCA liability protections to VHPs at qualifying free clinics, provided the clinic sponsors the VHPs by applying to the Health Resources and Services Administration.⁸ It does not require that an emergency be declared before immunity is conferred.

Public Readiness and Emergency Preparedness Act

The Public Readiness and Emergency Preparedness (PREP) Act of 2005⁹ authorizes the US Department of Health and Human Services (HHS) Secretary to issue a declaration that provides immunity to VHPs from tort liability for claims of loss caused by the use of authorized countermeasures (eg, vaccines) against diseases or other threats of public health emergencies.⁴ A separate emergency determination under Public Health Service Act Section 319 or another statute is not required for PREP Act immunities to take effect.⁴ The PREP Act covers individual persons and entities involved in the manufacture, testing, distribution, administration, and use of covered countermeasures.⁴

PREP Act immunity is not absolute and does not protect against claims of willful misconduct, violation of the Americans with Disabilities Act (ADA), or other civil rights violations.⁴ Liability protection under the PREP Act is limited to a specific emergency and includes only the countermeasures and other conditions listed in the PREP Act declaration by the HHS Secretary.⁴

State laws and regulations

States have a variety of standing liability protections that could apply to VHPs who provide care in an emergency. Some states have crafted executive orders to be put into effect during a disaster. Most of these executive orders, which can include extending liability protections, are similar to what other states have done by adopting model acts such as Model State Emergency Health Powers Act.⁶ These orders are not actually laws; they only become effective when the governor signs them at the time of the disaster. These orders also are time-limited and must be reissued in subsequent disasters.

State tort claims acts and state claims acts

Similar to the federal government, some states have waived sovereign immunity in certain circumstances through state tort claims or state claims acts.

Continue to: State tort claims act

State tort claims acts either abolish state sovereign immunity generally and provide immunity only in specific circumstances, or preserve sovereign immunity generally but identify certain exceptions in which immunity is waived.⁴

State claims acts limit state sovereign immunity by establishing procedures for making claims against the state.⁴ These acts typically immunize state government employees from tort liability for acts or omissions committed within the scope of their employment.⁴ Some states extend these protections to volunteers, and some states declare volunteers to be unpaid state employees during an emergency, which allows volunteers to assert the liability protections afforded of state employees.⁴

Emergency power statutes

State emergency laws can trigger additional powers, suspend certain administrative requirements, and provide or enhance liability protections to specified groups of volunteers and other responders upon a gubernatorial declaration of emergency.⁴ These statutes can extend the rights and immunities provided to governmental employees to volunteers performing work that is eligible for coverage under governmental immunity and state tort claims acts.⁴ There is a wide range in the types and degrees of coverage provided to volunteers under emergency powers statutes, and these provisions can be broad or duplicative of other provisions in state law.⁴

State volunteer protection statutes

All states have some statutory provisions for volunteers. Similar to the VPA, these state volunteer protection statutes generally do not require that an emergency be declared, apply to uncompensated individual volunteers for nonprofit and government entities only, and apply only to individuals and not to organizations.⁴ Many states have adopted specific liability protections for VHPs in addition to or to supplement their emergency powers and general volunteer protection statutes.⁴ These statutes confer immunity from civil liability provided that certain conditions are met and are not dependent on the declaration of an emergency.⁴ Each state statute differs in regard to who receives immunity, which acts are immune from liability, and what liability protections are available.

Good Samaritan laws

All 50 states and the District of Columbia have enacted Good Samaritan laws. These laws, which do not need an official declaration of an emergency in order to be applicable, generally protect VHPs from liability when volunteering in good faith and without compensation at the scene of an emergency.² Good Samaritan protections may also apply to care provided by VHPs in a hospital if the VHP is not on duty and does not charge a fee.² However, the effect and scope of Good Samaritan laws vary dramatically from state to state. Some states include hospital settings as an emergency scene in their statutes, while others expressly exclude hospitals from their statutes.⁶ Some state statutes only include declared emergencies, while others are drawn to broadly cover all emergency situations.⁶

Continue to: Limitations

Limitations. Many Good Samaritan statutes apply only to volunteers, and not all states have statutes that allow clinicians to be designated as such,⁶ so receiving compensation would take a clinician outside the scope of the statute. Further, most states only shield action taken at the scene of an accident, and immunity would not extend to a hospital emergency department, or in the aftermath of an emergency as normal conditions slowly return.⁶ Therefore, Good Samaritan liability protection would apply to the common scenario of assisting at the scene of a car crash, but not necessarily to treating individuals in the emergency department after a hurricane or during a pandemic.⁶ State laws vary considerably on what constitutes “good faith” and “without compensation,” which would determine whether protection applies for a clinician who is otherwise salaried in a regular job.¹

Mutual aid agreements

Mutual aid agreements are mechanisms through which jurisdictions can aid other jurisdictions during emergencies.⁴ These agreements also include provisions for reimbursing expenses, providing liability protections to governmental employees and volunteers who provide aid, and awarding compensation for injuries to personnel deployed under the agreement.⁴ These protections are not automatic and are limited in their applicability.

The Emergency Management Assistance Compact (EMAC), the most widely adopted mutual aid agreement in the United States, has been adopted by all 50 states, the District of Columbia, and some territories.¹⁰ It only becomes effective once an emergency has been declared. EMAC provides immunity to officers from the state that is rendering aid to the state requesting aid, in which officers are considered agents of the requesting state for tort liability and immunity purposes.⁸ These individuals, who must be properly dispatched in response to an EMAC request, are not to be held liable for acts or omissions rendered in good faith; however, EMAC does not provide liability protection for actions constituting willful misconduct, gross negligence, or recklessness.⁶ EMAC also provides reciprocity for individuals who are properly dispatched in response to an EMAC request who hold medical licenses to practice medicine in the receiving state, subject to any limitations imposed by the receiving state.⁴ Clinicians can familiarize themselves with a state’s medical licensing requirements by reviewing that state’s medical board website. For EMAC protections to apply, a state must make a request to another/other state(s) through EMAC, and such requests must be formally accepted by the rendering state.⁸ EMAC does not require participating states to actually provide aid.¹⁰

Non-volunteer health care clinicians

Non-volunteer (salaried or paid) health care clinicians are more likely to bear the brunt of providing care during a disaster, especially in the early stages before VHPs arrive; however, most legislation does not address the associated disproportionate liability risk burden of non-volunteer health care clinicians.^1,11 As opposed to VHPs and government employees, non-volunteer health care clinicians performing their regular job duties during a disaster are generally not provided immunity from negligence by most legislation.^1,6 One exception is the PREP Act, which provides immunity for all clinicians from claims that may arise from dispensing a specific counter­measure during a declared public health emergency.^1,9 Some states have enacted the Model State Emergency Health Powers Act, which may offer immunity from negligence if the non-volunteer clinician is rendering care under contract with or at the request of a state¹; however, non-volunteer clinicians who practice from their office or a local hospital will not receive protection through these laws.¹ Good Samaritan laws may not apply unless care is provided at a scene of an emergency.

A few states have attempted to narrow this legislative gap by enacting laws that provide immunity more broadly for clinicians, regardless of their volunteer or compensation status.¹ Elements of these states’ laws include acting in response to a declared emergency or disaster in which there is a recognized depletion of resources attributable to the disaster, at express or implied request of the state government, and consistent with emergency plans.¹

Continue to: Bottom Line

 

 

Bottom Line

There are potential liability risks when treating patients during a disaster. Statutory protections that limit liability may be enacted when the US President or a state Governor declares an official state of emergency. Although some federal and state laws and regulations provide liability protections during these situations, there is a discrepancy in the protections offered to non-volunteer vs volunteer clinicians.

Related Resources

• Federal Emergency Management Agency. https://www.fema.gov/
• Federation of State Medical Boards. https://www.fsmb.org

Disasters—both natural and human-caused—can strike at any time, causing severe trauma for those impacted. Disasters may create circumstances where the need for mental health resources could exceed capacity, and hospitals and clinics would be unable to meet the needs of the affected communities. As psychiatric clinicians, we may want to provide our services in such situations; however, we are still at risk for civil, criminal, or constitutional liability claims against us if we fail to meet our legal obligations related to psychiatric practice. Ideally, whether we live and work in an area affected by a disaster or volunteer from other states, we should be able to care for patients without fear of facing unreasonable liability risks. Although an exhaustive list of all relevant federal and state laws and regulations is beyond the scope of this article, here I discuss some of the federal and state laws and regulations that could provide protection from these risks, and some limitations of liability protection.

A familiar list of liability concerns

From a liability perspective, what should we be aware of when practicing during disasters? The same liability concerns we have during our day-to-day practice also exist during disasters, especially when there are suboptimal or adverse outcomes. Negligence, practicing without a proper state medical license, and abandonment are among the liability concerns that we could face when practicing during a disaster (Box^1,2).

