Punch biopsies from the right axilla (Figure) and right abdomen as well as a tangential biopsy from the left volar wrist papule showed an interstitial histiocytic infiltrate with focal palisading of histiocytes around central regions with collagen alteration and increased mucin. Grocott-Gomori methenamine-silver stain and acid-fast bacilli smear both were negative for organisms; these findings were consistent with a diagnosis of granuloma annulare (GA).

Granuloma annulare is a noninfectious granulomatous disease of unknown etiology. It most commonly appears as asymptomatic, flesh-colored, pink or violaceous annular patches or thin plaques favoring the trunk and extremities. Granuloma annulare has many documented presentations including generalized, patch, subcutaneous, and perforating forms. It can present as macules, papules, nodules, patches, or plaques. Reported associations include diabetes mellitus, hyperlipidemia, solid organ tumors, systemic infection, and thyroid disease.¹ Granuloma annulare can occur in any age group but is most common between the ages of 20 and 40 years.²

Diagnosis most often is made clinically and can be confirmed by histopathology. Histologic examination most commonly shows histiocytes within the dermis that palisade around a central area of mucin deposition between degenerating collagen fibers. The histiocytes of GA stain positive with vimentin, lysozyme, and CD68. The increased mucin stains with colloidal iron and Alcian blue. Multinucleated giant cells and perivascular lymphocytic infiltrate also are commonly seen.³

Cutaneous B-cell lymphoma has a wide range of presentations but usually occurs as hyperpigmented plaques and patches with dermal atrophy. Psoriasis can present in an inverse distribution but will show epidermal changes including scale. Sarcoidosis presents as multiple erythematous plaques and papules and also can be accompanied by erythema nodosum. Tinea corporis likely would have resolved with antifungal treatment.

Many different treatments have been described as effective, including cryosurgery, topical and intralesional corticosteroids, antibiotics, immune modulators, phototherapy, and oral corticosteroids.¹ We started our patient on triple-antibiotic therapy with rifampin 600 mg, minocycline 100 mg, and ofloxacin 400 mg all once monthly for 6 months, which has been shown to be efficacious in treating GA.⁴ The patient returned for follow-up 1 year after the initial presentation. At that time, she had faint pink patches on the waist and medial upper thighs, and the axillary lesions had cleared. In the interim, she developed more classic GA lesions—pink to violaceous smooth papules with no overlying epidermal changes—on the volar wrists and dorsal feet. These lesions were asymptomatic, and she currently is not undergoing any further treatment.

Punch biopsies from the right axilla (Figure) and right abdomen as well as a tangential biopsy from the left volar wrist papule showed an interstitial histiocytic infiltrate with focal palisading of histiocytes around central regions with collagen alteration and increased mucin. Grocott-Gomori methenamine-silver stain and acid-fast bacilli smear both were negative for organisms; these findings were consistent with a diagnosis of granuloma annulare (GA).

Granuloma annulare is a noninfectious granulomatous disease of unknown etiology. It most commonly appears as asymptomatic, flesh-colored, pink or violaceous annular patches or thin plaques favoring the trunk and extremities. Granuloma annulare has many documented presentations including generalized, patch, subcutaneous, and perforating forms. It can present as macules, papules, nodules, patches, or plaques. Reported associations include diabetes mellitus, hyperlipidemia, solid organ tumors, systemic infection, and thyroid disease.¹ Granuloma annulare can occur in any age group but is most common between the ages of 20 and 40 years.²

Diagnosis most often is made clinically and can be confirmed by histopathology. Histologic examination most commonly shows histiocytes within the dermis that palisade around a central area of mucin deposition between degenerating collagen fibers. The histiocytes of GA stain positive with vimentin, lysozyme, and CD68. The increased mucin stains with colloidal iron and Alcian blue. Multinucleated giant cells and perivascular lymphocytic infiltrate also are commonly seen.³

Cutaneous B-cell lymphoma has a wide range of presentations but usually occurs as hyperpigmented plaques and patches with dermal atrophy. Psoriasis can present in an inverse distribution but will show epidermal changes including scale. Sarcoidosis presents as multiple erythematous plaques and papules and also can be accompanied by erythema nodosum. Tinea corporis likely would have resolved with antifungal treatment.

Many different treatments have been described as effective, including cryosurgery, topical and intralesional corticosteroids, antibiotics, immune modulators, phototherapy, and oral corticosteroids.¹ We started our patient on triple-antibiotic therapy with rifampin 600 mg, minocycline 100 mg, and ofloxacin 400 mg all once monthly for 6 months, which has been shown to be efficacious in treating GA.⁴ The patient returned for follow-up 1 year after the initial presentation. At that time, she had faint pink patches on the waist and medial upper thighs, and the axillary lesions had cleared. In the interim, she developed more classic GA lesions—pink to violaceous smooth papules with no overlying epidermal changes—on the volar wrists and dorsal feet. These lesions were asymptomatic, and she currently is not undergoing any further treatment.

Punch biopsies from the right axilla (Figure) and right abdomen as well as a tangential biopsy from the left volar wrist papule showed an interstitial histiocytic infiltrate with focal palisading of histiocytes around central regions with collagen alteration and increased mucin. Grocott-Gomori methenamine-silver stain and acid-fast bacilli smear both were negative for organisms; these findings were consistent with a diagnosis of granuloma annulare (GA).

Granuloma annulare is a noninfectious granulomatous disease of unknown etiology. It most commonly appears as asymptomatic, flesh-colored, pink or violaceous annular patches or thin plaques favoring the trunk and extremities. Granuloma annulare has many documented presentations including generalized, patch, subcutaneous, and perforating forms. It can present as macules, papules, nodules, patches, or plaques. Reported associations include diabetes mellitus, hyperlipidemia, solid organ tumors, systemic infection, and thyroid disease.¹ Granuloma annulare can occur in any age group but is most common between the ages of 20 and 40 years.²

Diagnosis most often is made clinically and can be confirmed by histopathology. Histologic examination most commonly shows histiocytes within the dermis that palisade around a central area of mucin deposition between degenerating collagen fibers. The histiocytes of GA stain positive with vimentin, lysozyme, and CD68. The increased mucin stains with colloidal iron and Alcian blue. Multinucleated giant cells and perivascular lymphocytic infiltrate also are commonly seen.³

Cutaneous B-cell lymphoma has a wide range of presentations but usually occurs as hyperpigmented plaques and patches with dermal atrophy. Psoriasis can present in an inverse distribution but will show epidermal changes including scale. Sarcoidosis presents as multiple erythematous plaques and papules and also can be accompanied by erythema nodosum. Tinea corporis likely would have resolved with antifungal treatment.

Many different treatments have been described as effective, including cryosurgery, topical and intralesional corticosteroids, antibiotics, immune modulators, phototherapy, and oral corticosteroids.¹ We started our patient on triple-antibiotic therapy with rifampin 600 mg, minocycline 100 mg, and ofloxacin 400 mg all once monthly for 6 months, which has been shown to be efficacious in treating GA.⁴ The patient returned for follow-up 1 year after the initial presentation. At that time, she had faint pink patches on the waist and medial upper thighs, and the axillary lesions had cleared. In the interim, she developed more classic GA lesions—pink to violaceous smooth papules with no overlying epidermal changes—on the volar wrists and dorsal feet. These lesions were asymptomatic, and she currently is not undergoing any further treatment.

Dr Stanley Cohen, of the University of Texas, Southwestern Medical School in Dallas, reviews key abstracts on the management of patients with rheumatoid arthritis (RA) that were presented at this year's American College of Rheumatology (ACR) annual meeting, held virtually because of COVID-19.

Dr Cohen highlights the updated ACR pharmacologic recommendations for the treatment of RA, including the need to maximize methotrexate therapy as well as the avoidance of glucocorticoids and their associated long-term toxicity.

Dr Cohen discusses two abstracts addressing the use of the recombinant zoster vaccine (RZV) in patients with RA, including research from Sweden comparing immunologic response in patients taking JAK inhibitors with that of patients not on disease-modifying therapy. He also reports on a safety study from the Cleveland Clinic which followed patients after they received RZV and measured their rate of flares over 3 months.

Additionally, he discusses recent trial data on the incidence of and risk for venous thromboembolism events in patients with RA enrolled in the upadacitinib phase 3 clinical trial program.

--

Stanley B. Cohen, MD, Clinical Professor, Department of Internal Medicine, Rheumatic Diseases Division, UT Southwestern Medical School; Director, Division of Rheumatology, Texas Health Resources, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.

Stanley B. Cohen, MD, has disclosed the following relevant financial relationships:
Received research grant from: Amgen; AbbVie; Genentech; Gilead; Pfizer; Roche.
 

Dr Stanley Cohen, of the University of Texas, Southwestern Medical School in Dallas, reviews key abstracts on the management of patients with rheumatoid arthritis (RA) that were presented at this year's American College of Rheumatology (ACR) annual meeting, held virtually because of COVID-19.

Dr Cohen highlights the updated ACR pharmacologic recommendations for the treatment of RA, including the need to maximize methotrexate therapy as well as the avoidance of glucocorticoids and their associated long-term toxicity.

Dr Cohen discusses two abstracts addressing the use of the recombinant zoster vaccine (RZV) in patients with RA, including research from Sweden comparing immunologic response in patients taking JAK inhibitors with that of patients not on disease-modifying therapy. He also reports on a safety study from the Cleveland Clinic which followed patients after they received RZV and measured their rate of flares over 3 months.

Additionally, he discusses recent trial data on the incidence of and risk for venous thromboembolism events in patients with RA enrolled in the upadacitinib phase 3 clinical trial program.

--

Stanley B. Cohen, MD, Clinical Professor, Department of Internal Medicine, Rheumatic Diseases Division, UT Southwestern Medical School; Director, Division of Rheumatology, Texas Health Resources, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.

Stanley B. Cohen, MD, has disclosed the following relevant financial relationships:
Received research grant from: Amgen; AbbVie; Genentech; Gilead; Pfizer; Roche.
 

Dr Stanley Cohen, of the University of Texas, Southwestern Medical School in Dallas, reviews key abstracts on the management of patients with rheumatoid arthritis (RA) that were presented at this year's American College of Rheumatology (ACR) annual meeting, held virtually because of COVID-19.

Dr Cohen highlights the updated ACR pharmacologic recommendations for the treatment of RA, including the need to maximize methotrexate therapy as well as the avoidance of glucocorticoids and their associated long-term toxicity.

Dr Cohen discusses two abstracts addressing the use of the recombinant zoster vaccine (RZV) in patients with RA, including research from Sweden comparing immunologic response in patients taking JAK inhibitors with that of patients not on disease-modifying therapy. He also reports on a safety study from the Cleveland Clinic which followed patients after they received RZV and measured their rate of flares over 3 months.

Additionally, he discusses recent trial data on the incidence of and risk for venous thromboembolism events in patients with RA enrolled in the upadacitinib phase 3 clinical trial program.

--

Stanley B. Cohen, MD, Clinical Professor, Department of Internal Medicine, Rheumatic Diseases Division, UT Southwestern Medical School; Director, Division of Rheumatology, Texas Health Resources, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.

Stanley B. Cohen, MD, has disclosed the following relevant financial relationships:
Received research grant from: Amgen; AbbVie; Genentech; Gilead; Pfizer; Roche.
 

Background: Heart failure is a known risk factor for postoperative mortality and complications. Many of the studies used to establish this association, however, have focused on major high-risk surgeries and not on outpatient surgeries. Improved medical care has increased the survival rate of patients with heart failure and an increasing number of these patients are undergoing elective surgical procedures. This has led to an increasing need to better understand the degree to which heart failure affects preoperative risk in the outpatient setting.

Study design: A retrospective cohort study.

Setting: Multiple Veteran’s Affairs Hospitals using data from the VA Surgical Quality Improvement Program (VASQIP) and the VA Corporate Data Warehouse.

Synopsis: A total of 355,121 patients who underwent outpatient surgeries were analyzed. 19,353 patients had heart failure and 334,768 did not. Patients with heart failure had a higher risk of 90-day mortality with an adjusted odds ratio of 1.95 (95% confidence interval, 1.69-2.44), and this risk progressively increased as the ejection fraction decreased. The risk of 30-day complication also increased in patients with heart failure with an adjusted OR of 1.10 (95% CI, 1.02-1.19).

Limitations of this study include the patient population, which were all veterans and mostly male. The nature of the inclusion criteria was limiting as well, in that all the patients in this study were deemed fit for surgery. There were no data available for patients who had been considered but ultimately did not undergo surgery or for patients who were considered for ambulatory surgery but ultimately underwent inpatient surgery. These limitations may have resulted in a selection bias, which limited the generalizability of the study’s findings when assessing patients for ambulatory surgery.

Bottom line: Patients with heart failure had a higher risk of 90-day postoperative mortality and 30-day postoperative complication in ambulatory noncardiac surgery. The risk of postoperative mortality increased as systolic function decreased.

Citation: Lerman BJ et al. Association between heart failure and postoperative mortality among patients undergoing ambulatory noncardiac surgery. JAMA Surg. 2019 Jul 10. doi: 10.1001/jamasurg.2019.2110.

Dr. Cheatham is a hospitalist and clinical educator at St. Louis University School of Medicine.

Background: Heart failure is a known risk factor for postoperative mortality and complications. Many of the studies used to establish this association, however, have focused on major high-risk surgeries and not on outpatient surgeries. Improved medical care has increased the survival rate of patients with heart failure and an increasing number of these patients are undergoing elective surgical procedures. This has led to an increasing need to better understand the degree to which heart failure affects preoperative risk in the outpatient setting.

Study design: A retrospective cohort study.

Setting: Multiple Veteran’s Affairs Hospitals using data from the VA Surgical Quality Improvement Program (VASQIP) and the VA Corporate Data Warehouse.

Synopsis: A total of 355,121 patients who underwent outpatient surgeries were analyzed. 19,353 patients had heart failure and 334,768 did not. Patients with heart failure had a higher risk of 90-day mortality with an adjusted odds ratio of 1.95 (95% confidence interval, 1.69-2.44), and this risk progressively increased as the ejection fraction decreased. The risk of 30-day complication also increased in patients with heart failure with an adjusted OR of 1.10 (95% CI, 1.02-1.19).