Box

Liability protections

There are no comprehensive national liability protections for all practitioners during disasters.¹ Limited immunity is often provided through a patchwork of federal and state laws and regulations, which can be complex and are often modified. This immunity depends on several factors, such as applicable regulations, the type of services that are provided, and whether the clinicians are volunteering their services (ie, they are not being paid for providing services).² There is usually no immunity due to willful or wanton acts, gross negligence, providing care while intoxicated, or criminal acts.²

Federal laws and regulations

Most of the federal laws that provide liability protections are activated once a disaster is declared. However, some laws provide liability protections without requiring such declarations. Additional federal laws and regulations that provide additional liability protections, especially to volunteers, can be enacted after disasters occur.

Federal Tort Claims Act

The Federal Tort Claims Act (FTCA)³ protects federal government employees from tort liability by substituting the federal government as the defendant in certain types of suits brought against the federal government. These suits may involve injury, loss of personal property, personal injury, or death by the negligent or wrongful act or omission of any federal government employees while acting in the scope of their office or employment.^3,4 It does not require that an emergency be declared before immunity is conferred. FTCA covers all federal government employees, including volunteers.⁴ In the context of an emergency response, volunteers can assert the liability protections afforded to federal employees if they are designated as unpaid employees of the federal government.⁴ Federal employees are immune from suit under state tort law.⁴

Volunteer Protection Act

The Volunteer Protection Act (VPA) of 1997⁵ provides liability protections to uncompensated volunteer health professionals (VHPs) who perform services for nonprofit organizations or government entities against claims of ordinary negligence committed within the scope of their volunteer responsibilities.⁴ It does not require that an emergency be declared before immunity is conferred. Although VHPs are not liable for economic damages caused by providing medical care within the scope of their volunteer responsibilities, this exemption does not extend to non-economic damages, such as losses for suffering and mental anguish.⁵ VPA does not protect VHPs working in businesses (including for-profit hospitals) and organizational entities of any type (including nonprofit or governmental organizations) that use VHPs.⁴

VPA only protects VHPs practicing with a license as required by law in the state where the harm occurred, unless state authorities allow for licensure exceptions. VPA overrides state laws that are inconsistent with VPA, unless those state laws provide greater liability protection for VHPs.⁴ However, VPA protections are limited. VPA protects only volunteers, not clinicians working in their regular nonemergency roles and capacities.⁶ A nonprofit or government agent can still bring civil claims against VHPs.⁶ VPA does not override certain state laws that put conditions on volunteers, such as risk management requirements, vicarious liability, and a financially secure form of recovery for intended victims.⁶

Continue to: Health Insurance Portability and Accountability Act

 

 

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act (HIPAA) of 1996,⁷ specifically Section 194, extends eligibility for FTCA liability protections to VHPs at qualifying free clinics, provided the clinic sponsors the VHPs by applying to the Health Resources and Services Administration.⁸ It does not require that an emergency be declared before immunity is conferred.

Public Readiness and Emergency Preparedness Act

The Public Readiness and Emergency Preparedness (PREP) Act of 2005⁹ authorizes the US Department of Health and Human Services (HHS) Secretary to issue a declaration that provides immunity to VHPs from tort liability for claims of loss caused by the use of authorized countermeasures (eg, vaccines) against diseases or other threats of public health emergencies.⁴ A separate emergency determination under Public Health Service Act Section 319 or another statute is not required for PREP Act immunities to take effect.⁴ The PREP Act covers individual persons and entities involved in the manufacture, testing, distribution, administration, and use of covered countermeasures.⁴

PREP Act immunity is not absolute and does not protect against claims of willful misconduct, violation of the Americans with Disabilities Act (ADA), or other civil rights violations.⁴ Liability protection under the PREP Act is limited to a specific emergency and includes only the countermeasures and other conditions listed in the PREP Act declaration by the HHS Secretary.⁴

State laws and regulations

States have a variety of standing liability protections that could apply to VHPs who provide care in an emergency. Some states have crafted executive orders to be put into effect during a disaster. Most of these executive orders, which can include extending liability protections, are similar to what other states have done by adopting model acts such as Model State Emergency Health Powers Act.⁶ These orders are not actually laws; they only become effective when the governor signs them at the time of the disaster. These orders also are time-limited and must be reissued in subsequent disasters.

State tort claims acts and state claims acts

Similar to the federal government, some states have waived sovereign immunity in certain circumstances through state tort claims or state claims acts.

Continue to: State tort claims act

State tort claims acts either abolish state sovereign immunity generally and provide immunity only in specific circumstances, or preserve sovereign immunity generally but identify certain exceptions in which immunity is waived.⁴

State claims acts limit state sovereign immunity by establishing procedures for making claims against the state.⁴ These acts typically immunize state government employees from tort liability for acts or omissions committed within the scope of their employment.⁴ Some states extend these protections to volunteers, and some states declare volunteers to be unpaid state employees during an emergency, which allows volunteers to assert the liability protections afforded of state employees.⁴

Emergency power statutes

State emergency laws can trigger additional powers, suspend certain administrative requirements, and provide or enhance liability protections to specified groups of volunteers and other responders upon a gubernatorial declaration of emergency.⁴ These statutes can extend the rights and immunities provided to governmental employees to volunteers performing work that is eligible for coverage under governmental immunity and state tort claims acts.⁴ There is a wide range in the types and degrees of coverage provided to volunteers under emergency powers statutes, and these provisions can be broad or duplicative of other provisions in state law.⁴

State volunteer protection statutes

All states have some statutory provisions for volunteers. Similar to the VPA, these state volunteer protection statutes generally do not require that an emergency be declared, apply to uncompensated individual volunteers for nonprofit and government entities only, and apply only to individuals and not to organizations.⁴ Many states have adopted specific liability protections for VHPs in addition to or to supplement their emergency powers and general volunteer protection statutes.⁴ These statutes confer immunity from civil liability provided that certain conditions are met and are not dependent on the declaration of an emergency.⁴ Each state statute differs in regard to who receives immunity, which acts are immune from liability, and what liability protections are available.

Good Samaritan laws

All 50 states and the District of Columbia have enacted Good Samaritan laws. These laws, which do not need an official declaration of an emergency in order to be applicable, generally protect VHPs from liability when volunteering in good faith and without compensation at the scene of an emergency.² Good Samaritan protections may also apply to care provided by VHPs in a hospital if the VHP is not on duty and does not charge a fee.² However, the effect and scope of Good Samaritan laws vary dramatically from state to state. Some states include hospital settings as an emergency scene in their statutes, while others expressly exclude hospitals from their statutes.⁶ Some state statutes only include declared emergencies, while others are drawn to broadly cover all emergency situations.⁶

Continue to: Limitations

Limitations. Many Good Samaritan statutes apply only to volunteers, and not all states have statutes that allow clinicians to be designated as such,⁶ so receiving compensation would take a clinician outside the scope of the statute. Further, most states only shield action taken at the scene of an accident, and immunity would not extend to a hospital emergency department, or in the aftermath of an emergency as normal conditions slowly return.⁶ Therefore, Good Samaritan liability protection would apply to the common scenario of assisting at the scene of a car crash, but not necessarily to treating individuals in the emergency department after a hurricane or during a pandemic.⁶ State laws vary considerably on what constitutes “good faith” and “without compensation,” which would determine whether protection applies for a clinician who is otherwise salaried in a regular job.¹

Mutual aid agreements

Mutual aid agreements are mechanisms through which jurisdictions can aid other jurisdictions during emergencies.⁴ These agreements also include provisions for reimbursing expenses, providing liability protections to governmental employees and volunteers who provide aid, and awarding compensation for injuries to personnel deployed under the agreement.⁴ These protections are not automatic and are limited in their applicability.

The Emergency Management Assistance Compact (EMAC), the most widely adopted mutual aid agreement in the United States, has been adopted by all 50 states, the District of Columbia, and some territories.¹⁰ It only becomes effective once an emergency has been declared. EMAC provides immunity to officers from the state that is rendering aid to the state requesting aid, in which officers are considered agents of the requesting state for tort liability and immunity purposes.⁸ These individuals, who must be properly dispatched in response to an EMAC request, are not to be held liable for acts or omissions rendered in good faith; however, EMAC does not provide liability protection for actions constituting willful misconduct, gross negligence, or recklessness.⁶ EMAC also provides reciprocity for individuals who are properly dispatched in response to an EMAC request who hold medical licenses to practice medicine in the receiving state, subject to any limitations imposed by the receiving state.⁴ Clinicians can familiarize themselves with a state’s medical licensing requirements by reviewing that state’s medical board website. For EMAC protections to apply, a state must make a request to another/other state(s) through EMAC, and such requests must be formally accepted by the rendering state.⁸ EMAC does not require participating states to actually provide aid.¹⁰

Non-volunteer health care clinicians

Non-volunteer (salaried or paid) health care clinicians are more likely to bear the brunt of providing care during a disaster, especially in the early stages before VHPs arrive; however, most legislation does not address the associated disproportionate liability risk burden of non-volunteer health care clinicians.^1,11 As opposed to VHPs and government employees, non-volunteer health care clinicians performing their regular job duties during a disaster are generally not provided immunity from negligence by most legislation.^1,6 One exception is the PREP Act, which provides immunity for all clinicians from claims that may arise from dispensing a specific counter­measure during a declared public health emergency.^1,9 Some states have enacted the Model State Emergency Health Powers Act, which may offer immunity from negligence if the non-volunteer clinician is rendering care under contract with or at the request of a state¹; however, non-volunteer clinicians who practice from their office or a local hospital will not receive protection through these laws.¹ Good Samaritan laws may not apply unless care is provided at a scene of an emergency.