Limitations of this study include the patient population, which were all veterans and mostly male. The nature of the inclusion criteria was limiting as well, in that all the patients in this study were deemed fit for surgery. There were no data available for patients who had been considered but ultimately did not undergo surgery or for patients who were considered for ambulatory surgery but ultimately underwent inpatient surgery. These limitations may have resulted in a selection bias, which limited the generalizability of the study’s findings when assessing patients for ambulatory surgery.

Bottom line: Patients with heart failure had a higher risk of 90-day postoperative mortality and 30-day postoperative complication in ambulatory noncardiac surgery. The risk of postoperative mortality increased as systolic function decreased.

Citation: Lerman BJ et al. Association between heart failure and postoperative mortality among patients undergoing ambulatory noncardiac surgery. JAMA Surg. 2019 Jul 10. doi: 10.1001/jamasurg.2019.2110.

Dr. Cheatham is a hospitalist and clinical educator at St. Louis University School of Medicine.

Background: Heart failure is a known risk factor for postoperative mortality and complications. Many of the studies used to establish this association, however, have focused on major high-risk surgeries and not on outpatient surgeries. Improved medical care has increased the survival rate of patients with heart failure and an increasing number of these patients are undergoing elective surgical procedures. This has led to an increasing need to better understand the degree to which heart failure affects preoperative risk in the outpatient setting.

Study design: A retrospective cohort study.

Setting: Multiple Veteran’s Affairs Hospitals using data from the VA Surgical Quality Improvement Program (VASQIP) and the VA Corporate Data Warehouse.

Synopsis: A total of 355,121 patients who underwent outpatient surgeries were analyzed. 19,353 patients had heart failure and 334,768 did not. Patients with heart failure had a higher risk of 90-day mortality with an adjusted odds ratio of 1.95 (95% confidence interval, 1.69-2.44), and this risk progressively increased as the ejection fraction decreased. The risk of 30-day complication also increased in patients with heart failure with an adjusted OR of 1.10 (95% CI, 1.02-1.19).

Limitations of this study include the patient population, which were all veterans and mostly male. The nature of the inclusion criteria was limiting as well, in that all the patients in this study were deemed fit for surgery. There were no data available for patients who had been considered but ultimately did not undergo surgery or for patients who were considered for ambulatory surgery but ultimately underwent inpatient surgery. These limitations may have resulted in a selection bias, which limited the generalizability of the study’s findings when assessing patients for ambulatory surgery.

Bottom line: Patients with heart failure had a higher risk of 90-day postoperative mortality and 30-day postoperative complication in ambulatory noncardiac surgery. The risk of postoperative mortality increased as systolic function decreased.

Citation: Lerman BJ et al. Association between heart failure and postoperative mortality among patients undergoing ambulatory noncardiac surgery. JAMA Surg. 2019 Jul 10. doi: 10.1001/jamasurg.2019.2110.

Dr. Cheatham is a hospitalist and clinical educator at St. Louis University School of Medicine.

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To receive CME credit, please read the articles and go to www.omniaeducation.com/NIPT to access the post-test and evaluation.

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CME CREDITS: 1 CREDIT
To receive CME credit, please read the articles and go to www.omniaeducation.com/NIPT to access the post-test and evaluation.

The patient’s history of a rash that worsened with sweating and clinical findings of erythematous papulosquamous lesions was consistent with Grover disease, also known as transient acantholytic dermatosis. Typically, this is a short-lived condition; however, when symptoms have manifested for years, it is deemed persistent acantholytic dermatosis. The gold standard for diagnostic confirmation is a skin biopsy, although it can also be diagnosed clinically. Since the patient had previously received this diagnosis from another clinician, and his clinical presentation was consistent, a confirmatory biopsy was not performed.

The specific pathophysiology of acantholytic dermatosis is unclear. A study to assess for an autoimmune component found that all participants had autoantibodies that are reactive to proteins involved in cell development, activation, growth, death, adhesion, and motility. Another hypothesis involves occlusion of eccrine sweat glands.

Typical triggers are sweating, heat, sunlight, and mechanical irritation, although it can also be triggered by end-stage renal disease and solid organ transplantation. It has also been linked to certain drugs (eg, ribavirin, anastrozole), other skin diseases (eg, atopic dermatitis, xerosis cutis), bacterial/viral infections, and malignancies.

As heat and perspiration are common triggers, avoidance of activities that expose patients to these conditions is recommended. Otherwise, topical corticosteroids and emollients are the recommended first-line therapy, along with antihistamines to control itching. Other therapies include systemic corticosteroids, topical vitamin D analogs (eg, calcipotriene), systemic retinoids (acitretin or isotretinoin), phototherapy and photochemotherapy (PUVA), red-light 5-aminolevulinic acid photodynamic therapy (ALA-PDT), and etanercept.

Although the patient could not remember the name of the previously prescribed medication, his description suggested that a systemic retinoid had already been tried, with no improvement. Treatment with emollients and oral antihistamines was also unsuccessful, as was topical antiperspirants to control perspiration on his affected skin. The patient agreed to try topical calcipotriene twice daily. He also agreed to switch to a topical emollient containing ceramides.

‌

Image courtesy of Esther Walker, MD, and text courtesy of Esther Walker, MD, Department of Internal Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The patient’s history of a rash that worsened with sweating and clinical findings of erythematous papulosquamous lesions was consistent with Grover disease, also known as transient acantholytic dermatosis. Typically, this is a short-lived condition; however, when symptoms have manifested for years, it is deemed persistent acantholytic dermatosis. The gold standard for diagnostic confirmation is a skin biopsy, although it can also be diagnosed clinically. Since the patient had previously received this diagnosis from another clinician, and his clinical presentation was consistent, a confirmatory biopsy was not performed.

The specific pathophysiology of acantholytic dermatosis is unclear. A study to assess for an autoimmune component found that all participants had autoantibodies that are reactive to proteins involved in cell development, activation, growth, death, adhesion, and motility. Another hypothesis involves occlusion of eccrine sweat glands.

Typical triggers are sweating, heat, sunlight, and mechanical irritation, although it can also be triggered by end-stage renal disease and solid organ transplantation. It has also been linked to certain drugs (eg, ribavirin, anastrozole), other skin diseases (eg, atopic dermatitis, xerosis cutis), bacterial/viral infections, and malignancies.

As heat and perspiration are common triggers, avoidance of activities that expose patients to these conditions is recommended. Otherwise, topical corticosteroids and emollients are the recommended first-line therapy, along with antihistamines to control itching. Other therapies include systemic corticosteroids, topical vitamin D analogs (eg, calcipotriene), systemic retinoids (acitretin or isotretinoin), phototherapy and photochemotherapy (PUVA), red-light 5-aminolevulinic acid photodynamic therapy (ALA-PDT), and etanercept.

Although the patient could not remember the name of the previously prescribed medication, his description suggested that a systemic retinoid had already been tried, with no improvement. Treatment with emollients and oral antihistamines was also unsuccessful, as was topical antiperspirants to control perspiration on his affected skin. The patient agreed to try topical calcipotriene twice daily. He also agreed to switch to a topical emollient containing ceramides.

‌

Image courtesy of Esther Walker, MD, and text courtesy of Esther Walker, MD, Department of Internal Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The patient’s history of a rash that worsened with sweating and clinical findings of erythematous papulosquamous lesions was consistent with Grover disease, also known as transient acantholytic dermatosis. Typically, this is a short-lived condition; however, when symptoms have manifested for years, it is deemed persistent acantholytic dermatosis. The gold standard for diagnostic confirmation is a skin biopsy, although it can also be diagnosed clinically. Since the patient had previously received this diagnosis from another clinician, and his clinical presentation was consistent, a confirmatory biopsy was not performed.

The specific pathophysiology of acantholytic dermatosis is unclear. A study to assess for an autoimmune component found that all participants had autoantibodies that are reactive to proteins involved in cell development, activation, growth, death, adhesion, and motility. Another hypothesis involves occlusion of eccrine sweat glands.

Typical triggers are sweating, heat, sunlight, and mechanical irritation, although it can also be triggered by end-stage renal disease and solid organ transplantation. It has also been linked to certain drugs (eg, ribavirin, anastrozole), other skin diseases (eg, atopic dermatitis, xerosis cutis), bacterial/viral infections, and malignancies.

As heat and perspiration are common triggers, avoidance of activities that expose patients to these conditions is recommended. Otherwise, topical corticosteroids and emollients are the recommended first-line therapy, along with antihistamines to control itching. Other therapies include systemic corticosteroids, topical vitamin D analogs (eg, calcipotriene), systemic retinoids (acitretin or isotretinoin), phototherapy and photochemotherapy (PUVA), red-light 5-aminolevulinic acid photodynamic therapy (ALA-PDT), and etanercept.

Although the patient could not remember the name of the previously prescribed medication, his description suggested that a systemic retinoid had already been tried, with no improvement. Treatment with emollients and oral antihistamines was also unsuccessful, as was topical antiperspirants to control perspiration on his affected skin. The patient agreed to try topical calcipotriene twice daily. He also agreed to switch to a topical emollient containing ceramides.

‌

Image courtesy of Esther Walker, MD, and text courtesy of Esther Walker, MD, Department of Internal Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The numbers tell the story:

110,066 veterans diagnosed with COVID-19 as of November 30;

879,457 veterans and employees tested for COVID-19 as of November 6;

14,168 veterans admitted to a US Department of Veterans Affairs (VA) medical center for COVID-19 care;

1,525% increase in telehealth visits;

59,095 new staff hired to meet surge in demand for COVID-19 care;

75 completed Fourth Mission assignments; and

> 2,000 VA employees helping to support nonveteran patients and non-VA health care systems.

But those numbers are just some of the data in the COVID-19 Response Report, which the VA recently released. The report offers “an extensive look at VA’s complex COVID-19 response,” including how it prepared for the pandemic, the initial response, and key COVID-19 policies and directives.

The report was compiled from more than 90 interviews with health care leaders and stakeholders, along with documents and data pertaining to the Veterans Integrated Service Networks. The interviews were designed to “keep discussion at a strategic level.”

Meeting the crisis mandated that the Veterans Health Administration (VHA) act “with unity of effort and agility,” the authors note, across 18 networks with 170 medical centers. Not only is the VA called on to serve veterans, but its “Fourth Mission” explicitly calls on the VA to “improve the Nation’s preparedness for response to war, terrorism, national emergencies, and natural disasters.” But the VHA possessed some major assets, they add, including a nationwide capacity for inpatient health care, “considerable experience” generating and managing response to regional and local public health emergencies, and strong clinical processes focused on evidence-based guidelines. However, “[w]ithout national analytics of data from outbreaks in other nations, and without a national plan addressing the VHA role, forecasting demand for VHA inpatient services under the Fourth Mission required assumptions with a high degree of uncertainty.”

VHA planners adapted the existing High Consequence Infections Base Plan to COVID-19 and then developed the COVID-19 Response Plan as an annex to that. They released their plan to the public in the interest of a coordinated national response—although not all states were aware of VHA’s important safety-net capabilities. Despite that, the report says, during the pandemic, the mission assignments under the VA’s Fourth Mission have grown to the greatest scale and scope in the VA’s history.

“[H]ealth care in the United States will never be the same,” said Richard Stone, MD, VHA Executive in Charge, in his foreword to the report. Much of what we now consider routine, he said, such as parking lot screenings, digital questionnaires and rapid testing “were revolutionary and challenging to implement” when the pandemic began. “While we are certainly not perfect, we are a learning organization and seek to always find ways to improve.”

Identifying root causes for complex process problems is essential to improvement, the report authors say, and require “new knowledge.” To that end, the VA also has played a critical role in COVID-19–related research, participating in more than 90 and leading 28 multiple-site COVID-19 research studies, including research on 3D-printed respirator masks and convalescent plasma treatment.

The VA’s pandemic response has been “robust and far-reaching,” said VA Secretary Robert Wilkie. The report, he adds, “reflects VA’s agility throughout the pandemic to adapt based on lessons learned.”

The numbers tell the story:

110,066 veterans diagnosed with COVID-19 as of November 30;

879,457 veterans and employees tested for COVID-19 as of November 6;

14,168 veterans admitted to a US Department of Veterans Affairs (VA) medical center for COVID-19 care;

1,525% increase in telehealth visits;

59,095 new staff hired to meet surge in demand for COVID-19 care;

75 completed Fourth Mission assignments; and

> 2,000 VA employees helping to support nonveteran patients and non-VA health care systems.

But those numbers are just some of the data in the COVID-19 Response Report, which the VA recently released. The report offers “an extensive look at VA’s complex COVID-19 response,” including how it prepared for the pandemic, the initial response, and key COVID-19 policies and directives.

The report was compiled from more than 90 interviews with health care leaders and stakeholders, along with documents and data pertaining to the Veterans Integrated Service Networks. The interviews were designed to “keep discussion at a strategic level.”

Meeting the crisis mandated that the Veterans Health Administration (VHA) act “with unity of effort and agility,” the authors note, across 18 networks with 170 medical centers. Not only is the VA called on to serve veterans, but its “Fourth Mission” explicitly calls on the VA to “improve the Nation’s preparedness for response to war, terrorism, national emergencies, and natural disasters.” But the VHA possessed some major assets, they add, including a nationwide capacity for inpatient health care, “considerable experience” generating and managing response to regional and local public health emergencies, and strong clinical processes focused on evidence-based guidelines. However, “[w]ithout national analytics of data from outbreaks in other nations, and without a national plan addressing the VHA role, forecasting demand for VHA inpatient services under the Fourth Mission required assumptions with a high degree of uncertainty.”

VHA planners adapted the existing High Consequence Infections Base Plan to COVID-19 and then developed the COVID-19 Response Plan as an annex to that. They released their plan to the public in the interest of a coordinated national response—although not all states were aware of VHA’s important safety-net capabilities. Despite that, the report says, during the pandemic, the mission assignments under the VA’s Fourth Mission have grown to the greatest scale and scope in the VA’s history.

“[H]ealth care in the United States will never be the same,” said Richard Stone, MD, VHA Executive in Charge, in his foreword to the report. Much of what we now consider routine, he said, such as parking lot screenings, digital questionnaires and rapid testing “were revolutionary and challenging to implement” when the pandemic began. “While we are certainly not perfect, we are a learning organization and seek to always find ways to improve.”

Identifying root causes for complex process problems is essential to improvement, the report authors say, and require “new knowledge.” To that end, the VA also has played a critical role in COVID-19–related research, participating in more than 90 and leading 28 multiple-site COVID-19 research studies, including research on 3D-printed respirator masks and convalescent plasma treatment.

The VA’s pandemic response has been “robust and far-reaching,” said VA Secretary Robert Wilkie. The report, he adds, “reflects VA’s agility throughout the pandemic to adapt based on lessons learned.”

The numbers tell the story:

110,066 veterans diagnosed with COVID-19 as of November 30;

879,457 veterans and employees tested for COVID-19 as of November 6;

14,168 veterans admitted to a US Department of Veterans Affairs (VA) medical center for COVID-19 care;

1,525% increase in telehealth visits;

59,095 new staff hired to meet surge in demand for COVID-19 care;

75 completed Fourth Mission assignments; and

> 2,000 VA employees helping to support nonveteran patients and non-VA health care systems.

But those numbers are just some of the data in the COVID-19 Response Report, which the VA recently released. The report offers “an extensive look at VA’s complex COVID-19 response,” including how it prepared for the pandemic, the initial response, and key COVID-19 policies and directives.

The report was compiled from more than 90 interviews with health care leaders and stakeholders, along with documents and data pertaining to the Veterans Integrated Service Networks. The interviews were designed to “keep discussion at a strategic level.”

Meeting the crisis mandated that the Veterans Health Administration (VHA) act “with unity of effort and agility,” the authors note, across 18 networks with 170 medical centers. Not only is the VA called on to serve veterans, but its “Fourth Mission” explicitly calls on the VA to “improve the Nation’s preparedness for response to war, terrorism, national emergencies, and natural disasters.” But the VHA possessed some major assets, they add, including a nationwide capacity for inpatient health care, “considerable experience” generating and managing response to regional and local public health emergencies, and strong clinical processes focused on evidence-based guidelines. However, “[w]ithout national analytics of data from outbreaks in other nations, and without a national plan addressing the VHA role, forecasting demand for VHA inpatient services under the Fourth Mission required assumptions with a high degree of uncertainty.”

VHA planners adapted the existing High Consequence Infections Base Plan to COVID-19 and then developed the COVID-19 Response Plan as an annex to that. They released their plan to the public in the interest of a coordinated national response—although not all states were aware of VHA’s important safety-net capabilities. Despite that, the report says, during the pandemic, the mission assignments under the VA’s Fourth Mission have grown to the greatest scale and scope in the VA’s history.

“[H]ealth care in the United States will never be the same,” said Richard Stone, MD, VHA Executive in Charge, in his foreword to the report. Much of what we now consider routine, he said, such as parking lot screenings, digital questionnaires and rapid testing “were revolutionary and challenging to implement” when the pandemic began. “While we are certainly not perfect, we are a learning organization and seek to always find ways to improve.”

Identifying root causes for complex process problems is essential to improvement, the report authors say, and require “new knowledge.” To that end, the VA also has played a critical role in COVID-19–related research, participating in more than 90 and leading 28 multiple-site COVID-19 research studies, including research on 3D-printed respirator masks and convalescent plasma treatment.

The VA’s pandemic response has been “robust and far-reaching,” said VA Secretary Robert Wilkie. The report, he adds, “reflects VA’s agility throughout the pandemic to adapt based on lessons learned.”

As a result of the coronavirus disease 2019 (COVID-19) pandemic, the content of outpatient psychotherapy and psychopharmacology sessions has seen significant change, with many patients focusing on how the pandemic has altered their daily lives and emotional well-being. Most patients were suddenly limited in both the amount of time they spent, and in their interactions with people, outside of their homes. Additionally, employment-related stressors such as working from home and the potential loss of a job and/or income added to pandemic stress.¹ Patients simultaneously processed their experiences of the COVID-19 pandemic while often striving to adapt to new virtual modes of mental health care delivery via phone or video conferencing.

The clinic staff at our large, multidisciplinary, urban outpatient mental health practice conducts weekly case consultation meetings. In meetings held during the early stages of the COVID-19 pandemic, we noted 4 dominant clinical themes emerging across our patients’ experiences:

• isolation
• uncertainty
• household stress
• grief.

These themes occurred across many diagnostic categories, suggesting they reflect a dramatic shift brought on by the pandemic. Our group compared clinical experiences from the beginning of the pandemic through the end of May 2020. For this article, we considered several patients who expressed these 4 themes and created a “composite patient.” In the following sections, we describe the typical presentation of, and recommended interventions for, a composite patient for each of these 4 themes.

Isolation

Mr. J, a 60-year-old, single, African American man diagnosed with bipolar disorder with psychotic features, lives alone in an apartment in a densely populated area. Before COVID-19, he had been attending a day treatment program. His daily walks for coffee and cigarettes provided the scaffolding to his emotional stability and gave him a sense of belonging to a world outside of his home. Mr. J also had been able to engage in informal social activities in the common areas of his apartment complex.

The start of the COVID-19 pandemic ends his interpersonal interactions, from the passive and superficial conversations he had with strangers in coffee shops to the more intimate engagement with his peers in his treatment program. The common areas of Mr. J’s apartment building are closed, and his routine cigarette breaks with neighbors have become solitary events, with the added stress of having to schedule his use of the building’s designated smoking area. Before COVID-19, Mr. J had been regularly meeting his brother for coffee to talk about the recent death of their father, but these meetings end due to infection concerns by Mr. J and his brother, who cares for their ailing mother who is at high risk for COVID-19 infection.

Mr. J begins to report self-referential ideation when walking in public, citing his inability to see peoples’ facial expressions because they are wearing masks. As a result of the pandemic restrictions, he becomes depressed and develops increased paranoid ideation. Fortunately, Mr. J begins to participate in a virtual partial hospitalization program to address his paranoid ideation through intensive and clinically-based social interactions. He is unfamiliar with the technology used for virtual visits, but is given the necessary technical support. He is also able to begin virtual visits with his brother and mother. Mr. J soon reports his symptoms are reduced and his mood is more stable.

Engaging in interpersonal interactions can have a positive impact on mental health. Social isolation has demonstrated negative effects that are amplified in individuals with psychiatric disorders.² Interpersonal interactions can provide a shared experience, promote positive feelings of social connection, and aid in the development of social skills.^3,4 Among our patients, we have begun to see the effects of isolation manifest as loneliness and demoralization.

Continue to: Interventions

Interventions. Due to restrictions imposed to limit the spread of COVID-19, evidence-based interventions such as meeting a friend for a meal or participating in in-person support groups typically are not options, thus forcing clinicians to accommodate, adapt, and use technology to develop parallel interventions to provide the same therapeutic effects.^5,6 These solutions need to be individualized to accommodate each patient’s unique social and clinical situation (Table 1). Engaging through technology can be problematic for patients with psychosis and paranoid ideation, or those with depressive symptoms. Psychopharmacology or therapy visit time has to be dedicated to helping patients become comfortable and confident when using technology to access their clinicians. Patients can use this same technology to establish virtual social connections. Providing patients with accurate, factual information about infection control during clinical visits ultimately supports their mental health. Delivering clinical care during COVID-19 has required creativity and flexibility to optimize available resources and capitalize on patients’ social supports. These strategies help decrease isolation, loneliness, and exacerbation of psychiatric symptoms.

Uncertainty

Ms. L, age 42, has a history of posttraumatic stress disorder and obstructive sleep apnea, for which she uses a continuous airway positive pressure (CPAP) device. She had been working as a part-time nanny when her employer furloughed her early in the COVID-19 pandemic. Her anxiety has gotten worse throughout the quarantine; she fears her unemployment benefits will run out and she will lose her job. Her anxiety manifests as somatic “pit-of-stomach” sensations. Her sleep has been disrupted; she reports more frequent nightmares, and her partner says that Ms. L has had apneic episodes and bruxism. The parameters of Ms. L’s CPAP device need to be adjusted, but a previously scheduled overnight polysomnography test is deemed a nonessential procedure and canceled. Ms. L has been reluctant to go to a food pantry because she is afraid of being exposed to COVID-19. In virtual sessions, Ms. L says she is uncertain if she will be able to pay her rent, buy food, or access medical care, and expresses overriding helplessness.

During COVID-19, anxiety and insomnia are driven by the sudden manifestation of uncertainty regarding being able to work, pay rent or mortgage, buy food and other provisions, or visit family and friends, including those who are hospitalized or live in nursing homes. Additional uncertainties include how long the quarantine will last, who will become ill, and when, or if, life will return to normal. Taken together, these uncertainties impart a pervasive dread to daily experience.

Interventions. Clinicians can facilitate access to services (eg, social services, benefits specialists) and help patients parse out what they should and can address practically, and which challenges are outside of their personal or communal control (Table 2). Patients can be encouraged to identify paralytic rumination and shift their mental focus to engage in constructive projects. They can be advised to limit their intake of media that increases their anxiety and replace it with phone calls or e-mails to family and friends. Scheduled practice of mindfulness meditation and diaphragmatic breathing can help reduce anxiety.^7,8 Pharmacotherapeutic interventions should be low-risk to minimize burdening emergency departments saturated with patients who have COVID-19 and serve to reduce symptoms that interfere with behavioral activation. While the research on benzodiazepines and non-benzodiazepine receptor agonists (“Z-drugs” such as zolpidem and eszopiclone) in the setting of obstructive sleep apnea is complex, and there is some evidence that the latter may not exacerbate apnea,⁹ benzodiazepines and Z-drugs are associated with an array of risks, including tolerance, withdrawal, and traumatic falls, particularly in older adults.¹⁰ Sleep hygiene and cognitive-behavioral therapy are first-line therapies for insomnia.¹¹

Household stress

Ms. M, a 45-year-old single mother with a history of generalized anxiety disorder, is suddenly thrust into homeschooling her 2 children, ages 10 and 8, while trying to remain productive at her job as a software engineer. She no longer has time for herself, and spends much of her day helping her children with schoolwork or planning activities to keep them engaged rather than arguing with each other. She feels intense pressure, heightened stress, and increased anxiety as she tries to navigate this new daily routine.

Continue to: New household dynamics...

New household dynamics abound when people are suddenly forced into atypical routines. In the context of COVID-19, working parents may be forced to balance the demands of their jobs with homeschooling their children. Couples may find themselves arguing more frequently. Adult children may find themselves needing to care for their ill parents. Limited space, a lack of leisure activities, and uncertainty about the future coalesce to increase conflict and stress. Research suggests that how people cope with a stressor is a more reliable determinant of health and well-being than the stressor itself.¹²

Interventions. Mental health clinicians can offer several recommendations to help patients cope with increased household stress (Table 3). We can encourage patients to have clear communication with their loved ones regarding new expectations, roles, and their feelings. Demarcating specific areas within living spaces to each person in the household can help each member feel a sense of autonomy, regardless of how small their area may be. Clinicians can help patients learn to take the time as a family to work on establishing new household routines. Telepsychiatry offers clinicians a unique window into patients’ lives and family dynamics, and we can use this perspective to deepen our understanding of the patient’s context and household relationships and help them navigate the situation thrust upon them.

Grief

Following a psychiatric hospitalization for an acute exacerbation of psychosis, Ms. S, age 79, is transferred to a rehabilitation facility, where she contracts COVID-19. Because Ms. S did not have a history of chronic medical illness, her family anticipates a full recovery. Early in the course of Ms. S’s admission, the rehabilitation facility restricts visitations, and her family is unable to see her. Ms. S dies in this facility without her family’s presence and without her family having the opportunity to say goodbye. Ms. S’s psychiatrist offers her family a virtual session to provide support. During the virtual session, the psychiatrist notes signs of complicated bereavement among Ms. S’s family members, including nonacceptance of the death, rumination about the circumstances of the death, and describing life as having no purpose.

The COVID-19 pandemic has complicated the natural process of loss and grief across multiple dimensions. Studies have shown that an inability to say goodbye before death, a lack of social support,¹³ and a lack of preparation for loss¹⁴ are associated with complicated bereavement and depression. Many people are experiencing the loss of loved ones without having a chance to appropriately mourn. Forbidding visits to family members who are hospitalized also prevents the practice of religious and spiritual rituals that typically occur at the end of life. This is worsened by truncated or absent funeral services. Support for those who are grieving may be offered from a distance, if at all. When surviving family members have been with the deceased prior to hospitalization, they may be required to self-quarantine, potentially exacerbating their grief and other symptoms associated with loss.

Interventions. Because social support is a protective factor against complicated grief,¹⁴ there are several recommendations for survivors as they work through the process of grief (Table 4). These include preparing families for a potential death; discussing desired spiritual and memorial services¹⁵; connecting families to resources such as community grief support programs, counseling/therapy, funeral services, video conferencing, and other communication tools; and planning for additional support for surviving family and friends, both immediately after the death and in the long term. It is also important to provide appropriate counseling and support for surviving family members to focus on their own well-being by exercising, eating nutritious meals, getting enough sleep, and abstaining from alcohol and drugs of abuse.¹⁶

Continue to: An ongoing challenge

 

 

An ongoing challenge

Our clinical team recommends further investigation to define additional psycho­therapeutic themes arising from the COVID-19 pandemic and provide evidence-based interventions to address these categories, which we expect will increase in clinical salience in the months and years ahead. Close monitoring, follow-up by clinical and research staff, and evidence-based interventions will help address these dominant themes, with the goal of alleviating patient suffering.

Bottom Line

Our team identified 4 dominant clinical themes emerging across our patients’ experiences during the coronavirus disease 2019 pandemic: isolation, uncertainty, household stress, and grief. Clinicians can implement specific interventions to reduce the impact of these themes, which we expect to remain clinically relevant in the upcoming months and years.

Related Resources

• Sharma RA, Maheshwari S, Bronsther R. COVID-19 in the era of loneliness. Current Psychiatry. 2020;19(5):31-32,39.
• Carr D, Boerner K, Moorman S. Bereavement in the time of coronavirus: unprecedented challenges demand novel interventions. J Aging Soc Policy. 2020;32(4-5):425-431.