A few states have attempted to narrow this legislative gap by enacting laws that provide immunity more broadly for clinicians, regardless of their volunteer or compensation status.¹ Elements of these states’ laws include acting in response to a declared emergency or disaster in which there is a recognized depletion of resources attributable to the disaster, at express or implied request of the state government, and consistent with emergency plans.¹

Continue to: Bottom Line

 

 

Bottom Line

There are potential liability risks when treating patients during a disaster. Statutory protections that limit liability may be enacted when the US President or a state Governor declares an official state of emergency. Although some federal and state laws and regulations provide liability protections during these situations, there is a discrepancy in the protections offered to non-volunteer vs volunteer clinicians.

Related Resources

• Federal Emergency Management Agency. https://www.fema.gov/
• Federation of State Medical Boards. https://www.fsmb.org

At morning shift change a few months ago on my consultation-liaison rotation, I thanked the night float resident who had been called to a case that was not at all psychiatrically acute. When I told my colleague I was sorry she had had such a “soft consult” during a busy shift, she graciously replied that the patient had been exceedingly pleasant. She said, “Sometimes we just offer our presence, and you know what? I’m glad I’m in that kind of field. The ‘being-present’ kind of field.”

As mental health professionals, we pride ourselves on being present for our patients and our colleagues alike. Winnicott¹ originally coined the psychoanalytic term “holding” to denote one of the earliest stages of parental care, wherein an environment of both physical and emotional reliability allows a child to develop their sense of self. The complementary concept of “containing,” developed by Bion,² indicates a parental figure’s receiving the child’s emotions, however difficult, and then processing them into a more tolerable form. I am frequently struck by how often our role as psychiatrists is not necessarily to offer a specific diagnosis or medication recommendation, but instead to “hold” by listening, “contain” whatever emotions emerge, and offer a sense of validation and perhaps a biopsychosocial formulation for the patient’s experience.^3-5 In the consultation-liaison setting, we might assess the contribution of sleep cycle disturbance, postoperative opioids, and anticholinergic medications on a patient’s mental status. Just as important, we might help the patient and their primary team understand that the patient’s history of childhood trauma could, under stressful conditions such as a prolonged hospitalization, lead to affective dysregulation and result in projective identification through which the team felt just as frustrated and helpless as the patient.

The relentless pursuit of efficiency vs time spent with patients

In inpatient work, I may serve as short-term psychotherapist for the patient, their family members, or a consulting team, and I treasure the time spent in those roles. But I concurrently hold various other responsibilities during my shift, including the roles of triage clinician, medical ethicist, and psychopharmacology expert (or, in the case of a newly-third-year resident such as myself, a nonexpert trying to build her knowledge base). I am also literally holding a pager, which intrudes—with aggressive cacophony, vibration, or both—upon the sanctity of any space. The pager is a reminder of a myriad of tasks: calling collateral, answering questions from team members, pre-charting, note-writing, ordering labs, checking labs, updating the handoff, reconciling medication lists, filling out legal paperwork, triaging the next consult. These are unavoidable and generally necessary parts of clinical work, but sometimes they veer into sheer drudgery.

As a medical student, learning to complete tasks is a substantial part of each clinical rotation, and task completion provides plenty of dopaminergic reinforcements that could masquerade as job satisfaction. Through my first year and a half of residency, I pushed hard to build “efficiency” in my workflow, but eventually, task completion stopped providing sufficient inherent satisfaction. It has been a relief to find that amid the stream of checkboxes, the true work of psychiatric care (the interactions with patients, their clinical presentations, and considering their differential diagnoses and treatment options) feels deeply meaningful and ever more fascinating.

At times, I am angered by the reality of limited clinician bandwidth. This frustration motivates me to seek system-level improvements that can enable us to deliver quality psychiatric care while mitigating the risk of clinician burnout. What ends up shortchanged in the relentless pursuit of efficiency is the time spent with patients. This is never more apparent than during a busy inpatient shift, when I often need to compress patient interactions and focus only on the most acute clinical questions. When I have to apologize for stepping out of the interview room to answer yet another page, I marvel at seeing attending psychiatrists who—with apparent ease—make patients feel as if they have all the time in the world, and I wonder when I will be able to do the same.

And yet, there are other times when my pager stays blessedly quiet, time can slow down in the room, and I can make a patient feel heard, held, and contained. In those moments, I also hold my own need for connection with the patient, and can recall what my colleague reminded me: what a privilege it is to be in the “being-present” kind of field.

At morning shift change a few months ago on my consultation-liaison rotation, I thanked the night float resident who had been called to a case that was not at all psychiatrically acute. When I told my colleague I was sorry she had had such a “soft consult” during a busy shift, she graciously replied that the patient had been exceedingly pleasant. She said, “Sometimes we just offer our presence, and you know what? I’m glad I’m in that kind of field. The ‘being-present’ kind of field.”

As mental health professionals, we pride ourselves on being present for our patients and our colleagues alike. Winnicott¹ originally coined the psychoanalytic term “holding” to denote one of the earliest stages of parental care, wherein an environment of both physical and emotional reliability allows a child to develop their sense of self. The complementary concept of “containing,” developed by Bion,² indicates a parental figure’s receiving the child’s emotions, however difficult, and then processing them into a more tolerable form. I am frequently struck by how often our role as psychiatrists is not necessarily to offer a specific diagnosis or medication recommendation, but instead to “hold” by listening, “contain” whatever emotions emerge, and offer a sense of validation and perhaps a biopsychosocial formulation for the patient’s experience.^3-5 In the consultation-liaison setting, we might assess the contribution of sleep cycle disturbance, postoperative opioids, and anticholinergic medications on a patient’s mental status. Just as important, we might help the patient and their primary team understand that the patient’s history of childhood trauma could, under stressful conditions such as a prolonged hospitalization, lead to affective dysregulation and result in projective identification through which the team felt just as frustrated and helpless as the patient.

The relentless pursuit of efficiency vs time spent with patients

In inpatient work, I may serve as short-term psychotherapist for the patient, their family members, or a consulting team, and I treasure the time spent in those roles. But I concurrently hold various other responsibilities during my shift, including the roles of triage clinician, medical ethicist, and psychopharmacology expert (or, in the case of a newly-third-year resident such as myself, a nonexpert trying to build her knowledge base). I am also literally holding a pager, which intrudes—with aggressive cacophony, vibration, or both—upon the sanctity of any space. The pager is a reminder of a myriad of tasks: calling collateral, answering questions from team members, pre-charting, note-writing, ordering labs, checking labs, updating the handoff, reconciling medication lists, filling out legal paperwork, triaging the next consult. These are unavoidable and generally necessary parts of clinical work, but sometimes they veer into sheer drudgery.

As a medical student, learning to complete tasks is a substantial part of each clinical rotation, and task completion provides plenty of dopaminergic reinforcements that could masquerade as job satisfaction. Through my first year and a half of residency, I pushed hard to build “efficiency” in my workflow, but eventually, task completion stopped providing sufficient inherent satisfaction. It has been a relief to find that amid the stream of checkboxes, the true work of psychiatric care (the interactions with patients, their clinical presentations, and considering their differential diagnoses and treatment options) feels deeply meaningful and ever more fascinating.

At times, I am angered by the reality of limited clinician bandwidth. This frustration motivates me to seek system-level improvements that can enable us to deliver quality psychiatric care while mitigating the risk of clinician burnout. What ends up shortchanged in the relentless pursuit of efficiency is the time spent with patients. This is never more apparent than during a busy inpatient shift, when I often need to compress patient interactions and focus only on the most acute clinical questions. When I have to apologize for stepping out of the interview room to answer yet another page, I marvel at seeing attending psychiatrists who—with apparent ease—make patients feel as if they have all the time in the world, and I wonder when I will be able to do the same.

And yet, there are other times when my pager stays blessedly quiet, time can slow down in the room, and I can make a patient feel heard, held, and contained. In those moments, I also hold my own need for connection with the patient, and can recall what my colleague reminded me: what a privilege it is to be in the “being-present” kind of field.

At morning shift change a few months ago on my consultation-liaison rotation, I thanked the night float resident who had been called to a case that was not at all psychiatrically acute. When I told my colleague I was sorry she had had such a “soft consult” during a busy shift, she graciously replied that the patient had been exceedingly pleasant. She said, “Sometimes we just offer our presence, and you know what? I’m glad I’m in that kind of field. The ‘being-present’ kind of field.”

As mental health professionals, we pride ourselves on being present for our patients and our colleagues alike. Winnicott¹ originally coined the psychoanalytic term “holding” to denote one of the earliest stages of parental care, wherein an environment of both physical and emotional reliability allows a child to develop their sense of self. The complementary concept of “containing,” developed by Bion,² indicates a parental figure’s receiving the child’s emotions, however difficult, and then processing them into a more tolerable form. I am frequently struck by how often our role as psychiatrists is not necessarily to offer a specific diagnosis or medication recommendation, but instead to “hold” by listening, “contain” whatever emotions emerge, and offer a sense of validation and perhaps a biopsychosocial formulation for the patient’s experience.^3-5 In the consultation-liaison setting, we might assess the contribution of sleep cycle disturbance, postoperative opioids, and anticholinergic medications on a patient’s mental status. Just as important, we might help the patient and their primary team understand that the patient’s history of childhood trauma could, under stressful conditions such as a prolonged hospitalization, lead to affective dysregulation and result in projective identification through which the team felt just as frustrated and helpless as the patient.

The relentless pursuit of efficiency vs time spent with patients

In inpatient work, I may serve as short-term psychotherapist for the patient, their family members, or a consulting team, and I treasure the time spent in those roles. But I concurrently hold various other responsibilities during my shift, including the roles of triage clinician, medical ethicist, and psychopharmacology expert (or, in the case of a newly-third-year resident such as myself, a nonexpert trying to build her knowledge base). I am also literally holding a pager, which intrudes—with aggressive cacophony, vibration, or both—upon the sanctity of any space. The pager is a reminder of a myriad of tasks: calling collateral, answering questions from team members, pre-charting, note-writing, ordering labs, checking labs, updating the handoff, reconciling medication lists, filling out legal paperwork, triaging the next consult. These are unavoidable and generally necessary parts of clinical work, but sometimes they veer into sheer drudgery.

As a medical student, learning to complete tasks is a substantial part of each clinical rotation, and task completion provides plenty of dopaminergic reinforcements that could masquerade as job satisfaction. Through my first year and a half of residency, I pushed hard to build “efficiency” in my workflow, but eventually, task completion stopped providing sufficient inherent satisfaction. It has been a relief to find that amid the stream of checkboxes, the true work of psychiatric care (the interactions with patients, their clinical presentations, and considering their differential diagnoses and treatment options) feels deeply meaningful and ever more fascinating.

At times, I am angered by the reality of limited clinician bandwidth. This frustration motivates me to seek system-level improvements that can enable us to deliver quality psychiatric care while mitigating the risk of clinician burnout. What ends up shortchanged in the relentless pursuit of efficiency is the time spent with patients. This is never more apparent than during a busy inpatient shift, when I often need to compress patient interactions and focus only on the most acute clinical questions. When I have to apologize for stepping out of the interview room to answer yet another page, I marvel at seeing attending psychiatrists who—with apparent ease—make patients feel as if they have all the time in the world, and I wonder when I will be able to do the same.

And yet, there are other times when my pager stays blessedly quiet, time can slow down in the room, and I can make a patient feel heard, held, and contained. In those moments, I also hold my own need for connection with the patient, and can recall what my colleague reminded me: what a privilege it is to be in the “being-present” kind of field.

Man is a political animal.

— Aristotle, Politics , Book 1, Section 1253a

Religion is the opium of the people.

— Karl Marx, A contribution to the critique of Hegel’s philosophy of right , introduction

Beliefs are at the core of psychiatric practice. Our patients are often shackled by their anomalous beliefs, which are not reality-based. These beliefs are often the primary targets of psychiatric treatment. Consider a day at the office of a psychiatrist who may see several patients impaired by false beliefs, such as:

• My neighbor is reading my mind remotely and is plotting to kill me
• If I ride on a plane, it will crash and I will die
• I am a failure, a worthless person, and a burden on my family
• I am hopeless and helpless; life is too painful and not worth living anymore
• I am a prophet with supernatural gifts, and I can predict the future
• Whenever I take this substance, I feel I can jump out of a window and fly
• If I do not shower 5 times in a row every night before going to bed, something terrible will happen to my family.

Patients with false beliefs obviously need psychiatric care. However, a large number of religious individuals harbor “unusual” beliefs involving angels and devils and hell and paradise after death. Those people of faith are not considered to have a DSM-5 psychiatric disorder. Billions of people around the world belong to one of the approximately 4,300 religions, which they celebrate using one of the more than 6,800 living languages. Psychiatrists encourage patients to have a faith because it can be quite comforting to its adherents, enhancing their social relations and providing them with hope and resilience during the darkest days of life. Regular attendance at a house of worship is a measure of the strong roots of one’s faith.

So why have there been so many religious wars over centuries of recorded history? Why have millions of people died during conflicts among religions? Why does one religious group adamantly believe that theirs is the real God, while the god of other religions is fake? And why have people who withdrew from or refused to adopt a certain religious belief been persecuted; labeled as “heretic,” “infidel,” “heathen,” or “apostate”; and burned at the stake or beheaded? Perhaps religion is not always a kinder, gentler belief system.

Continue to: Recent statistics...

Recent statistics show a precipitous decline in religious observance in the United States.¹ So what happens to a society that gradually abandons its previously entrenched religious beliefs and becomes secular? This trend is spreading widely in Europe and North America. But widely held beliefs with powerful personal meaning don’t just fizzle away: they re-emerge in another form. The substantial energy of religious faith must be invested elsewhere and manifested in an alternative form with similar dynamics.

Enter politics!

It seems that humans’ need to uphold a strong belief is so powerful that they either incorporate political doctrines side-by-side with their religious beliefs (if the 2 are compatible) or adopt a strong political belief if they abandon their religion and become secular. This does not have to be an intellectually wrenching change because there are many similarities between hyper-religiosity and fanatic political beliefs (Table).

The toxic hyperpartisanship that has dominated the United States over the past several years may be the culmination of an intensified “religification” of politics. The incendiary mix of religious zealotry and political fanaticism is conducive to intensified loathing, hostility, and animus to those with an opposing political ideology.

So it all boils down to the human imperative of harboring a strong personal belief. What is the origin of beliefs, religious, political, or otherwise? Why does the human species have the overwhelming need to uphold a belief? Research suggests that it is the result of evolution and the phylogenetic enlargement of the brain, including the parietal and medial frontal cortex in humans.² And according to many studies, abnormal and delusional beliefs encountered in psychiatric practice appear to be caused by altered perception and/or misattribution of aversive meaning.³ Lesions in the right hemisphere have been reported to play an important role in generating delusional beliefs.⁴ A healthy right hemisphere plays an important role in:

• pragmatic communications
• perceptual integration
• attentional surveillance and anomaly novelty detection
• belief updating.⁴

Right hemispheric pathology disrupts those functions and can lead to false beliefs such as delusions, or, on a milder scale, strongly held superstitions.

One wonders how the structure and function of the right hemisphere generates and perpetuates a belief in a religion or political ideology that ultimately shapes one’s life. Religiosity and politics are an inherent part of human nature, and they can replace each other or merge together. If one is to believe what Durkheim⁵ proposed more than a century ago, the existence of belief systems is essential for societal stability. He posited that the absence of stable belief systems can lead to what he labeled “anomie,” leading to a surge of suicide and crime. If that is true, then the coexistence of religious and political beliefs may have a significant upside, but also with a palpable downside when either or both of those belief systems become excessively antagonistic or extreme. Three cheers for religious and political moderation that allows them to peacefully coexist.

Man is a political animal.

— Aristotle, Politics , Book 1, Section 1253a

Religion is the opium of the people.

— Karl Marx, A contribution to the critique of Hegel’s philosophy of right , introduction

Beliefs are at the core of psychiatric practice. Our patients are often shackled by their anomalous beliefs, which are not reality-based. These beliefs are often the primary targets of psychiatric treatment. Consider a day at the office of a psychiatrist who may see several patients impaired by false beliefs, such as:

• My neighbor is reading my mind remotely and is plotting to kill me
• If I ride on a plane, it will crash and I will die
• I am a failure, a worthless person, and a burden on my family
• I am hopeless and helpless; life is too painful and not worth living anymore
• I am a prophet with supernatural gifts, and I can predict the future
• Whenever I take this substance, I feel I can jump out of a window and fly
• If I do not shower 5 times in a row every night before going to bed, something terrible will happen to my family.