Drug Brand Names

Eszopiclone • Lunesta
Zolpidem • Ambien

As a result of the coronavirus disease 2019 (COVID-19) pandemic, the content of outpatient psychotherapy and psychopharmacology sessions has seen significant change, with many patients focusing on how the pandemic has altered their daily lives and emotional well-being. Most patients were suddenly limited in both the amount of time they spent, and in their interactions with people, outside of their homes. Additionally, employment-related stressors such as working from home and the potential loss of a job and/or income added to pandemic stress.¹ Patients simultaneously processed their experiences of the COVID-19 pandemic while often striving to adapt to new virtual modes of mental health care delivery via phone or video conferencing.

The clinic staff at our large, multidisciplinary, urban outpatient mental health practice conducts weekly case consultation meetings. In meetings held during the early stages of the COVID-19 pandemic, we noted 4 dominant clinical themes emerging across our patients’ experiences:

• isolation
• uncertainty
• household stress
• grief.

These themes occurred across many diagnostic categories, suggesting they reflect a dramatic shift brought on by the pandemic. Our group compared clinical experiences from the beginning of the pandemic through the end of May 2020. For this article, we considered several patients who expressed these 4 themes and created a “composite patient.” In the following sections, we describe the typical presentation of, and recommended interventions for, a composite patient for each of these 4 themes.

Isolation

Mr. J, a 60-year-old, single, African American man diagnosed with bipolar disorder with psychotic features, lives alone in an apartment in a densely populated area. Before COVID-19, he had been attending a day treatment program. His daily walks for coffee and cigarettes provided the scaffolding to his emotional stability and gave him a sense of belonging to a world outside of his home. Mr. J also had been able to engage in informal social activities in the common areas of his apartment complex.

The start of the COVID-19 pandemic ends his interpersonal interactions, from the passive and superficial conversations he had with strangers in coffee shops to the more intimate engagement with his peers in his treatment program. The common areas of Mr. J’s apartment building are closed, and his routine cigarette breaks with neighbors have become solitary events, with the added stress of having to schedule his use of the building’s designated smoking area. Before COVID-19, Mr. J had been regularly meeting his brother for coffee to talk about the recent death of their father, but these meetings end due to infection concerns by Mr. J and his brother, who cares for their ailing mother who is at high risk for COVID-19 infection.

Mr. J begins to report self-referential ideation when walking in public, citing his inability to see peoples’ facial expressions because they are wearing masks. As a result of the pandemic restrictions, he becomes depressed and develops increased paranoid ideation. Fortunately, Mr. J begins to participate in a virtual partial hospitalization program to address his paranoid ideation through intensive and clinically-based social interactions. He is unfamiliar with the technology used for virtual visits, but is given the necessary technical support. He is also able to begin virtual visits with his brother and mother. Mr. J soon reports his symptoms are reduced and his mood is more stable.

Engaging in interpersonal interactions can have a positive impact on mental health. Social isolation has demonstrated negative effects that are amplified in individuals with psychiatric disorders.² Interpersonal interactions can provide a shared experience, promote positive feelings of social connection, and aid in the development of social skills.^3,4 Among our patients, we have begun to see the effects of isolation manifest as loneliness and demoralization.

Continue to: Interventions

Interventions. Due to restrictions imposed to limit the spread of COVID-19, evidence-based interventions such as meeting a friend for a meal or participating in in-person support groups typically are not options, thus forcing clinicians to accommodate, adapt, and use technology to develop parallel interventions to provide the same therapeutic effects.^5,6 These solutions need to be individualized to accommodate each patient’s unique social and clinical situation (Table 1). Engaging through technology can be problematic for patients with psychosis and paranoid ideation, or those with depressive symptoms. Psychopharmacology or therapy visit time has to be dedicated to helping patients become comfortable and confident when using technology to access their clinicians. Patients can use this same technology to establish virtual social connections. Providing patients with accurate, factual information about infection control during clinical visits ultimately supports their mental health. Delivering clinical care during COVID-19 has required creativity and flexibility to optimize available resources and capitalize on patients’ social supports. These strategies help decrease isolation, loneliness, and exacerbation of psychiatric symptoms.

Uncertainty

Ms. L, age 42, has a history of posttraumatic stress disorder and obstructive sleep apnea, for which she uses a continuous airway positive pressure (CPAP) device. She had been working as a part-time nanny when her employer furloughed her early in the COVID-19 pandemic. Her anxiety has gotten worse throughout the quarantine; she fears her unemployment benefits will run out and she will lose her job. Her anxiety manifests as somatic “pit-of-stomach” sensations. Her sleep has been disrupted; she reports more frequent nightmares, and her partner says that Ms. L has had apneic episodes and bruxism. The parameters of Ms. L’s CPAP device need to be adjusted, but a previously scheduled overnight polysomnography test is deemed a nonessential procedure and canceled. Ms. L has been reluctant to go to a food pantry because she is afraid of being exposed to COVID-19. In virtual sessions, Ms. L says she is uncertain if she will be able to pay her rent, buy food, or access medical care, and expresses overriding helplessness.

During COVID-19, anxiety and insomnia are driven by the sudden manifestation of uncertainty regarding being able to work, pay rent or mortgage, buy food and other provisions, or visit family and friends, including those who are hospitalized or live in nursing homes. Additional uncertainties include how long the quarantine will last, who will become ill, and when, or if, life will return to normal. Taken together, these uncertainties impart a pervasive dread to daily experience.

Interventions. Clinicians can facilitate access to services (eg, social services, benefits specialists) and help patients parse out what they should and can address practically, and which challenges are outside of their personal or communal control (Table 2). Patients can be encouraged to identify paralytic rumination and shift their mental focus to engage in constructive projects. They can be advised to limit their intake of media that increases their anxiety and replace it with phone calls or e-mails to family and friends. Scheduled practice of mindfulness meditation and diaphragmatic breathing can help reduce anxiety.^7,8 Pharmacotherapeutic interventions should be low-risk to minimize burdening emergency departments saturated with patients who have COVID-19 and serve to reduce symptoms that interfere with behavioral activation. While the research on benzodiazepines and non-benzodiazepine receptor agonists (“Z-drugs” such as zolpidem and eszopiclone) in the setting of obstructive sleep apnea is complex, and there is some evidence that the latter may not exacerbate apnea,⁹ benzodiazepines and Z-drugs are associated with an array of risks, including tolerance, withdrawal, and traumatic falls, particularly in older adults.¹⁰ Sleep hygiene and cognitive-behavioral therapy are first-line therapies for insomnia.¹¹

Household stress

Ms. M, a 45-year-old single mother with a history of generalized anxiety disorder, is suddenly thrust into homeschooling her 2 children, ages 10 and 8, while trying to remain productive at her job as a software engineer. She no longer has time for herself, and spends much of her day helping her children with schoolwork or planning activities to keep them engaged rather than arguing with each other. She feels intense pressure, heightened stress, and increased anxiety as she tries to navigate this new daily routine.

Continue to: New household dynamics...

New household dynamics abound when people are suddenly forced into atypical routines. In the context of COVID-19, working parents may be forced to balance the demands of their jobs with homeschooling their children. Couples may find themselves arguing more frequently. Adult children may find themselves needing to care for their ill parents. Limited space, a lack of leisure activities, and uncertainty about the future coalesce to increase conflict and stress. Research suggests that how people cope with a stressor is a more reliable determinant of health and well-being than the stressor itself.¹²

Interventions. Mental health clinicians can offer several recommendations to help patients cope with increased household stress (Table 3). We can encourage patients to have clear communication with their loved ones regarding new expectations, roles, and their feelings. Demarcating specific areas within living spaces to each person in the household can help each member feel a sense of autonomy, regardless of how small their area may be. Clinicians can help patients learn to take the time as a family to work on establishing new household routines. Telepsychiatry offers clinicians a unique window into patients’ lives and family dynamics, and we can use this perspective to deepen our understanding of the patient’s context and household relationships and help them navigate the situation thrust upon them.

Grief

Following a psychiatric hospitalization for an acute exacerbation of psychosis, Ms. S, age 79, is transferred to a rehabilitation facility, where she contracts COVID-19. Because Ms. S did not have a history of chronic medical illness, her family anticipates a full recovery. Early in the course of Ms. S’s admission, the rehabilitation facility restricts visitations, and her family is unable to see her. Ms. S dies in this facility without her family’s presence and without her family having the opportunity to say goodbye. Ms. S’s psychiatrist offers her family a virtual session to provide support. During the virtual session, the psychiatrist notes signs of complicated bereavement among Ms. S’s family members, including nonacceptance of the death, rumination about the circumstances of the death, and describing life as having no purpose.

The COVID-19 pandemic has complicated the natural process of loss and grief across multiple dimensions. Studies have shown that an inability to say goodbye before death, a lack of social support,¹³ and a lack of preparation for loss¹⁴ are associated with complicated bereavement and depression. Many people are experiencing the loss of loved ones without having a chance to appropriately mourn. Forbidding visits to family members who are hospitalized also prevents the practice of religious and spiritual rituals that typically occur at the end of life. This is worsened by truncated or absent funeral services. Support for those who are grieving may be offered from a distance, if at all. When surviving family members have been with the deceased prior to hospitalization, they may be required to self-quarantine, potentially exacerbating their grief and other symptoms associated with loss.

Interventions. Because social support is a protective factor against complicated grief,¹⁴ there are several recommendations for survivors as they work through the process of grief (Table 4). These include preparing families for a potential death; discussing desired spiritual and memorial services¹⁵; connecting families to resources such as community grief support programs, counseling/therapy, funeral services, video conferencing, and other communication tools; and planning for additional support for surviving family and friends, both immediately after the death and in the long term. It is also important to provide appropriate counseling and support for surviving family members to focus on their own well-being by exercising, eating nutritious meals, getting enough sleep, and abstaining from alcohol and drugs of abuse.¹⁶

Continue to: An ongoing challenge

 

 

An ongoing challenge

Our clinical team recommends further investigation to define additional psycho­therapeutic themes arising from the COVID-19 pandemic and provide evidence-based interventions to address these categories, which we expect will increase in clinical salience in the months and years ahead. Close monitoring, follow-up by clinical and research staff, and evidence-based interventions will help address these dominant themes, with the goal of alleviating patient suffering.

Bottom Line

Our team identified 4 dominant clinical themes emerging across our patients’ experiences during the coronavirus disease 2019 pandemic: isolation, uncertainty, household stress, and grief. Clinicians can implement specific interventions to reduce the impact of these themes, which we expect to remain clinically relevant in the upcoming months and years.

Related Resources

• Sharma RA, Maheshwari S, Bronsther R. COVID-19 in the era of loneliness. Current Psychiatry. 2020;19(5):31-32,39.
• Carr D, Boerner K, Moorman S. Bereavement in the time of coronavirus: unprecedented challenges demand novel interventions. J Aging Soc Policy. 2020;32(4-5):425-431.

Drug Brand Names

Eszopiclone • Lunesta
Zolpidem • Ambien

As a result of the coronavirus disease 2019 (COVID-19) pandemic, the content of outpatient psychotherapy and psychopharmacology sessions has seen significant change, with many patients focusing on how the pandemic has altered their daily lives and emotional well-being. Most patients were suddenly limited in both the amount of time they spent, and in their interactions with people, outside of their homes. Additionally, employment-related stressors such as working from home and the potential loss of a job and/or income added to pandemic stress.¹ Patients simultaneously processed their experiences of the COVID-19 pandemic while often striving to adapt to new virtual modes of mental health care delivery via phone or video conferencing.

The clinic staff at our large, multidisciplinary, urban outpatient mental health practice conducts weekly case consultation meetings. In meetings held during the early stages of the COVID-19 pandemic, we noted 4 dominant clinical themes emerging across our patients’ experiences:

• isolation
• uncertainty
• household stress
• grief.

These themes occurred across many diagnostic categories, suggesting they reflect a dramatic shift brought on by the pandemic. Our group compared clinical experiences from the beginning of the pandemic through the end of May 2020. For this article, we considered several patients who expressed these 4 themes and created a “composite patient.” In the following sections, we describe the typical presentation of, and recommended interventions for, a composite patient for each of these 4 themes.

Isolation

Mr. J, a 60-year-old, single, African American man diagnosed with bipolar disorder with psychotic features, lives alone in an apartment in a densely populated area. Before COVID-19, he had been attending a day treatment program. His daily walks for coffee and cigarettes provided the scaffolding to his emotional stability and gave him a sense of belonging to a world outside of his home. Mr. J also had been able to engage in informal social activities in the common areas of his apartment complex.

The start of the COVID-19 pandemic ends his interpersonal interactions, from the passive and superficial conversations he had with strangers in coffee shops to the more intimate engagement with his peers in his treatment program. The common areas of Mr. J’s apartment building are closed, and his routine cigarette breaks with neighbors have become solitary events, with the added stress of having to schedule his use of the building’s designated smoking area. Before COVID-19, Mr. J had been regularly meeting his brother for coffee to talk about the recent death of their father, but these meetings end due to infection concerns by Mr. J and his brother, who cares for their ailing mother who is at high risk for COVID-19 infection.

Mr. J begins to report self-referential ideation when walking in public, citing his inability to see peoples’ facial expressions because they are wearing masks. As a result of the pandemic restrictions, he becomes depressed and develops increased paranoid ideation. Fortunately, Mr. J begins to participate in a virtual partial hospitalization program to address his paranoid ideation through intensive and clinically-based social interactions. He is unfamiliar with the technology used for virtual visits, but is given the necessary technical support. He is also able to begin virtual visits with his brother and mother. Mr. J soon reports his symptoms are reduced and his mood is more stable.

Engaging in interpersonal interactions can have a positive impact on mental health. Social isolation has demonstrated negative effects that are amplified in individuals with psychiatric disorders.² Interpersonal interactions can provide a shared experience, promote positive feelings of social connection, and aid in the development of social skills.^3,4 Among our patients, we have begun to see the effects of isolation manifest as loneliness and demoralization.

Continue to: Interventions

Interventions. Due to restrictions imposed to limit the spread of COVID-19, evidence-based interventions such as meeting a friend for a meal or participating in in-person support groups typically are not options, thus forcing clinicians to accommodate, adapt, and use technology to develop parallel interventions to provide the same therapeutic effects.^5,6 These solutions need to be individualized to accommodate each patient’s unique social and clinical situation (Table 1). Engaging through technology can be problematic for patients with psychosis and paranoid ideation, or those with depressive symptoms. Psychopharmacology or therapy visit time has to be dedicated to helping patients become comfortable and confident when using technology to access their clinicians. Patients can use this same technology to establish virtual social connections. Providing patients with accurate, factual information about infection control during clinical visits ultimately supports their mental health. Delivering clinical care during COVID-19 has required creativity and flexibility to optimize available resources and capitalize on patients’ social supports. These strategies help decrease isolation, loneliness, and exacerbation of psychiatric symptoms.

Uncertainty

Ms. L, age 42, has a history of posttraumatic stress disorder and obstructive sleep apnea, for which she uses a continuous airway positive pressure (CPAP) device. She had been working as a part-time nanny when her employer furloughed her early in the COVID-19 pandemic. Her anxiety has gotten worse throughout the quarantine; she fears her unemployment benefits will run out and she will lose her job. Her anxiety manifests as somatic “pit-of-stomach” sensations. Her sleep has been disrupted; she reports more frequent nightmares, and her partner says that Ms. L has had apneic episodes and bruxism. The parameters of Ms. L’s CPAP device need to be adjusted, but a previously scheduled overnight polysomnography test is deemed a nonessential procedure and canceled. Ms. L has been reluctant to go to a food pantry because she is afraid of being exposed to COVID-19. In virtual sessions, Ms. L says she is uncertain if she will be able to pay her rent, buy food, or access medical care, and expresses overriding helplessness.

During COVID-19, anxiety and insomnia are driven by the sudden manifestation of uncertainty regarding being able to work, pay rent or mortgage, buy food and other provisions, or visit family and friends, including those who are hospitalized or live in nursing homes. Additional uncertainties include how long the quarantine will last, who will become ill, and when, or if, life will return to normal. Taken together, these uncertainties impart a pervasive dread to daily experience.

Interventions. Clinicians can facilitate access to services (eg, social services, benefits specialists) and help patients parse out what they should and can address practically, and which challenges are outside of their personal or communal control (Table 2). Patients can be encouraged to identify paralytic rumination and shift their mental focus to engage in constructive projects. They can be advised to limit their intake of media that increases their anxiety and replace it with phone calls or e-mails to family and friends. Scheduled practice of mindfulness meditation and diaphragmatic breathing can help reduce anxiety.^7,8 Pharmacotherapeutic interventions should be low-risk to minimize burdening emergency departments saturated with patients who have COVID-19 and serve to reduce symptoms that interfere with behavioral activation. While the research on benzodiazepines and non-benzodiazepine receptor agonists (“Z-drugs” such as zolpidem and eszopiclone) in the setting of obstructive sleep apnea is complex, and there is some evidence that the latter may not exacerbate apnea,⁹ benzodiazepines and Z-drugs are associated with an array of risks, including tolerance, withdrawal, and traumatic falls, particularly in older adults.¹⁰ Sleep hygiene and cognitive-behavioral therapy are first-line therapies for insomnia.¹¹

Household stress

Ms. M, a 45-year-old single mother with a history of generalized anxiety disorder, is suddenly thrust into homeschooling her 2 children, ages 10 and 8, while trying to remain productive at her job as a software engineer. She no longer has time for herself, and spends much of her day helping her children with schoolwork or planning activities to keep them engaged rather than arguing with each other. She feels intense pressure, heightened stress, and increased anxiety as she tries to navigate this new daily routine.

Continue to: New household dynamics...

New household dynamics abound when people are suddenly forced into atypical routines. In the context of COVID-19, working parents may be forced to balance the demands of their jobs with homeschooling their children. Couples may find themselves arguing more frequently. Adult children may find themselves needing to care for their ill parents. Limited space, a lack of leisure activities, and uncertainty about the future coalesce to increase conflict and stress. Research suggests that how people cope with a stressor is a more reliable determinant of health and well-being than the stressor itself.¹²

Interventions. Mental health clinicians can offer several recommendations to help patients cope with increased household stress (Table 3). We can encourage patients to have clear communication with their loved ones regarding new expectations, roles, and their feelings. Demarcating specific areas within living spaces to each person in the household can help each member feel a sense of autonomy, regardless of how small their area may be. Clinicians can help patients learn to take the time as a family to work on establishing new household routines. Telepsychiatry offers clinicians a unique window into patients’ lives and family dynamics, and we can use this perspective to deepen our understanding of the patient’s context and household relationships and help them navigate the situation thrust upon them.

Grief

Following a psychiatric hospitalization for an acute exacerbation of psychosis, Ms. S, age 79, is transferred to a rehabilitation facility, where she contracts COVID-19. Because Ms. S did not have a history of chronic medical illness, her family anticipates a full recovery. Early in the course of Ms. S’s admission, the rehabilitation facility restricts visitations, and her family is unable to see her. Ms. S dies in this facility without her family’s presence and without her family having the opportunity to say goodbye. Ms. S’s psychiatrist offers her family a virtual session to provide support. During the virtual session, the psychiatrist notes signs of complicated bereavement among Ms. S’s family members, including nonacceptance of the death, rumination about the circumstances of the death, and describing life as having no purpose.

The COVID-19 pandemic has complicated the natural process of loss and grief across multiple dimensions. Studies have shown that an inability to say goodbye before death, a lack of social support,¹³ and a lack of preparation for loss¹⁴ are associated with complicated bereavement and depression. Many people are experiencing the loss of loved ones without having a chance to appropriately mourn. Forbidding visits to family members who are hospitalized also prevents the practice of religious and spiritual rituals that typically occur at the end of life. This is worsened by truncated or absent funeral services. Support for those who are grieving may be offered from a distance, if at all. When surviving family members have been with the deceased prior to hospitalization, they may be required to self-quarantine, potentially exacerbating their grief and other symptoms associated with loss.

Interventions. Because social support is a protective factor against complicated grief,¹⁴ there are several recommendations for survivors as they work through the process of grief (Table 4). These include preparing families for a potential death; discussing desired spiritual and memorial services¹⁵; connecting families to resources such as community grief support programs, counseling/therapy, funeral services, video conferencing, and other communication tools; and planning for additional support for surviving family and friends, both immediately after the death and in the long term. It is also important to provide appropriate counseling and support for surviving family members to focus on their own well-being by exercising, eating nutritious meals, getting enough sleep, and abstaining from alcohol and drugs of abuse.¹⁶

Continue to: An ongoing challenge

 

 

An ongoing challenge

Our clinical team recommends further investigation to define additional psycho­therapeutic themes arising from the COVID-19 pandemic and provide evidence-based interventions to address these categories, which we expect will increase in clinical salience in the months and years ahead. Close monitoring, follow-up by clinical and research staff, and evidence-based interventions will help address these dominant themes, with the goal of alleviating patient suffering.

Bottom Line

Our team identified 4 dominant clinical themes emerging across our patients’ experiences during the coronavirus disease 2019 pandemic: isolation, uncertainty, household stress, and grief. Clinicians can implement specific interventions to reduce the impact of these themes, which we expect to remain clinically relevant in the upcoming months and years.

Related Resources

• Sharma RA, Maheshwari S, Bronsther R. COVID-19 in the era of loneliness. Current Psychiatry. 2020;19(5):31-32,39.
• Carr D, Boerner K, Moorman S. Bereavement in the time of coronavirus: unprecedented challenges demand novel interventions. J Aging Soc Policy. 2020;32(4-5):425-431.

Drug Brand Names

Eszopiclone • Lunesta
Zolpidem • Ambien

Many laser and light-based technologies fall short when it comes to treating people of color, according to Haley L. Marks, PhD.

For one thing, melanin’s extinction overlaps with common laser lines, which affects the safety and efficacy of laser treatments in dermatology, but also in imaging and wearable devices that use LEDs in the visible range. “Pheomelanin and eumelanin are chemically very similar and both have this property of having very high extinction coefficients in the visible range, meaning that melanins both absorb and scatter light which we commonly use for laser treatments and for wearable medical devices,” Dr. Marks, a research scientist in dermatology at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Melanins also shadow a number of other biological signals that we look for in the skin, such as those from hemoglobin.”

A number of different scales can be used to estimate the amount of eumelanin, or darkly pigmented melanin, in the skin, but the most famous is Fitzpatrick skin typing, the classification system that ranges from I to VI originally intended to quantify the skin’s response to UV light. “It’s so famous that it’s used in the emoji modifier of the Unicode Consortium lookup table,” said Dr. Marks, who spoke on behalf of the Wellman Anti-Racism Effort (WARE), a grassroots working group within the Wellman Center for Photomedicine at Massachusetts General Hospital. (The mission of the group is to eradicate racism in STEM, medicine, and academia starting with its own research and Center.)

Dr. Marks referred to a Northwestern University study published in 2013, which found that both patients and dermatologists failed to accurately determine Fitzpatrick skin type (FST) when compared with reflectance spectrophotometry used to measure melanin index objectively. “There is a need to classify skin type with reliable questions with responses suitable for all skin types,” the authors concluded.

Plenty more can go wrong when clinicians ignore or misunderstand the role of melanin as a background contrast agent, Dr. Marks continued. She cited the common misconception that melanomas do not occur in darker pigmented skin, a topic discussed in an article published online in January 2020 in Cancer Cytopathology.

“While they do occur at a lower rate, this misconception leads to an alarmingly low survival rate for black melanoma patients,” Dr. Marks said. “Acral lentiginous melanoma is one example of this. It is not related to sun exposure, yet it occurs in 30% to 70% of melanomas in black patients. This also exposes a mortality rate of 1 in 3 for Black melanoma patients, compared with 1 in 11 for White patients. In fact, Black patients face a lower survival for most cancers, often attributed to social and economic disparities rather than biological differences.”

Another significant contributing factor may be the lack of data and awareness of clinical research related to patients with skin of color. The Skin of Color Society’s “Find a Doctor” database is attempting to address this by improving patients’ access to board-certified dermatologists who specialize in skin of color. “Some of the discrepancies in dermatology education, screening, and treatment for Black, indigenous, and people of color is likely attributed to the fact that only 4.5% of images in general medical textbooks show darker skin, as they are only 5% of clinical trial participants despite making up 17% of the U.S. population,” Dr. Marks said at the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. Mind The Gap, a handbook of clinical signs and symptoms in black and brown skin, was published in 2020 by students and staff at St. George’s University of London. It can be downloaded for free.

Some 40 years after Kodak was criticized for not acknowledging inherent biases in their film stocks based on its “Kodak Shirley” color correction card, Dr. Marks said that camera makers are still ignoring racial bias in their technologies. “This is likely a ‘garbage in, garbage out’ phenomenon,” she said. “Due to the lack of diverse images, these biases get ingrained into machine learning models themselves, either because patients were not served in the first place, resulting in missing data, or because of mislabeling due to a lack of knowledge in properly classifying these images. So, while machine learning has the potential to step in where dermatologists fall short, we must be very diligent about recognizing any bias we are ingraining into these algorithms,” she said.

“That said, no technology is ‘born racist,’ of course; it is up to us to prevent history from repeating itself and prevent these biases from being ingrained in our work,” she added. “We can start by holding ourselves and others accountable when designing studies that have exclusion criteria, by challenging our sponsors on the exclusion of Fitzpatrick V and VI if you feel it is not scientifically sound, and by ensuring inclusive algorithm development. If these things are not possible, please use a disclaimer to make these limitations clear.”

According to Dr. Marks and WARE, clinicians can increase diversity in clinical trials by widening eligibility criteria, tapping into community-based medical centers, connecting with patient advocacy groups, using point-of-care and telemedicine technologies, supporting diversity-focused public policy on a larger scale, and making diversity an internal mandate, “within your institution, and within yourselves.”

Some community efforts stemming from Wellman inventions so far include the Texas-based Removery INK-nitiative program, which removes racist and hateful tattoos for free via laser tattoo removal technology that was invented at Wellman. Dr. Marks and her WARE colleagues also work with the Dream Beam Foundation, which is a global initiative bringing laser-based technologies to children in Vietnam, Armenia, Israel, Brazil, and Lebanon.

Dr. Marks reported having no financial disclosures.

dbrunk@mdedge.com

Many laser and light-based technologies fall short when it comes to treating people of color, according to Haley L. Marks, PhD.

For one thing, melanin’s extinction overlaps with common laser lines, which affects the safety and efficacy of laser treatments in dermatology, but also in imaging and wearable devices that use LEDs in the visible range. “Pheomelanin and eumelanin are chemically very similar and both have this property of having very high extinction coefficients in the visible range, meaning that melanins both absorb and scatter light which we commonly use for laser treatments and for wearable medical devices,” Dr. Marks, a research scientist in dermatology at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Melanins also shadow a number of other biological signals that we look for in the skin, such as those from hemoglobin.”

A number of different scales can be used to estimate the amount of eumelanin, or darkly pigmented melanin, in the skin, but the most famous is Fitzpatrick skin typing, the classification system that ranges from I to VI originally intended to quantify the skin’s response to UV light. “It’s so famous that it’s used in the emoji modifier of the Unicode Consortium lookup table,” said Dr. Marks, who spoke on behalf of the Wellman Anti-Racism Effort (WARE), a grassroots working group within the Wellman Center for Photomedicine at Massachusetts General Hospital. (The mission of the group is to eradicate racism in STEM, medicine, and academia starting with its own research and Center.)

Dr. Marks referred to a Northwestern University study published in 2013, which found that both patients and dermatologists failed to accurately determine Fitzpatrick skin type (FST) when compared with reflectance spectrophotometry used to measure melanin index objectively. “There is a need to classify skin type with reliable questions with responses suitable for all skin types,” the authors concluded.

Plenty more can go wrong when clinicians ignore or misunderstand the role of melanin as a background contrast agent, Dr. Marks continued. She cited the common misconception that melanomas do not occur in darker pigmented skin, a topic discussed in an article published online in January 2020 in Cancer Cytopathology.

“While they do occur at a lower rate, this misconception leads to an alarmingly low survival rate for black melanoma patients,” Dr. Marks said. “Acral lentiginous melanoma is one example of this. It is not related to sun exposure, yet it occurs in 30% to 70% of melanomas in black patients. This also exposes a mortality rate of 1 in 3 for Black melanoma patients, compared with 1 in 11 for White patients. In fact, Black patients face a lower survival for most cancers, often attributed to social and economic disparities rather than biological differences.”