Patients with false beliefs obviously need psychiatric care. However, a large number of religious individuals harbor “unusual” beliefs involving angels and devils and hell and paradise after death. Those people of faith are not considered to have a DSM-5 psychiatric disorder. Billions of people around the world belong to one of the approximately 4,300 religions, which they celebrate using one of the more than 6,800 living languages. Psychiatrists encourage patients to have a faith because it can be quite comforting to its adherents, enhancing their social relations and providing them with hope and resilience during the darkest days of life. Regular attendance at a house of worship is a measure of the strong roots of one’s faith.

So why have there been so many religious wars over centuries of recorded history? Why have millions of people died during conflicts among religions? Why does one religious group adamantly believe that theirs is the real God, while the god of other religions is fake? And why have people who withdrew from or refused to adopt a certain religious belief been persecuted; labeled as “heretic,” “infidel,” “heathen,” or “apostate”; and burned at the stake or beheaded? Perhaps religion is not always a kinder, gentler belief system.

Continue to: Recent statistics...

Recent statistics show a precipitous decline in religious observance in the United States.¹ So what happens to a society that gradually abandons its previously entrenched religious beliefs and becomes secular? This trend is spreading widely in Europe and North America. But widely held beliefs with powerful personal meaning don’t just fizzle away: they re-emerge in another form. The substantial energy of religious faith must be invested elsewhere and manifested in an alternative form with similar dynamics.

Enter politics!

It seems that humans’ need to uphold a strong belief is so powerful that they either incorporate political doctrines side-by-side with their religious beliefs (if the 2 are compatible) or adopt a strong political belief if they abandon their religion and become secular. This does not have to be an intellectually wrenching change because there are many similarities between hyper-religiosity and fanatic political beliefs (Table).

The toxic hyperpartisanship that has dominated the United States over the past several years may be the culmination of an intensified “religification” of politics. The incendiary mix of religious zealotry and political fanaticism is conducive to intensified loathing, hostility, and animus to those with an opposing political ideology.

So it all boils down to the human imperative of harboring a strong personal belief. What is the origin of beliefs, religious, political, or otherwise? Why does the human species have the overwhelming need to uphold a belief? Research suggests that it is the result of evolution and the phylogenetic enlargement of the brain, including the parietal and medial frontal cortex in humans.² And according to many studies, abnormal and delusional beliefs encountered in psychiatric practice appear to be caused by altered perception and/or misattribution of aversive meaning.³ Lesions in the right hemisphere have been reported to play an important role in generating delusional beliefs.⁴ A healthy right hemisphere plays an important role in:

• pragmatic communications
• perceptual integration
• attentional surveillance and anomaly novelty detection
• belief updating.⁴

Right hemispheric pathology disrupts those functions and can lead to false beliefs such as delusions, or, on a milder scale, strongly held superstitions.

One wonders how the structure and function of the right hemisphere generates and perpetuates a belief in a religion or political ideology that ultimately shapes one’s life. Religiosity and politics are an inherent part of human nature, and they can replace each other or merge together. If one is to believe what Durkheim⁵ proposed more than a century ago, the existence of belief systems is essential for societal stability. He posited that the absence of stable belief systems can lead to what he labeled “anomie,” leading to a surge of suicide and crime. If that is true, then the coexistence of religious and political beliefs may have a significant upside, but also with a palpable downside when either or both of those belief systems become excessively antagonistic or extreme. Three cheers for religious and political moderation that allows them to peacefully coexist.

Man is a political animal.

— Aristotle, Politics , Book 1, Section 1253a

Religion is the opium of the people.

— Karl Marx, A contribution to the critique of Hegel’s philosophy of right , introduction

Beliefs are at the core of psychiatric practice. Our patients are often shackled by their anomalous beliefs, which are not reality-based. These beliefs are often the primary targets of psychiatric treatment. Consider a day at the office of a psychiatrist who may see several patients impaired by false beliefs, such as:

• My neighbor is reading my mind remotely and is plotting to kill me
• If I ride on a plane, it will crash and I will die
• I am a failure, a worthless person, and a burden on my family
• I am hopeless and helpless; life is too painful and not worth living anymore
• I am a prophet with supernatural gifts, and I can predict the future
• Whenever I take this substance, I feel I can jump out of a window and fly
• If I do not shower 5 times in a row every night before going to bed, something terrible will happen to my family.

Patients with false beliefs obviously need psychiatric care. However, a large number of religious individuals harbor “unusual” beliefs involving angels and devils and hell and paradise after death. Those people of faith are not considered to have a DSM-5 psychiatric disorder. Billions of people around the world belong to one of the approximately 4,300 religions, which they celebrate using one of the more than 6,800 living languages. Psychiatrists encourage patients to have a faith because it can be quite comforting to its adherents, enhancing their social relations and providing them with hope and resilience during the darkest days of life. Regular attendance at a house of worship is a measure of the strong roots of one’s faith.

So why have there been so many religious wars over centuries of recorded history? Why have millions of people died during conflicts among religions? Why does one religious group adamantly believe that theirs is the real God, while the god of other religions is fake? And why have people who withdrew from or refused to adopt a certain religious belief been persecuted; labeled as “heretic,” “infidel,” “heathen,” or “apostate”; and burned at the stake or beheaded? Perhaps religion is not always a kinder, gentler belief system.

Continue to: Recent statistics...

Recent statistics show a precipitous decline in religious observance in the United States.¹ So what happens to a society that gradually abandons its previously entrenched religious beliefs and becomes secular? This trend is spreading widely in Europe and North America. But widely held beliefs with powerful personal meaning don’t just fizzle away: they re-emerge in another form. The substantial energy of religious faith must be invested elsewhere and manifested in an alternative form with similar dynamics.

Enter politics!

It seems that humans’ need to uphold a strong belief is so powerful that they either incorporate political doctrines side-by-side with their religious beliefs (if the 2 are compatible) or adopt a strong political belief if they abandon their religion and become secular. This does not have to be an intellectually wrenching change because there are many similarities between hyper-religiosity and fanatic political beliefs (Table).

The toxic hyperpartisanship that has dominated the United States over the past several years may be the culmination of an intensified “religification” of politics. The incendiary mix of religious zealotry and political fanaticism is conducive to intensified loathing, hostility, and animus to those with an opposing political ideology.

So it all boils down to the human imperative of harboring a strong personal belief. What is the origin of beliefs, religious, political, or otherwise? Why does the human species have the overwhelming need to uphold a belief? Research suggests that it is the result of evolution and the phylogenetic enlargement of the brain, including the parietal and medial frontal cortex in humans.² And according to many studies, abnormal and delusional beliefs encountered in psychiatric practice appear to be caused by altered perception and/or misattribution of aversive meaning.³ Lesions in the right hemisphere have been reported to play an important role in generating delusional beliefs.⁴ A healthy right hemisphere plays an important role in:

• pragmatic communications
• perceptual integration
• attentional surveillance and anomaly novelty detection
• belief updating.⁴

Right hemispheric pathology disrupts those functions and can lead to false beliefs such as delusions, or, on a milder scale, strongly held superstitions.

One wonders how the structure and function of the right hemisphere generates and perpetuates a belief in a religion or political ideology that ultimately shapes one’s life. Religiosity and politics are an inherent part of human nature, and they can replace each other or merge together. If one is to believe what Durkheim⁵ proposed more than a century ago, the existence of belief systems is essential for societal stability. He posited that the absence of stable belief systems can lead to what he labeled “anomie,” leading to a surge of suicide and crime. If that is true, then the coexistence of religious and political beliefs may have a significant upside, but also with a palpable downside when either or both of those belief systems become excessively antagonistic or extreme. Three cheers for religious and political moderation that allows them to peacefully coexist.

Benefits of early LAI use

I want to thank Dr. Nasrallah for his editorial calling for more frequent and earlier use of long-acting injectable antipsychotics (LAIs) in schizophrenia (From the Editor, Current Psychiatry, May 2021, p. 9-12). I consider LAIs to be lifesaving interventions, so I’ve offered LAI administration via a drive-up service over the past year to ensure patients could continue to receive their treatment, even through the worst times of the COVID-19 pandemic.¹ LAIs can be beneficial for anyone living with schizophrenia, but are never more important than in first-episode psychosis (FEP), when repeated psychotic relapses have not yet ravaged the brain. Earlier aggressive treatment of FEP and subsequent relapses with LAIs can dramatically improve long-term outcomes for people with schizophrenia.

In addition to the neuroprotective biologic effects of early LAI usage, I’ve found that many of my FEP patients find great psychological comfort from incorporating LAIs into their treatment plan. The first psychotic break is generally when a person (and their family) feels the most afraid about the future and is in desperate need of hope that they can have a full life—with educational opportunities, sustained employment, meaningful relationships, and more. Just as society has seen the COVID-19 vaccines as a symbol of hope and the first step in overcoming the oppression of living in fear of an uncertain future, we need to help people experiencing FEP find hope in a needle.