Another significant contributing factor may be the lack of data and awareness of clinical research related to patients with skin of color. The Skin of Color Society’s “Find a Doctor” database is attempting to address this by improving patients’ access to board-certified dermatologists who specialize in skin of color. “Some of the discrepancies in dermatology education, screening, and treatment for Black, indigenous, and people of color is likely attributed to the fact that only 4.5% of images in general medical textbooks show darker skin, as they are only 5% of clinical trial participants despite making up 17% of the U.S. population,” Dr. Marks said at the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. Mind The Gap, a handbook of clinical signs and symptoms in black and brown skin, was published in 2020 by students and staff at St. George’s University of London. It can be downloaded for free.

Some 40 years after Kodak was criticized for not acknowledging inherent biases in their film stocks based on its “Kodak Shirley” color correction card, Dr. Marks said that camera makers are still ignoring racial bias in their technologies. “This is likely a ‘garbage in, garbage out’ phenomenon,” she said. “Due to the lack of diverse images, these biases get ingrained into machine learning models themselves, either because patients were not served in the first place, resulting in missing data, or because of mislabeling due to a lack of knowledge in properly classifying these images. So, while machine learning has the potential to step in where dermatologists fall short, we must be very diligent about recognizing any bias we are ingraining into these algorithms,” she said.

“That said, no technology is ‘born racist,’ of course; it is up to us to prevent history from repeating itself and prevent these biases from being ingrained in our work,” she added. “We can start by holding ourselves and others accountable when designing studies that have exclusion criteria, by challenging our sponsors on the exclusion of Fitzpatrick V and VI if you feel it is not scientifically sound, and by ensuring inclusive algorithm development. If these things are not possible, please use a disclaimer to make these limitations clear.”

According to Dr. Marks and WARE, clinicians can increase diversity in clinical trials by widening eligibility criteria, tapping into community-based medical centers, connecting with patient advocacy groups, using point-of-care and telemedicine technologies, supporting diversity-focused public policy on a larger scale, and making diversity an internal mandate, “within your institution, and within yourselves.”

Some community efforts stemming from Wellman inventions so far include the Texas-based Removery INK-nitiative program, which removes racist and hateful tattoos for free via laser tattoo removal technology that was invented at Wellman. Dr. Marks and her WARE colleagues also work with the Dream Beam Foundation, which is a global initiative bringing laser-based technologies to children in Vietnam, Armenia, Israel, Brazil, and Lebanon.

Dr. Marks reported having no financial disclosures.

dbrunk@mdedge.com

Many laser and light-based technologies fall short when it comes to treating people of color, according to Haley L. Marks, PhD.

For one thing, melanin’s extinction overlaps with common laser lines, which affects the safety and efficacy of laser treatments in dermatology, but also in imaging and wearable devices that use LEDs in the visible range. “Pheomelanin and eumelanin are chemically very similar and both have this property of having very high extinction coefficients in the visible range, meaning that melanins both absorb and scatter light which we commonly use for laser treatments and for wearable medical devices,” Dr. Marks, a research scientist in dermatology at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Melanins also shadow a number of other biological signals that we look for in the skin, such as those from hemoglobin.”

A number of different scales can be used to estimate the amount of eumelanin, or darkly pigmented melanin, in the skin, but the most famous is Fitzpatrick skin typing, the classification system that ranges from I to VI originally intended to quantify the skin’s response to UV light. “It’s so famous that it’s used in the emoji modifier of the Unicode Consortium lookup table,” said Dr. Marks, who spoke on behalf of the Wellman Anti-Racism Effort (WARE), a grassroots working group within the Wellman Center for Photomedicine at Massachusetts General Hospital. (The mission of the group is to eradicate racism in STEM, medicine, and academia starting with its own research and Center.)

Dr. Marks referred to a Northwestern University study published in 2013, which found that both patients and dermatologists failed to accurately determine Fitzpatrick skin type (FST) when compared with reflectance spectrophotometry used to measure melanin index objectively. “There is a need to classify skin type with reliable questions with responses suitable for all skin types,” the authors concluded.

Plenty more can go wrong when clinicians ignore or misunderstand the role of melanin as a background contrast agent, Dr. Marks continued. She cited the common misconception that melanomas do not occur in darker pigmented skin, a topic discussed in an article published online in January 2020 in Cancer Cytopathology.

“While they do occur at a lower rate, this misconception leads to an alarmingly low survival rate for black melanoma patients,” Dr. Marks said. “Acral lentiginous melanoma is one example of this. It is not related to sun exposure, yet it occurs in 30% to 70% of melanomas in black patients. This also exposes a mortality rate of 1 in 3 for Black melanoma patients, compared with 1 in 11 for White patients. In fact, Black patients face a lower survival for most cancers, often attributed to social and economic disparities rather than biological differences.”

Another significant contributing factor may be the lack of data and awareness of clinical research related to patients with skin of color. The Skin of Color Society’s “Find a Doctor” database is attempting to address this by improving patients’ access to board-certified dermatologists who specialize in skin of color. “Some of the discrepancies in dermatology education, screening, and treatment for Black, indigenous, and people of color is likely attributed to the fact that only 4.5% of images in general medical textbooks show darker skin, as they are only 5% of clinical trial participants despite making up 17% of the U.S. population,” Dr. Marks said at the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. Mind The Gap, a handbook of clinical signs and symptoms in black and brown skin, was published in 2020 by students and staff at St. George’s University of London. It can be downloaded for free.

Some 40 years after Kodak was criticized for not acknowledging inherent biases in their film stocks based on its “Kodak Shirley” color correction card, Dr. Marks said that camera makers are still ignoring racial bias in their technologies. “This is likely a ‘garbage in, garbage out’ phenomenon,” she said. “Due to the lack of diverse images, these biases get ingrained into machine learning models themselves, either because patients were not served in the first place, resulting in missing data, or because of mislabeling due to a lack of knowledge in properly classifying these images. So, while machine learning has the potential to step in where dermatologists fall short, we must be very diligent about recognizing any bias we are ingraining into these algorithms,” she said.

“That said, no technology is ‘born racist,’ of course; it is up to us to prevent history from repeating itself and prevent these biases from being ingrained in our work,” she added. “We can start by holding ourselves and others accountable when designing studies that have exclusion criteria, by challenging our sponsors on the exclusion of Fitzpatrick V and VI if you feel it is not scientifically sound, and by ensuring inclusive algorithm development. If these things are not possible, please use a disclaimer to make these limitations clear.”

According to Dr. Marks and WARE, clinicians can increase diversity in clinical trials by widening eligibility criteria, tapping into community-based medical centers, connecting with patient advocacy groups, using point-of-care and telemedicine technologies, supporting diversity-focused public policy on a larger scale, and making diversity an internal mandate, “within your institution, and within yourselves.”

Some community efforts stemming from Wellman inventions so far include the Texas-based Removery INK-nitiative program, which removes racist and hateful tattoos for free via laser tattoo removal technology that was invented at Wellman. Dr. Marks and her WARE colleagues also work with the Dream Beam Foundation, which is a global initiative bringing laser-based technologies to children in Vietnam, Armenia, Israel, Brazil, and Lebanon.

Dr. Marks reported having no financial disclosures.

dbrunk@mdedge.com

Delayed health care brought on by the pandemic is taking its toll on patients, a survey of primary care doctors shows. 

More than half (56%) of responding clinicians reported seeing a decline in patient health because of delayed or inaccessible care amid the pandemic, according to the results of the latest survey by the Larry A. Green Center and the Primary Care Collaborative. The survey was conducted in mid-October and the results were published online Nov. 17.  

In addition, 37% of respondents said their patients with chronic conditions showed “noticeably worse health resulting from the pandemic.” And a resounding 85% said patient mental health had worsened. 

“I think it’s worse than we thought,” said Rebecca Etz, PhD, codirector of the Larry Green Center. “It’s the outcome of not sufficiently sending resources to primary care either before or during the pandemic.” According to Dr. Etz, survey respondents noted substantial increases in patient weight gain as well as weight loss, anxiety and depression, sleep issues, domestic abuse, and poor oral and eye health, among others.

One clinician from Pennsylvania wrote: “Patients are becoming sicker during the pandemic. I’m seeing more uncontrolled [diabetes]and new [patients with diabetes]. They prefer telehealth yet [have] no access to glucose monitoring or a blood pressure cuff. I am concerned about patients’ isolation and mental health. People are delaying care.”

Now, with COVID numbers peaking across much of the country, many clinicians are trying to close the gap in care with telehealth – something they’re more prepared to do now than they were in March. Over two-thirds of practices are using telehealth for visits to keep up with patients who have stable chronic conditions, according to the survey.

Over 60% of physicians report using telehealth for mental health visits. But a much smaller number – only 16% of respondents – said their practice had added staff to help manage the rising number of behavioral and mental health cases. About one-third (35%) of practices say they’re not financially able to take on new staff.

“We’ve been looking for more ways for patients to do self-support. A big part of chronic disease is health behaviors,” Alex Krist, MD, MPH, a family doctor in Fairfax, Va., and chairperson of the U.S. Preventive Services Task Force, said in an interview. And unfortunately, on top of limited access to basic care, healthy habits that are essential to managing many chronic conditions have become more difficult and less consistent during the pandemic. 

The survey – the 22nd iteration in a series of surveys the Green Center and the Primary Care Collaborative have conducted – received 580 respondents from 47 states and Guam. Over two-thirds of respondents were primary care physicians (MDs and DOs). Over half were owners, partners, or employees of a private practice, 66% of which were family medicine practices. And one fifth of respondents provided care in a rural area.

Funding and support for primary care has been wildly insufficient, Dr. Etz said in an interview. If that doesn’t change, patient health, clinic staffing, and public health strategies amid the pandemic will continue to suffer.

“When you think of the COVID vaccine, who do you think is going to be sending that out?” Dr. Etz asked. “If we don’t bolster primary care now how are they going to handle that.”
 

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

Delayed health care brought on by the pandemic is taking its toll on patients, a survey of primary care doctors shows. 

More than half (56%) of responding clinicians reported seeing a decline in patient health because of delayed or inaccessible care amid the pandemic, according to the results of the latest survey by the Larry A. Green Center and the Primary Care Collaborative. The survey was conducted in mid-October and the results were published online Nov. 17.  

In addition, 37% of respondents said their patients with chronic conditions showed “noticeably worse health resulting from the pandemic.” And a resounding 85% said patient mental health had worsened. 

“I think it’s worse than we thought,” said Rebecca Etz, PhD, codirector of the Larry Green Center. “It’s the outcome of not sufficiently sending resources to primary care either before or during the pandemic.” According to Dr. Etz, survey respondents noted substantial increases in patient weight gain as well as weight loss, anxiety and depression, sleep issues, domestic abuse, and poor oral and eye health, among others.

One clinician from Pennsylvania wrote: “Patients are becoming sicker during the pandemic. I’m seeing more uncontrolled [diabetes]and new [patients with diabetes]. They prefer telehealth yet [have] no access to glucose monitoring or a blood pressure cuff. I am concerned about patients’ isolation and mental health. People are delaying care.”

Now, with COVID numbers peaking across much of the country, many clinicians are trying to close the gap in care with telehealth – something they’re more prepared to do now than they were in March. Over two-thirds of practices are using telehealth for visits to keep up with patients who have stable chronic conditions, according to the survey.

Over 60% of physicians report using telehealth for mental health visits. But a much smaller number – only 16% of respondents – said their practice had added staff to help manage the rising number of behavioral and mental health cases. About one-third (35%) of practices say they’re not financially able to take on new staff.

“We’ve been looking for more ways for patients to do self-support. A big part of chronic disease is health behaviors,” Alex Krist, MD, MPH, a family doctor in Fairfax, Va., and chairperson of the U.S. Preventive Services Task Force, said in an interview. And unfortunately, on top of limited access to basic care, healthy habits that are essential to managing many chronic conditions have become more difficult and less consistent during the pandemic. 

The survey – the 22nd iteration in a series of surveys the Green Center and the Primary Care Collaborative have conducted – received 580 respondents from 47 states and Guam. Over two-thirds of respondents were primary care physicians (MDs and DOs). Over half were owners, partners, or employees of a private practice, 66% of which were family medicine practices. And one fifth of respondents provided care in a rural area.

Funding and support for primary care has been wildly insufficient, Dr. Etz said in an interview. If that doesn’t change, patient health, clinic staffing, and public health strategies amid the pandemic will continue to suffer.

“When you think of the COVID vaccine, who do you think is going to be sending that out?” Dr. Etz asked. “If we don’t bolster primary care now how are they going to handle that.”
 

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

Delayed health care brought on by the pandemic is taking its toll on patients, a survey of primary care doctors shows. 

More than half (56%) of responding clinicians reported seeing a decline in patient health because of delayed or inaccessible care amid the pandemic, according to the results of the latest survey by the Larry A. Green Center and the Primary Care Collaborative. The survey was conducted in mid-October and the results were published online Nov. 17.  

In addition, 37% of respondents said their patients with chronic conditions showed “noticeably worse health resulting from the pandemic.” And a resounding 85% said patient mental health had worsened. 

“I think it’s worse than we thought,” said Rebecca Etz, PhD, codirector of the Larry Green Center. “It’s the outcome of not sufficiently sending resources to primary care either before or during the pandemic.” According to Dr. Etz, survey respondents noted substantial increases in patient weight gain as well as weight loss, anxiety and depression, sleep issues, domestic abuse, and poor oral and eye health, among others.

One clinician from Pennsylvania wrote: “Patients are becoming sicker during the pandemic. I’m seeing more uncontrolled [diabetes]and new [patients with diabetes]. They prefer telehealth yet [have] no access to glucose monitoring or a blood pressure cuff. I am concerned about patients’ isolation and mental health. People are delaying care.”

Now, with COVID numbers peaking across much of the country, many clinicians are trying to close the gap in care with telehealth – something they’re more prepared to do now than they were in March. Over two-thirds of practices are using telehealth for visits to keep up with patients who have stable chronic conditions, according to the survey.

Over 60% of physicians report using telehealth for mental health visits. But a much smaller number – only 16% of respondents – said their practice had added staff to help manage the rising number of behavioral and mental health cases. About one-third (35%) of practices say they’re not financially able to take on new staff.