Craig Chepke, MD, FAPA
Excel Psychiatric Associates
Huntersville, North Carolina

Reference

1. Chepke C. Drive-up pharmacotherapy during the COVID-19 pandemic. Current Psychiatry. 2020;19(5):29-30.

Dr. Nasrallah responds

Thank you, Dr. Chepke, for your letter confirming full support for using LAIs in schizophrenia. I like the phrase you coined: “hope in a needle.” The early use of LAIs in schizophrenia can provide the same type of hope that the vaccines against the life-threatening COVID-19 virus have generated in our society. Based on my direct observations, I also agree with you that the longer patients with schizophrenia remain on LAIs, the more engaged and happy they are with their progress and the quality of their lives. It is tragic that many patients never had the opportunity to return to their baseline with the early use of LAIs immediately following their first psychotic episode, instead of relapsing again and again due to their inability to adhere completely to their oral medications.

Henry A. Nasrallah, MD
Editor-In-Chief

Continue to: LAIs as the standard of care

 

 

LAIs as the standard of care

Thank you, Dr. Nasrallah, for reiterating the importance of compliance with pharmacologic management of schizophrenia after FEP (From the Editor, Current Psychiatry, May 2021, p. 9-12). Long before LAIs, I appreciated the successes patients with schizophrenia experienced when they complied with treatment after the first episode. It was clear that success was forthcoming for patients who had an interested psychiatrist and a committed relationship with them.

As you point out in your editorial, the facts are powerful, well-known, undisputed, and yet not adopted in the United States, when in other countries LAIs are first-line care. Yes, LAIs are expensive, but not nearly as expensive as the disabilities caused by noncompliance are to society.

Why isn’t LAI use the standard of care here in the United States? In the United States, there is advocacy for treatment because there’s money in it. There is no good advocacy for preventive care because there’s no immediate money in it. We have another good example of this in the United States: private, for-profit prisons. They have a vested interest in keeping prisons full and building new ones. Patients with FEP are most often treated in the hospital, where a standard of care could easily be established that mandates LAIs as first-tier care. Why is that not so? Who is pushing for it? Who is resisting?

Your editorial inspired me to advocate more strongly. Do you have advice about how to effect policy change? I know administrators respond when we talk dollars and cents, not quality of care. What is the dollar cost of not using LAIs as the standard of care after FEP? Who cares? Who would listen to the numbers?

Edward A. Major, MD, LFAPA
Clinical Professor of Psychiatry
Upstate Medical Center
Syracuse, New York

Dr. Nasrallah responds

Dr. Major, thanks for your message. Establishing a standard of care for the use of LAIs (or any other therapy) is not that simple. It requires well-coordinated collaboration among several stakeholders (clinicians, researchers, payors, advocacy groups, and a national organization such as the American Psychiatric Association). The cost issue is certainly powerful, but the equation works in favor of LAIs because 1 psychiatric hospitalization due to a psychotic relapse costs up to 3 times the annual cost of an LAI medication that can prevent that rehospitalization. In addition, disability comprises the lion’s share of the large indirect costs of schizophrenia (disability payments, lifetime room and board, incarceration and legal costs, and loss of work and generation of taxes). LAIs can save both lives and expenditures, and a lot of suffering by patients and their families. I, too, long to see the emergence of a rational standard of care for schizophrenia using LAIs right after the initial psychotic episode. Oncology and cardiology have standards of care, so why not psychiatry?

Henry A. Nasrallah, MD
Editor-In-Chief

Continue to: Psychosis and epilepsy

 

 

Psychosis and epilepsy

I just read your editorial regarding the devastating consequences of psychotic relapses (From the Editor, Current Psychiatry, May 2021, p. 9-12). I was shocked to read of the extent of the damage caused by such relapses and the positive impact of LAIs, and I thank you for opening my eyes. 

I work in the spheres of psychiatry, epileptology, and whole genome sequencing, and have experienced a psychotic episode myself (in 2013, after temporal lobe resection and overdose). I now consider myself even more lucky to be out the other side! As Governor for South London and Maudsley NHS Foundation Trust (SLaM) and Trustee for Epilepsy Action, many of our patients have psychosis. Some patients with epilepsy even experience postictal psychosis. Just yesterday, we had a call at SLaM regarding patients from a secure unit, and a psychiatric nurse spoke about patients at risk to themselves and others because of their psychotic illness, and how crucial effective long-term care was.

Torie Robinson
CEO, Epilepsy Sparks

Dr. Nasrallah responds

Ms. Robinson, thank you for sharing your story. It is important to note that the neuro­biology of the psychosis that may occur with epilepsy may not be as neurodegenerative as the psychosis of schizophrenia. Many neurologic conditions can be associated with psychotic episodes, not only epilepsy. I am glad you overcame your post-temporal lobectomy psychotic episode and have had a very good outcome with high functioning.

Henry A. Nasrallah, MD
Editor-In-Chief

Disclosures
Dr. Chepke is a consultant to and speaker for Janssen Pharmaceuticals, Otsuka Pharmaceuticals, and Alkermes. The other authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

Benefits of early LAI use

I want to thank Dr. Nasrallah for his editorial calling for more frequent and earlier use of long-acting injectable antipsychotics (LAIs) in schizophrenia (From the Editor, Current Psychiatry, May 2021, p. 9-12). I consider LAIs to be lifesaving interventions, so I’ve offered LAI administration via a drive-up service over the past year to ensure patients could continue to receive their treatment, even through the worst times of the COVID-19 pandemic.¹ LAIs can be beneficial for anyone living with schizophrenia, but are never more important than in first-episode psychosis (FEP), when repeated psychotic relapses have not yet ravaged the brain. Earlier aggressive treatment of FEP and subsequent relapses with LAIs can dramatically improve long-term outcomes for people with schizophrenia.

In addition to the neuroprotective biologic effects of early LAI usage, I’ve found that many of my FEP patients find great psychological comfort from incorporating LAIs into their treatment plan. The first psychotic break is generally when a person (and their family) feels the most afraid about the future and is in desperate need of hope that they can have a full life—with educational opportunities, sustained employment, meaningful relationships, and more. Just as society has seen the COVID-19 vaccines as a symbol of hope and the first step in overcoming the oppression of living in fear of an uncertain future, we need to help people experiencing FEP find hope in a needle.

Craig Chepke, MD, FAPA
Excel Psychiatric Associates
Huntersville, North Carolina

Reference

1. Chepke C. Drive-up pharmacotherapy during the COVID-19 pandemic. Current Psychiatry. 2020;19(5):29-30.

Dr. Nasrallah responds

Thank you, Dr. Chepke, for your letter confirming full support for using LAIs in schizophrenia. I like the phrase you coined: “hope in a needle.” The early use of LAIs in schizophrenia can provide the same type of hope that the vaccines against the life-threatening COVID-19 virus have generated in our society. Based on my direct observations, I also agree with you that the longer patients with schizophrenia remain on LAIs, the more engaged and happy they are with their progress and the quality of their lives. It is tragic that many patients never had the opportunity to return to their baseline with the early use of LAIs immediately following their first psychotic episode, instead of relapsing again and again due to their inability to adhere completely to their oral medications.

Henry A. Nasrallah, MD
Editor-In-Chief

Continue to: LAIs as the standard of care

 

 

LAIs as the standard of care

Thank you, Dr. Nasrallah, for reiterating the importance of compliance with pharmacologic management of schizophrenia after FEP (From the Editor, Current Psychiatry, May 2021, p. 9-12). Long before LAIs, I appreciated the successes patients with schizophrenia experienced when they complied with treatment after the first episode. It was clear that success was forthcoming for patients who had an interested psychiatrist and a committed relationship with them.

As you point out in your editorial, the facts are powerful, well-known, undisputed, and yet not adopted in the United States, when in other countries LAIs are first-line care. Yes, LAIs are expensive, but not nearly as expensive as the disabilities caused by noncompliance are to society.

Why isn’t LAI use the standard of care here in the United States? In the United States, there is advocacy for treatment because there’s money in it. There is no good advocacy for preventive care because there’s no immediate money in it. We have another good example of this in the United States: private, for-profit prisons. They have a vested interest in keeping prisons full and building new ones. Patients with FEP are most often treated in the hospital, where a standard of care could easily be established that mandates LAIs as first-tier care. Why is that not so? Who is pushing for it? Who is resisting?

Your editorial inspired me to advocate more strongly. Do you have advice about how to effect policy change? I know administrators respond when we talk dollars and cents, not quality of care. What is the dollar cost of not using LAIs as the standard of care after FEP? Who cares? Who would listen to the numbers?