“We’ve been looking for more ways for patients to do self-support. A big part of chronic disease is health behaviors,” Alex Krist, MD, MPH, a family doctor in Fairfax, Va., and chairperson of the U.S. Preventive Services Task Force, said in an interview. And unfortunately, on top of limited access to basic care, healthy habits that are essential to managing many chronic conditions have become more difficult and less consistent during the pandemic. 

The survey – the 22nd iteration in a series of surveys the Green Center and the Primary Care Collaborative have conducted – received 580 respondents from 47 states and Guam. Over two-thirds of respondents were primary care physicians (MDs and DOs). Over half were owners, partners, or employees of a private practice, 66% of which were family medicine practices. And one fifth of respondents provided care in a rural area.

Funding and support for primary care has been wildly insufficient, Dr. Etz said in an interview. If that doesn’t change, patient health, clinic staffing, and public health strategies amid the pandemic will continue to suffer.

“When you think of the COVID vaccine, who do you think is going to be sending that out?” Dr. Etz asked. “If we don’t bolster primary care now how are they going to handle that.”
 

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

Mr. N, age 55, has a long, documented history of schizophrenia. His overall baseline functioning has been poor because he is socially isolated, does not work, and lives in subsidized housing paid for by the county where he lives. His psychosocial circumstances have limited his ability to afford or otherwise obtain nutritious food or participate in any type of regular exercise program. He has been maintained on olanzapine, 20 mg nightly, for the past 5 years. During the past year, his functioning and overall quality of life have declined even further after he was diagnosed with hypertension. Mr. N’s in-office blood pressure was 160/95 mm Hg (normal range: systolic blood pressure, 90 to 120 mm Hg, and diastolic blood pressure, 60 to 80 mm Hg). He says his primary care physician informed him that he is pre-diabetic after his hemoglobin A1c came back at 6.0 mg/dL (normal range <5.7 mg/dL) and his body mass index was 32 kg/m² (normal range 18.5 to 24.9 kg/m²). Currently, Mr. N’s psychiatric symptoms are stable, but his functional decline is now largely driven by metabolic parameters. Along with lifestyle changes and nonpharmacologic interventions, what else should you consider to help him?

In addition to positive, negative, and cognitive symptoms, schizophrenia is accompanied by disturbances in metabolism,¹ inflammatory markers,² and sleep/wake cycles.³ Current treatment strategies focus on addressing symptoms and functioning, but the metabolic and inflammatory targets that account for significant morbidity and mortality remain largely unaddressed.

Some patients with schizophrenia meet the criteria for metabolic syndrome, a cluster of conditions—including obesity, insulin resistance, dyslipidemia, and hypertension—that increase the risk of cardiovascular disease and type 2 diabetes mellitus (Table 1⁴). Metabolic syndrome and its related consequences are a major barrier to the successful treatment of patients with schizophrenia, and lead to increased mortality. Druss et al⁵ found that individuals with significant mental illness died on average 8.2 years earlier than age-matched controls. The most common cause of death was cardiovascular disease (Table 2⁵).

“Off-label” prescribing has been used in an attempt to delay or treat emerging metabolic syndrome in individuals with schizophrenia. Unfortunately, comprehensive strategies with a uniform application in clinical settings remain elusive. In this article, we review 3 off-label agents—metformin, topiramate, and melatonin—that may be used to address weight gain and metabolic syndrome in patients with schizophrenia.

Metformin

Metformin is an oral medication used to treat type 2 diabetes. It works by decreasing glucose absorption, suppressing gluconeogenesis in the liver, and increasing insulin sensitivity in peripheral tissues. It was FDA-approved for use in the United States in 1994. In addition to improving glucose homeostasis, metformin has also been associated with decreased body mass index (BMI), triglycerides, and low-density lipoprotein (LDL) cholesterol, and increased high-density lipoprotein (HDL) cholesterol in individuals at risk for diabetes.⁶

Recent consensus guidelines suggest that metformin has sufficient evidence to support its clinical use for preventing or treating antipsychotic-induced weight gain.⁷ A meta-analysis that included >40 randomized clinical trials (RCTs) found that metformin^8-11:

• reduces antipsychotic-induced weight gain (approximately 3 kg, up to 5 kg in patients with first-episode psychosis)
• reduces fasting glucose levels, hemoglobin A1c, fasting insulin levels, and insulin resistance
• leads to a more favorable lipid profile (reduced triglycerides, LDL, and total cholesterol, and increased HDL).

Not surprisingly, metformin’s effects are augmented when used in conjunction with lifestyle interventions (diet and exercise), leading to further weight reductions of 1.5 kg and BMI reductions of 1.08 kg/m² when compared with metformin alone.¹¹ The mechanism underlying metformin’s attenuation of antipsychotic-induced weight gain is not fully understood, but preclinical studies suggest that it may prevent olanzapine-induced brown adipose tissue loss,^12,13 alter Wnt signaling (an assortment of signal transduction pathways important for glucose homeostasis and metabolism),¹³ and influence the gut microbiome.¹⁴

Continue to: Metformin is generally...

Metformin is generally well tolerated. Common adverse effects include diarrhea, nausea, and abdominal pain, which are generally transient and can be ameliorated by using the extended-release formulation and lower starting doses.¹⁵ The frequency of medication discontinuation was minimal and similar in patients receiving metformin vs placebo.^8,16 Despite these positive findings, most studies of metformin have had a follow-up of ≤24 weeks, and its long-term effects on antipsychotic-induced weight gain and metabolic parameters remain unknown.

When prescribing metformin for a patient with schizophrenia, consider a starting dose of 500 mg twice daily.

Topiramate

Topiramate is FDA-approved for treating generalized tonic-clonic and complex partial seizures¹⁷ and for migraine prophylaxis. More recently, it has been used off-label for weight loss in both psychiatric and non-psychiatric patients. Topiramate’s proposed mechanism for weight loss is by decreasing plasma leptin levels and increasing plasma adiponectin. A recent literature review of 8 RCTS that included 336 patients who received second-generation antipsychotics (SGAs) and adjunctive placebo or topiramate (100 to 300 mg/d) found that patients who received topiramate lost a statistically significant 2.83 kg vs placebo.¹⁸ Several case studies confirm similar findings, showing that patients with schizophrenia lost 2 to 5 kg when started on topiramate along with an SGA.¹⁹ Importantly, weight loss has been observed both in patients started on topiramate prophylactically along with an SGA, and those who had been receiving SGAs for an extended period of time before starting topiramate.

Tolerability has been a concern in patients receiving topiramate. Frequent complaints include cognitive dulling, sedation, and coldness or tingling of the extremities. In a meta-analysis of topiramate, metformin, and other medications used to induce weight loss in patients receiving SGAs, Zhuo et al²⁰ found that topiramate was reported intolerable more frequently than other agents, although the difference was not statistically significant.

When prescribing topiramate for a patient with schizophrenia, consider a starting dose of 25 mg at bedtime.

Continue to: Melatonin

 

 

Melatonin

Melatonin is a naturally occurring hormone that is available over-the-counter and is frequently used to treat insomnia. Melatonin appears to have few adverse effects, is not habit-forming, and is inexpensive. It is a hormone produced primarily by the pineal gland, although it is also produced by many other cell types, including the skin, gut, bone marrow, thymus, and retina.^21,22 Melatonin is a highly conserved essential hormone²³ that acts via both G protein-coupled membrane bound receptors and nuclear receptors.^23-25 Its ability to function both intra- and extracellularly implies it has an essential role in maintaining homeostatic mechanisms. Melatonin’s putative mechanism of action may derive from its effects on circadian rhythms, which in turn affect systolic blood pressure, glycemic control, and oxidative stress. In rodents, pinealectomy led to the rapid development of hypertension and metabolic syndrome. Daily administration of melatonin²⁶ in these animals restored metabolism by decreasing abdominal fat and plasma leptin levels. These studies suggest that melatonin plays a central role in metabolism.

A recent study of patients with first-episode psychosis (n = 48) examined the effects of melatonin (3 mg/d) as an add-on treatment to olanzapine vs placebo.²⁷ Compared with those in the placebo group, participants in the melatonin group experienced a statistically significant decrease in body weight, BMI, waist circumference, and triglyceride levels.²⁷ In another study, the melatonin receptor agonist ramelteon was used in conjunction with SGAs.²⁸ Augmentation with ramelteon led to significantly lower rises in total cholesterol levels compared with placebo.²⁸

When recommending melatonin for a patient with schizophrenia, suggest that he/she begin by taking a starting dose of 3 mg nightly.

Weighing the options

Which medication to prescribe for a patient such as Mr. N would depend on the patient’s specific complaint/health target.

Weight gain or diabetes. If the patient’s primary concerns are avoiding weight gain or the development of diabetes, metformin is an excellent starting point.

Continue to: Migraines or desire to lose weight

Migraines or desire to lose weight. If the patient reports frequent migraines or a history of migraines, or if he/she is interested in weight loss, a trial of topiramate may be appropriate.

Sleep difficulties. If sleep is the patient’s primary concern, then adding melatonin might be a good first choice.

At this point, the available data points to metformin as the most efficacious medication in ameliorating some of the metabolic adverse effects associated with the long-term use of SGAs.^8-11 Comprehensive treatment of patients with schizophrenia should include addressing underlying metabolic issues not only to improve health outcomes and reduce morbidity and mortality, but also to improve psychosocial functioning and quality of life.

Bottom Line

Preventing or treating metabolic syndrome is an important consideration in all patients with schizophrenia. Metformin, topiramate, and melatonin show some promise in helping ameliorate metabolic syndrome and its associated morbidity and mortality, and also may help improve patients’ functioning and quality of life.

Related Resources

• Mitchell AJ, Vancampfort D, Sweers K, et al. Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders--a systematic review and meta-analysis. Schizophr Bull. 2013;39(2):306-318.
• Majeed MH, Khalil HA. Cardiovascular adverse effects of psychotropics: what to look for. Current Psychiatry. 2018; 17(7):54-55
• Wake, LA, Balon R. Should psychiatrists prescribe nonpsychotropic medications? Current Psychiatry. 2019; 18(11):52-56.

Drug Brand Names

Metformin • Glucophage
Olanzapine • Zyprexa
Ramelteon • Rozerem
Topiramate • Topamax

Mr. N, age 55, has a long, documented history of schizophrenia. His overall baseline functioning has been poor because he is socially isolated, does not work, and lives in subsidized housing paid for by the county where he lives. His psychosocial circumstances have limited his ability to afford or otherwise obtain nutritious food or participate in any type of regular exercise program. He has been maintained on olanzapine, 20 mg nightly, for the past 5 years. During the past year, his functioning and overall quality of life have declined even further after he was diagnosed with hypertension. Mr. N’s in-office blood pressure was 160/95 mm Hg (normal range: systolic blood pressure, 90 to 120 mm Hg, and diastolic blood pressure, 60 to 80 mm Hg). He says his primary care physician informed him that he is pre-diabetic after his hemoglobin A1c came back at 6.0 mg/dL (normal range <5.7 mg/dL) and his body mass index was 32 kg/m² (normal range 18.5 to 24.9 kg/m²). Currently, Mr. N’s psychiatric symptoms are stable, but his functional decline is now largely driven by metabolic parameters. Along with lifestyle changes and nonpharmacologic interventions, what else should you consider to help him?

In addition to positive, negative, and cognitive symptoms, schizophrenia is accompanied by disturbances in metabolism,¹ inflammatory markers,² and sleep/wake cycles.³ Current treatment strategies focus on addressing symptoms and functioning, but the metabolic and inflammatory targets that account for significant morbidity and mortality remain largely unaddressed.

Some patients with schizophrenia meet the criteria for metabolic syndrome, a cluster of conditions—including obesity, insulin resistance, dyslipidemia, and hypertension—that increase the risk of cardiovascular disease and type 2 diabetes mellitus (Table 1⁴). Metabolic syndrome and its related consequences are a major barrier to the successful treatment of patients with schizophrenia, and lead to increased mortality. Druss et al⁵ found that individuals with significant mental illness died on average 8.2 years earlier than age-matched controls. The most common cause of death was cardiovascular disease (Table 2⁵).

“Off-label” prescribing has been used in an attempt to delay or treat emerging metabolic syndrome in individuals with schizophrenia. Unfortunately, comprehensive strategies with a uniform application in clinical settings remain elusive. In this article, we review 3 off-label agents—metformin, topiramate, and melatonin—that may be used to address weight gain and metabolic syndrome in patients with schizophrenia.

Metformin

Metformin is an oral medication used to treat type 2 diabetes. It works by decreasing glucose absorption, suppressing gluconeogenesis in the liver, and increasing insulin sensitivity in peripheral tissues. It was FDA-approved for use in the United States in 1994. In addition to improving glucose homeostasis, metformin has also been associated with decreased body mass index (BMI), triglycerides, and low-density lipoprotein (LDL) cholesterol, and increased high-density lipoprotein (HDL) cholesterol in individuals at risk for diabetes.⁶

Recent consensus guidelines suggest that metformin has sufficient evidence to support its clinical use for preventing or treating antipsychotic-induced weight gain.⁷ A meta-analysis that included >40 randomized clinical trials (RCTs) found that metformin^8-11:

• reduces antipsychotic-induced weight gain (approximately 3 kg, up to 5 kg in patients with first-episode psychosis)
• reduces fasting glucose levels, hemoglobin A1c, fasting insulin levels, and insulin resistance
• leads to a more favorable lipid profile (reduced triglycerides, LDL, and total cholesterol, and increased HDL).

Not surprisingly, metformin’s effects are augmented when used in conjunction with lifestyle interventions (diet and exercise), leading to further weight reductions of 1.5 kg and BMI reductions of 1.08 kg/m² when compared with metformin alone.¹¹ The mechanism underlying metformin’s attenuation of antipsychotic-induced weight gain is not fully understood, but preclinical studies suggest that it may prevent olanzapine-induced brown adipose tissue loss,^12,13 alter Wnt signaling (an assortment of signal transduction pathways important for glucose homeostasis and metabolism),¹³ and influence the gut microbiome.¹⁴

Continue to: Metformin is generally...

Metformin is generally well tolerated. Common adverse effects include diarrhea, nausea, and abdominal pain, which are generally transient and can be ameliorated by using the extended-release formulation and lower starting doses.¹⁵ The frequency of medication discontinuation was minimal and similar in patients receiving metformin vs placebo.^8,16 Despite these positive findings, most studies of metformin have had a follow-up of ≤24 weeks, and its long-term effects on antipsychotic-induced weight gain and metabolic parameters remain unknown.

When prescribing metformin for a patient with schizophrenia, consider a starting dose of 500 mg twice daily.

Topiramate

Topiramate is FDA-approved for treating generalized tonic-clonic and complex partial seizures¹⁷ and for migraine prophylaxis. More recently, it has been used off-label for weight loss in both psychiatric and non-psychiatric patients. Topiramate’s proposed mechanism for weight loss is by decreasing plasma leptin levels and increasing plasma adiponectin. A recent literature review of 8 RCTS that included 336 patients who received second-generation antipsychotics (SGAs) and adjunctive placebo or topiramate (100 to 300 mg/d) found that patients who received topiramate lost a statistically significant 2.83 kg vs placebo.¹⁸ Several case studies confirm similar findings, showing that patients with schizophrenia lost 2 to 5 kg when started on topiramate along with an SGA.¹⁹ Importantly, weight loss has been observed both in patients started on topiramate prophylactically along with an SGA, and those who had been receiving SGAs for an extended period of time before starting topiramate.

Tolerability has been a concern in patients receiving topiramate. Frequent complaints include cognitive dulling, sedation, and coldness or tingling of the extremities. In a meta-analysis of topiramate, metformin, and other medications used to induce weight loss in patients receiving SGAs, Zhuo et al²⁰ found that topiramate was reported intolerable more frequently than other agents, although the difference was not statistically significant.

When prescribing topiramate for a patient with schizophrenia, consider a starting dose of 25 mg at bedtime.

Continue to: Melatonin

 

 

Melatonin

Melatonin is a naturally occurring hormone that is available over-the-counter and is frequently used to treat insomnia. Melatonin appears to have few adverse effects, is not habit-forming, and is inexpensive. It is a hormone produced primarily by the pineal gland, although it is also produced by many other cell types, including the skin, gut, bone marrow, thymus, and retina.^21,22 Melatonin is a highly conserved essential hormone²³ that acts via both G protein-coupled membrane bound receptors and nuclear receptors.^23-25 Its ability to function both intra- and extracellularly implies it has an essential role in maintaining homeostatic mechanisms. Melatonin’s putative mechanism of action may derive from its effects on circadian rhythms, which in turn affect systolic blood pressure, glycemic control, and oxidative stress. In rodents, pinealectomy led to the rapid development of hypertension and metabolic syndrome. Daily administration of melatonin²⁶ in these animals restored metabolism by decreasing abdominal fat and plasma leptin levels. These studies suggest that melatonin plays a central role in metabolism.

A recent study of patients with first-episode psychosis (n = 48) examined the effects of melatonin (3 mg/d) as an add-on treatment to olanzapine vs placebo.²⁷ Compared with those in the placebo group, participants in the melatonin group experienced a statistically significant decrease in body weight, BMI, waist circumference, and triglyceride levels.²⁷ In another study, the melatonin receptor agonist ramelteon was used in conjunction with SGAs.²⁸ Augmentation with ramelteon led to significantly lower rises in total cholesterol levels compared with placebo.²⁸

When recommending melatonin for a patient with schizophrenia, suggest that he/she begin by taking a starting dose of 3 mg nightly.

Weighing the options

Which medication to prescribe for a patient such as Mr. N would depend on the patient’s specific complaint/health target.

Weight gain or diabetes. If the patient’s primary concerns are avoiding weight gain or the development of diabetes, metformin is an excellent starting point.

Continue to: Migraines or desire to lose weight

Migraines or desire to lose weight. If the patient reports frequent migraines or a history of migraines, or if he/she is interested in weight loss, a trial of topiramate may be appropriate.

Sleep difficulties. If sleep is the patient’s primary concern, then adding melatonin might be a good first choice.

At this point, the available data points to metformin as the most efficacious medication in ameliorating some of the metabolic adverse effects associated with the long-term use of SGAs.^8-11 Comprehensive treatment of patients with schizophrenia should include addressing underlying metabolic issues not only to improve health outcomes and reduce morbidity and mortality, but also to improve psychosocial functioning and quality of life.

Bottom Line

Preventing or treating metabolic syndrome is an important consideration in all patients with schizophrenia. Metformin, topiramate, and melatonin show some promise in helping ameliorate metabolic syndrome and its associated morbidity and mortality, and also may help improve patients’ functioning and quality of life.

Related Resources

• Mitchell AJ, Vancampfort D, Sweers K, et al. Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders--a systematic review and meta-analysis. Schizophr Bull. 2013;39(2):306-318.
• Majeed MH, Khalil HA. Cardiovascular adverse effects of psychotropics: what to look for. Current Psychiatry. 2018; 17(7):54-55
• Wake, LA, Balon R. Should psychiatrists prescribe nonpsychotropic medications? Current Psychiatry. 2019; 18(11):52-56.

Drug Brand Names

Metformin • Glucophage
Olanzapine • Zyprexa
Ramelteon • Rozerem
Topiramate • Topamax

Mr. N, age 55, has a long, documented history of schizophrenia. His overall baseline functioning has been poor because he is socially isolated, does not work, and lives in subsidized housing paid for by the county where he lives. His psychosocial circumstances have limited his ability to afford or otherwise obtain nutritious food or participate in any type of regular exercise program. He has been maintained on olanzapine, 20 mg nightly, for the past 5 years. During the past year, his functioning and overall quality of life have declined even further after he was diagnosed with hypertension. Mr. N’s in-office blood pressure was 160/95 mm Hg (normal range: systolic blood pressure, 90 to 120 mm Hg, and diastolic blood pressure, 60 to 80 mm Hg). He says his primary care physician informed him that he is pre-diabetic after his hemoglobin A1c came back at 6.0 mg/dL (normal range <5.7 mg/dL) and his body mass index was 32 kg/m² (normal range 18.5 to 24.9 kg/m²). Currently, Mr. N’s psychiatric symptoms are stable, but his functional decline is now largely driven by metabolic parameters. Along with lifestyle changes and nonpharmacologic interventions, what else should you consider to help him?

In addition to positive, negative, and cognitive symptoms, schizophrenia is accompanied by disturbances in metabolism,¹ inflammatory markers,² and sleep/wake cycles.³ Current treatment strategies focus on addressing symptoms and functioning, but the metabolic and inflammatory targets that account for significant morbidity and mortality remain largely unaddressed.

Some patients with schizophrenia meet the criteria for metabolic syndrome, a cluster of conditions—including obesity, insulin resistance, dyslipidemia, and hypertension—that increase the risk of cardiovascular disease and type 2 diabetes mellitus (Table 1⁴). Metabolic syndrome and its related consequences are a major barrier to the successful treatment of patients with schizophrenia, and lead to increased mortality. Druss et al⁵ found that individuals with significant mental illness died on average 8.2 years earlier than age-matched controls. The most common cause of death was cardiovascular disease (Table 2⁵).

“Off-label” prescribing has been used in an attempt to delay or treat emerging metabolic syndrome in individuals with schizophrenia. Unfortunately, comprehensive strategies with a uniform application in clinical settings remain elusive. In this article, we review 3 off-label agents—metformin, topiramate, and melatonin—that may be used to address weight gain and metabolic syndrome in patients with schizophrenia.

Metformin

Metformin is an oral medication used to treat type 2 diabetes. It works by decreasing glucose absorption, suppressing gluconeogenesis in the liver, and increasing insulin sensitivity in peripheral tissues. It was FDA-approved for use in the United States in 1994. In addition to improving glucose homeostasis, metformin has also been associated with decreased body mass index (BMI), triglycerides, and low-density lipoprotein (LDL) cholesterol, and increased high-density lipoprotein (HDL) cholesterol in individuals at risk for diabetes.⁶

Recent consensus guidelines suggest that metformin has sufficient evidence to support its clinical use for preventing or treating antipsychotic-induced weight gain.⁷ A meta-analysis that included >40 randomized clinical trials (RCTs) found that metformin^8-11:

• reduces antipsychotic-induced weight gain (approximately 3 kg, up to 5 kg in patients with first-episode psychosis)
• reduces fasting glucose levels, hemoglobin A1c, fasting insulin levels, and insulin resistance
• leads to a more favorable lipid profile (reduced triglycerides, LDL, and total cholesterol, and increased HDL).

Not surprisingly, metformin’s effects are augmented when used in conjunction with lifestyle interventions (diet and exercise), leading to further weight reductions of 1.5 kg and BMI reductions of 1.08 kg/m² when compared with metformin alone.¹¹ The mechanism underlying metformin’s attenuation of antipsychotic-induced weight gain is not fully understood, but preclinical studies suggest that it may prevent olanzapine-induced brown adipose tissue loss,^12,13 alter Wnt signaling (an assortment of signal transduction pathways important for glucose homeostasis and metabolism),¹³ and influence the gut microbiome.¹⁴

Continue to: Metformin is generally...

Metformin is generally well tolerated. Common adverse effects include diarrhea, nausea, and abdominal pain, which are generally transient and can be ameliorated by using the extended-release formulation and lower starting doses.¹⁵ The frequency of medication discontinuation was minimal and similar in patients receiving metformin vs placebo.^8,16 Despite these positive findings, most studies of metformin have had a follow-up of ≤24 weeks, and its long-term effects on antipsychotic-induced weight gain and metabolic parameters remain unknown.

When prescribing metformin for a patient with schizophrenia, consider a starting dose of 500 mg twice daily.

Topiramate

Topiramate is FDA-approved for treating generalized tonic-clonic and complex partial seizures¹⁷ and for migraine prophylaxis. More recently, it has been used off-label for weight loss in both psychiatric and non-psychiatric patients. Topiramate’s proposed mechanism for weight loss is by decreasing plasma leptin levels and increasing plasma adiponectin. A recent literature review of 8 RCTS that included 336 patients who received second-generation antipsychotics (SGAs) and adjunctive placebo or topiramate (100 to 300 mg/d) found that patients who received topiramate lost a statistically significant 2.83 kg vs placebo.¹⁸ Several case studies confirm similar findings, showing that patients with schizophrenia lost 2 to 5 kg when started on topiramate along with an SGA.¹⁹ Importantly, weight loss has been observed both in patients started on topiramate prophylactically along with an SGA, and those who had been receiving SGAs for an extended period of time before starting topiramate.

Tolerability has been a concern in patients receiving topiramate. Frequent complaints include cognitive dulling, sedation, and coldness or tingling of the extremities. In a meta-analysis of topiramate, metformin, and other medications used to induce weight loss in patients receiving SGAs, Zhuo et al²⁰ found that topiramate was reported intolerable more frequently than other agents, although the difference was not statistically significant.

When prescribing topiramate for a patient with schizophrenia, consider a starting dose of 25 mg at bedtime.

Continue to: Melatonin

 

 

Melatonin

Melatonin is a naturally occurring hormone that is available over-the-counter and is frequently used to treat insomnia. Melatonin appears to have few adverse effects, is not habit-forming, and is inexpensive. It is a hormone produced primarily by the pineal gland, although it is also produced by many other cell types, including the skin, gut, bone marrow, thymus, and retina.^21,22 Melatonin is a highly conserved essential hormone²³ that acts via both G protein-coupled membrane bound receptors and nuclear receptors.^23-25 Its ability to function both intra- and extracellularly implies it has an essential role in maintaining homeostatic mechanisms. Melatonin’s putative mechanism of action may derive from its effects on circadian rhythms, which in turn affect systolic blood pressure, glycemic control, and oxidative stress. In rodents, pinealectomy led to the rapid development of hypertension and metabolic syndrome. Daily administration of melatonin²⁶ in these animals restored metabolism by decreasing abdominal fat and plasma leptin levels. These studies suggest that melatonin plays a central role in metabolism.

A recent study of patients with first-episode psychosis (n = 48) examined the effects of melatonin (3 mg/d) as an add-on treatment to olanzapine vs placebo.²⁷ Compared with those in the placebo group, participants in the melatonin group experienced a statistically significant decrease in body weight, BMI, waist circumference, and triglyceride levels.²⁷ In another study, the melatonin receptor agonist ramelteon was used in conjunction with SGAs.²⁸ Augmentation with ramelteon led to significantly lower rises in total cholesterol levels compared with placebo.²⁸

When recommending melatonin for a patient with schizophrenia, suggest that he/she begin by taking a starting dose of 3 mg nightly.

Weighing the options

Which medication to prescribe for a patient such as Mr. N would depend on the patient’s specific complaint/health target.

Weight gain or diabetes. If the patient’s primary concerns are avoiding weight gain or the development of diabetes, metformin is an excellent starting point.

Continue to: Migraines or desire to lose weight

Migraines or desire to lose weight. If the patient reports frequent migraines or a history of migraines, or if he/she is interested in weight loss, a trial of topiramate may be appropriate.

Sleep difficulties. If sleep is the patient’s primary concern, then adding melatonin might be a good first choice.

At this point, the available data points to metformin as the most efficacious medication in ameliorating some of the metabolic adverse effects associated with the long-term use of SGAs.^8-11 Comprehensive treatment of patients with schizophrenia should include addressing underlying metabolic issues not only to improve health outcomes and reduce morbidity and mortality, but also to improve psychosocial functioning and quality of life.

Bottom Line

Preventing or treating metabolic syndrome is an important consideration in all patients with schizophrenia. Metformin, topiramate, and melatonin show some promise in helping ameliorate metabolic syndrome and its associated morbidity and mortality, and also may help improve patients’ functioning and quality of life.

Related Resources

• Mitchell AJ, Vancampfort D, Sweers K, et al. Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders--a systematic review and meta-analysis. Schizophr Bull. 2013;39(2):306-318.
• Majeed MH, Khalil HA. Cardiovascular adverse effects of psychotropics: what to look for. Current Psychiatry. 2018; 17(7):54-55
• Wake, LA, Balon R. Should psychiatrists prescribe nonpsychotropic medications? Current Psychiatry. 2019; 18(11):52-56.

Drug Brand Names

Metformin • Glucophage
Olanzapine • Zyprexa
Ramelteon • Rozerem
Topiramate • Topamax