Edward A. Major, MD, LFAPA
Clinical Professor of Psychiatry
Upstate Medical Center
Syracuse, New York

Dr. Nasrallah responds

Dr. Major, thanks for your message. Establishing a standard of care for the use of LAIs (or any other therapy) is not that simple. It requires well-coordinated collaboration among several stakeholders (clinicians, researchers, payors, advocacy groups, and a national organization such as the American Psychiatric Association). The cost issue is certainly powerful, but the equation works in favor of LAIs because 1 psychiatric hospitalization due to a psychotic relapse costs up to 3 times the annual cost of an LAI medication that can prevent that rehospitalization. In addition, disability comprises the lion’s share of the large indirect costs of schizophrenia (disability payments, lifetime room and board, incarceration and legal costs, and loss of work and generation of taxes). LAIs can save both lives and expenditures, and a lot of suffering by patients and their families. I, too, long to see the emergence of a rational standard of care for schizophrenia using LAIs right after the initial psychotic episode. Oncology and cardiology have standards of care, so why not psychiatry?

Henry A. Nasrallah, MD
Editor-In-Chief

Continue to: Psychosis and epilepsy

 

 

Psychosis and epilepsy

I just read your editorial regarding the devastating consequences of psychotic relapses (From the Editor, Current Psychiatry, May 2021, p. 9-12). I was shocked to read of the extent of the damage caused by such relapses and the positive impact of LAIs, and I thank you for opening my eyes. 

I work in the spheres of psychiatry, epileptology, and whole genome sequencing, and have experienced a psychotic episode myself (in 2013, after temporal lobe resection and overdose). I now consider myself even more lucky to be out the other side! As Governor for South London and Maudsley NHS Foundation Trust (SLaM) and Trustee for Epilepsy Action, many of our patients have psychosis. Some patients with epilepsy even experience postictal psychosis. Just yesterday, we had a call at SLaM regarding patients from a secure unit, and a psychiatric nurse spoke about patients at risk to themselves and others because of their psychotic illness, and how crucial effective long-term care was.

Torie Robinson
CEO, Epilepsy Sparks

Dr. Nasrallah responds

Ms. Robinson, thank you for sharing your story. It is important to note that the neuro­biology of the psychosis that may occur with epilepsy may not be as neurodegenerative as the psychosis of schizophrenia. Many neurologic conditions can be associated with psychotic episodes, not only epilepsy. I am glad you overcame your post-temporal lobectomy psychotic episode and have had a very good outcome with high functioning.

Henry A. Nasrallah, MD
Editor-In-Chief

Disclosures
Dr. Chepke is a consultant to and speaker for Janssen Pharmaceuticals, Otsuka Pharmaceuticals, and Alkermes. The other authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

Benefits of early LAI use

I want to thank Dr. Nasrallah for his editorial calling for more frequent and earlier use of long-acting injectable antipsychotics (LAIs) in schizophrenia (From the Editor, Current Psychiatry, May 2021, p. 9-12). I consider LAIs to be lifesaving interventions, so I’ve offered LAI administration via a drive-up service over the past year to ensure patients could continue to receive their treatment, even through the worst times of the COVID-19 pandemic.¹ LAIs can be beneficial for anyone living with schizophrenia, but are never more important than in first-episode psychosis (FEP), when repeated psychotic relapses have not yet ravaged the brain. Earlier aggressive treatment of FEP and subsequent relapses with LAIs can dramatically improve long-term outcomes for people with schizophrenia.

In addition to the neuroprotective biologic effects of early LAI usage, I’ve found that many of my FEP patients find great psychological comfort from incorporating LAIs into their treatment plan. The first psychotic break is generally when a person (and their family) feels the most afraid about the future and is in desperate need of hope that they can have a full life—with educational opportunities, sustained employment, meaningful relationships, and more. Just as society has seen the COVID-19 vaccines as a symbol of hope and the first step in overcoming the oppression of living in fear of an uncertain future, we need to help people experiencing FEP find hope in a needle.

Craig Chepke, MD, FAPA
Excel Psychiatric Associates
Huntersville, North Carolina

Reference

1. Chepke C. Drive-up pharmacotherapy during the COVID-19 pandemic. Current Psychiatry. 2020;19(5):29-30.

Dr. Nasrallah responds

Thank you, Dr. Chepke, for your letter confirming full support for using LAIs in schizophrenia. I like the phrase you coined: “hope in a needle.” The early use of LAIs in schizophrenia can provide the same type of hope that the vaccines against the life-threatening COVID-19 virus have generated in our society. Based on my direct observations, I also agree with you that the longer patients with schizophrenia remain on LAIs, the more engaged and happy they are with their progress and the quality of their lives. It is tragic that many patients never had the opportunity to return to their baseline with the early use of LAIs immediately following their first psychotic episode, instead of relapsing again and again due to their inability to adhere completely to their oral medications.

Henry A. Nasrallah, MD
Editor-In-Chief

Continue to: LAIs as the standard of care

 

 

LAIs as the standard of care

Thank you, Dr. Nasrallah, for reiterating the importance of compliance with pharmacologic management of schizophrenia after FEP (From the Editor, Current Psychiatry, May 2021, p. 9-12). Long before LAIs, I appreciated the successes patients with schizophrenia experienced when they complied with treatment after the first episode. It was clear that success was forthcoming for patients who had an interested psychiatrist and a committed relationship with them.

As you point out in your editorial, the facts are powerful, well-known, undisputed, and yet not adopted in the United States, when in other countries LAIs are first-line care. Yes, LAIs are expensive, but not nearly as expensive as the disabilities caused by noncompliance are to society.

Why isn’t LAI use the standard of care here in the United States? In the United States, there is advocacy for treatment because there’s money in it. There is no good advocacy for preventive care because there’s no immediate money in it. We have another good example of this in the United States: private, for-profit prisons. They have a vested interest in keeping prisons full and building new ones. Patients with FEP are most often treated in the hospital, where a standard of care could easily be established that mandates LAIs as first-tier care. Why is that not so? Who is pushing for it? Who is resisting?

Your editorial inspired me to advocate more strongly. Do you have advice about how to effect policy change? I know administrators respond when we talk dollars and cents, not quality of care. What is the dollar cost of not using LAIs as the standard of care after FEP? Who cares? Who would listen to the numbers?

Edward A. Major, MD, LFAPA
Clinical Professor of Psychiatry
Upstate Medical Center
Syracuse, New York

Dr. Nasrallah responds

Dr. Major, thanks for your message. Establishing a standard of care for the use of LAIs (or any other therapy) is not that simple. It requires well-coordinated collaboration among several stakeholders (clinicians, researchers, payors, advocacy groups, and a national organization such as the American Psychiatric Association). The cost issue is certainly powerful, but the equation works in favor of LAIs because 1 psychiatric hospitalization due to a psychotic relapse costs up to 3 times the annual cost of an LAI medication that can prevent that rehospitalization. In addition, disability comprises the lion’s share of the large indirect costs of schizophrenia (disability payments, lifetime room and board, incarceration and legal costs, and loss of work and generation of taxes). LAIs can save both lives and expenditures, and a lot of suffering by patients and their families. I, too, long to see the emergence of a rational standard of care for schizophrenia using LAIs right after the initial psychotic episode. Oncology and cardiology have standards of care, so why not psychiatry?

Henry A. Nasrallah, MD
Editor-In-Chief

Continue to: Psychosis and epilepsy

 

 

Psychosis and epilepsy

I just read your editorial regarding the devastating consequences of psychotic relapses (From the Editor, Current Psychiatry, May 2021, p. 9-12). I was shocked to read of the extent of the damage caused by such relapses and the positive impact of LAIs, and I thank you for opening my eyes. 

I work in the spheres of psychiatry, epileptology, and whole genome sequencing, and have experienced a psychotic episode myself (in 2013, after temporal lobe resection and overdose). I now consider myself even more lucky to be out the other side! As Governor for South London and Maudsley NHS Foundation Trust (SLaM) and Trustee for Epilepsy Action, many of our patients have psychosis. Some patients with epilepsy even experience postictal psychosis. Just yesterday, we had a call at SLaM regarding patients from a secure unit, and a psychiatric nurse spoke about patients at risk to themselves and others because of their psychotic illness, and how crucial effective long-term care was.

Torie Robinson
CEO, Epilepsy Sparks

Dr. Nasrallah responds

Ms. Robinson, thank you for sharing your story. It is important to note that the neuro­biology of the psychosis that may occur with epilepsy may not be as neurodegenerative as the psychosis of schizophrenia. Many neurologic conditions can be associated with psychotic episodes, not only epilepsy. I am glad you overcame your post-temporal lobectomy psychotic episode and have had a very good outcome with high functioning.

Henry A. Nasrallah, MD
Editor-In-Chief

Disclosures
Dr. Chepke is a consultant to and speaker for Janssen Pharmaceuticals, Otsuka Pharmaceuticals, and Alkermes. The other authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.

The impact of the COVID-19 pandemic on the well-being of youth has been significant. Its possible effects range from boredom, depression, anxiety, and suicidal ideation to potential increased rates of internet gaming disorder (IGD), which may have worsened during a nationwide shutdown and extended period of limited social interactions. Presently, there is a paucity of research on the impact of internet gaming on children and adolescents’ mental health and well-being during COVID-19. This article aims to bring awareness to the possible rising impact of the COVID-19 pandemic on IGD and mental health in youth.

Gaming offers benefits—and risks

The gaming industry has grown immensely over the past several years. While many businesses were impacted negatively during the pandemic, the gaming industry grew. It was estimated to be worth $159.3 billion in 2020, an increase of 9.3% from 2019.¹

Stay-at-home orders and quarantine protocols during the COVID-19 pandemic have significantly disrupted normal activities, resulting in increased time for digital entertainment, including online gaming and related activities. Internet gaming offers some benefits for children and adolescents, including socialization and connection with peers, which was especially important for avoiding isolation during the pandemic. Empirical evidence of the positive effects of internet gaming can be seen in studies of youth undergoing chemotherapy, those receiving psychotherapy for anxiety or depression, and those having emotional and behavioral problems.² Internet gaming also provides participants with a platform to communicate with the outside world while maintaining social distancing, and might reduce anxiety, and in some cases, depression.³

Despite these benefits, for some youth, excessive internet gaming can have adverse effects. Due to its addictive properties, internet gaming can be dangerous for vulnerable individuals and lead to unhealthy habits, such as disturbed sleep patterns and increased anxiety.⁴ In a cross-sectional study conducted in China, Yu et al⁵ examined the association between IGD and suicidal ideation. They concluded that IGD was positively associated with insomnia and then depression, which in turn contributed to suicide ideation.⁵ A study based on a survey conducted in Iran from May to August 2020 in individuals age 13 to 18 years found that depression, anxiety, and stress were significant mediators in the association between IGD and self-reported quality of life.²

Internet gaming disorder is included in DSM-5 as a “condition for further study” and in ICD-11.⁶ Before the COVID-19 pandemic, a study of 1,178 American youth age 8 to 18 years revealed that 8.5% of gamers met the criteria for IGD.⁷ In a meta-analysis that included 16 studies, the pooled prevalence of IGD among adolescents was 4.6%.⁸ Some countries, including China and South Korea, have developed treatment plans for IGD,⁶ but in the United States treatment guidelines have not been established due to insufficient evidence.⁹

The COVID-19 pandemic has likely led to an increased number of children and adolescents with IGD and its adverse effects on their mental health and well-being. It remains to be seen whether these youth will improve as the pandemic resolves and they resume normal activities, or if impairments will persist.

In conclusion, while internet gaming during the COVID-19 pandemic has provided benefits for many children and adolescents, the negative impact for those who develop IGD may be significant. We should be prepared to detect and address the needs of these youth and their families. Additional research is needed on the post-pandemic prevalence of IGD, its impact on youth mental health, and treatment strategies.

The impact of the COVID-19 pandemic on the well-being of youth has been significant. Its possible effects range from boredom, depression, anxiety, and suicidal ideation to potential increased rates of internet gaming disorder (IGD), which may have worsened during a nationwide shutdown and extended period of limited social interactions. Presently, there is a paucity of research on the impact of internet gaming on children and adolescents’ mental health and well-being during COVID-19. This article aims to bring awareness to the possible rising impact of the COVID-19 pandemic on IGD and mental health in youth.

Gaming offers benefits—and risks

The gaming industry has grown immensely over the past several years. While many businesses were impacted negatively during the pandemic, the gaming industry grew. It was estimated to be worth $159.3 billion in 2020, an increase of 9.3% from 2019.¹

Stay-at-home orders and quarantine protocols during the COVID-19 pandemic have significantly disrupted normal activities, resulting in increased time for digital entertainment, including online gaming and related activities. Internet gaming offers some benefits for children and adolescents, including socialization and connection with peers, which was especially important for avoiding isolation during the pandemic. Empirical evidence of the positive effects of internet gaming can be seen in studies of youth undergoing chemotherapy, those receiving psychotherapy for anxiety or depression, and those having emotional and behavioral problems.² Internet gaming also provides participants with a platform to communicate with the outside world while maintaining social distancing, and might reduce anxiety, and in some cases, depression.³

Despite these benefits, for some youth, excessive internet gaming can have adverse effects. Due to its addictive properties, internet gaming can be dangerous for vulnerable individuals and lead to unhealthy habits, such as disturbed sleep patterns and increased anxiety.⁴ In a cross-sectional study conducted in China, Yu et al⁵ examined the association between IGD and suicidal ideation. They concluded that IGD was positively associated with insomnia and then depression, which in turn contributed to suicide ideation.⁵ A study based on a survey conducted in Iran from May to August 2020 in individuals age 13 to 18 years found that depression, anxiety, and stress were significant mediators in the association between IGD and self-reported quality of life.²

Internet gaming disorder is included in DSM-5 as a “condition for further study” and in ICD-11.⁶ Before the COVID-19 pandemic, a study of 1,178 American youth age 8 to 18 years revealed that 8.5% of gamers met the criteria for IGD.⁷ In a meta-analysis that included 16 studies, the pooled prevalence of IGD among adolescents was 4.6%.⁸ Some countries, including China and South Korea, have developed treatment plans for IGD,⁶ but in the United States treatment guidelines have not been established due to insufficient evidence.⁹

The COVID-19 pandemic has likely led to an increased number of children and adolescents with IGD and its adverse effects on their mental health and well-being. It remains to be seen whether these youth will improve as the pandemic resolves and they resume normal activities, or if impairments will persist.

In conclusion, while internet gaming during the COVID-19 pandemic has provided benefits for many children and adolescents, the negative impact for those who develop IGD may be significant. We should be prepared to detect and address the needs of these youth and their families. Additional research is needed on the post-pandemic prevalence of IGD, its impact on youth mental health, and treatment strategies.

The impact of the COVID-19 pandemic on the well-being of youth has been significant. Its possible effects range from boredom, depression, anxiety, and suicidal ideation to potential increased rates of internet gaming disorder (IGD), which may have worsened during a nationwide shutdown and extended period of limited social interactions. Presently, there is a paucity of research on the impact of internet gaming on children and adolescents’ mental health and well-being during COVID-19. This article aims to bring awareness to the possible rising impact of the COVID-19 pandemic on IGD and mental health in youth.

Gaming offers benefits—and risks

The gaming industry has grown immensely over the past several years. While many businesses were impacted negatively during the pandemic, the gaming industry grew. It was estimated to be worth $159.3 billion in 2020, an increase of 9.3% from 2019.¹

Stay-at-home orders and quarantine protocols during the COVID-19 pandemic have significantly disrupted normal activities, resulting in increased time for digital entertainment, including online gaming and related activities. Internet gaming offers some benefits for children and adolescents, including socialization and connection with peers, which was especially important for avoiding isolation during the pandemic. Empirical evidence of the positive effects of internet gaming can be seen in studies of youth undergoing chemotherapy, those receiving psychotherapy for anxiety or depression, and those having emotional and behavioral problems.² Internet gaming also provides participants with a platform to communicate with the outside world while maintaining social distancing, and might reduce anxiety, and in some cases, depression.³

Despite these benefits, for some youth, excessive internet gaming can have adverse effects. Due to its addictive properties, internet gaming can be dangerous for vulnerable individuals and lead to unhealthy habits, such as disturbed sleep patterns and increased anxiety.⁴ In a cross-sectional study conducted in China, Yu et al⁵ examined the association between IGD and suicidal ideation. They concluded that IGD was positively associated with insomnia and then depression, which in turn contributed to suicide ideation.⁵ A study based on a survey conducted in Iran from May to August 2020 in individuals age 13 to 18 years found that depression, anxiety, and stress were significant mediators in the association between IGD and self-reported quality of life.²

Internet gaming disorder is included in DSM-5 as a “condition for further study” and in ICD-11.⁶ Before the COVID-19 pandemic, a study of 1,178 American youth age 8 to 18 years revealed that 8.5% of gamers met the criteria for IGD.⁷ In a meta-analysis that included 16 studies, the pooled prevalence of IGD among adolescents was 4.6%.⁸ Some countries, including China and South Korea, have developed treatment plans for IGD,⁶ but in the United States treatment guidelines have not been established due to insufficient evidence.⁹

The COVID-19 pandemic has likely led to an increased number of children and adolescents with IGD and its adverse effects on their mental health and well-being. It remains to be seen whether these youth will improve as the pandemic resolves and they resume normal activities, or if impairments will persist.

In conclusion, while internet gaming during the COVID-19 pandemic has provided benefits for many children and adolescents, the negative impact for those who develop IGD may be significant. We should be prepared to detect and address the needs of these youth and their families. Additional research is needed on the post-pandemic prevalence of IGD, its impact on youth mental health, and treatment strategies.