Commentary

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

A new report by the Veterans Healthcare Policy Institute (VHPI) documents how elements included in many bills passed on Capitol Hill have failed to improve the efficacy of mental health services for our nation’s former service members.¹ The authors argue that while these efforts may be well intended, they often compound problems by squandering precious financial resources and stretching an already overtaxed workforce. Clearly, there are shortcomings in the US Department of Veterans Affairs (VA), our nation’s largest integrated health care system, but rather than bash the VA, as the media and Congress tend to favor, let’s learn from its successes as we improve its services.

To do this we must avoid several policy pitfalls. Consider, for example, the VA MISSION Act (38 USC § 1703), which aimed to increase veteran access to quality health care outside the VA system. Studies confirmed that private sector mental health providers are not ready to deliver veteran-specific mental health care.^2,3 Indeed, a RAND report found that psychotherapists in the private sector were unlikely to have the requisite skills necessary to deliver high-quality mental health care to service members or veterans.⁴

The MISSION Act meant to fix this clinical deficit by directing that competency standards be set for non-VA mental health providers who treat veterans for posttraumatic stress disorder (PTSD), traumatic brain injury, and military sexual trauma. But to date, no minimum competency standards have been set for non-VA mental health providers who treat veterans’ common psychological conditions. A license is all they need.

Legislation like the MISSION Act and the newly passed Commander John Scott Hannon Act (38 USC § 101) also assume that veterans who are suicidal or have mental health problems and don’t go to the VA will seek care from private sector providers. Nothing is further from the truth. Many veterans are deeply resistant to seeking mental health care no matter where that care is delivered.^4,5 Sometimes veterans believe that mental health problems are a sign of weakness and are loathe to seek help.

To address this issue, the VA pioneered models of integrated mental health and primary care services.⁶ This means that if a veteran goes to an outpatient primary care clinic at a VA medical facility or community-based outpatient clinic and discusses a mental health or substance abuse problem, the veteran can get immediate care with a mental health provider without making a separate mental health appointment. In addition, the VA already provides routine, annual screening for PTSD and sexual assault as well as depression and substance abuse at all its primary care clinics nationwide. Thanks to comprehensive screening (at a level unknown in most other health care systems) even if a veteran doesn’t spontaneously report a trauma history or mental health distress, VA is able to identify the problem and offer help right in the primary care clinic. This one-stop shopping reduces the shame and stigma of having to make an appointment with a mental health provider, allows treatment to begin immediately, and reduces no shows at follow-up appointments.

Other health care systems are trying to copy the VA model of integrated primary and mental health care, but given our fragmented insurance system, it’s not easy to replicate.⁷ According to Suzanne Gordon coauthor of the VHPI study, “This VA innovation encourages veterans, socialized by the military to conceal serious mental health problems, to get immediate help. So do many other VA programs, like peer support groups and networks. Legislation needs to strengthen, not weaken, such programs that are almost impossible to reproduce in the private sector.” Outside of VA, mental health challenges faced by veterans likely go undetected, and many veterans will not receive the care that might change, or even save, their lives.

VA best practices include an unprecedented national training initiative on 16 evidence-based psychotherapies that has been in operation for more than a decade.⁸ These high-quality treatments target debilitating conditions such as depression, PTSD, substance use disorders, insomnia, and chronic pain.^9-13 More than 12,700 VA mental health providers have received training in these evidence-based psychotherapies.

“There is no way that non-VA health care systems can ever duplicate the quality of training and supervision that has now been provided, nationally, to VA mental health professionals,” Josef Ruzek, PhD, former Director of the VA National Center for PTSD Dissemination and Training Division told me in a phone conversation (January 14, 2021). “Their program of training and implementation in the very best treatments for veteran mental health conditions stands as an international model of a complex, well-executed, large-scale program to improve mental health service delivery and improve the outcomes of treatment.”

The VA not only paid for the training of these mental health providers, but also contributed substantial efforts to assist in the implementation and sustainability of such practices. These include policy changes mandating their availability at all VA facilities, designation of local evidence-based coordinators at each medical center, and even a nationwide PTSD mentoring program to help PTSD clinic managers make organizational changes and to guide the efforts of any VA clinician seeking advice on how to engage and work with a veteran living with PTSD.¹⁴ All these incredible dissemination and implementation endeavors have resulted in a substantial overall decrease in mental health symptoms and substance misuse behaviors and increase in functional outcomes, like improvement in relationship functioning and increase in quality of life for many veterans.

As a trauma psychologist and former VA employee, I urge lawmakers to assure that veterans are not sent to private sector providers who don’t understand their unique needs and aren’t trained to serve them well, and to similarly assure that systems of care are carefully designed to meet the specific needs of veterans.

A new report by the Veterans Healthcare Policy Institute (VHPI) documents how elements included in many bills passed on Capitol Hill have failed to improve the efficacy of mental health services for our nation’s former service members.¹ The authors argue that while these efforts may be well intended, they often compound problems by squandering precious financial resources and stretching an already overtaxed workforce. Clearly, there are shortcomings in the US Department of Veterans Affairs (VA), our nation’s largest integrated health care system, but rather than bash the VA, as the media and Congress tend to favor, let’s learn from its successes as we improve its services.

To do this we must avoid several policy pitfalls. Consider, for example, the VA MISSION Act (38 USC § 1703), which aimed to increase veteran access to quality health care outside the VA system. Studies confirmed that private sector mental health providers are not ready to deliver veteran-specific mental health care.^2,3 Indeed, a RAND report found that psychotherapists in the private sector were unlikely to have the requisite skills necessary to deliver high-quality mental health care to service members or veterans.⁴

The MISSION Act meant to fix this clinical deficit by directing that competency standards be set for non-VA mental health providers who treat veterans for posttraumatic stress disorder (PTSD), traumatic brain injury, and military sexual trauma. But to date, no minimum competency standards have been set for non-VA mental health providers who treat veterans’ common psychological conditions. A license is all they need.

Legislation like the MISSION Act and the newly passed Commander John Scott Hannon Act (38 USC § 101) also assume that veterans who are suicidal or have mental health problems and don’t go to the VA will seek care from private sector providers. Nothing is further from the truth. Many veterans are deeply resistant to seeking mental health care no matter where that care is delivered.^4,5 Sometimes veterans believe that mental health problems are a sign of weakness and are loathe to seek help.

To address this issue, the VA pioneered models of integrated mental health and primary care services.⁶ This means that if a veteran goes to an outpatient primary care clinic at a VA medical facility or community-based outpatient clinic and discusses a mental health or substance abuse problem, the veteran can get immediate care with a mental health provider without making a separate mental health appointment. In addition, the VA already provides routine, annual screening for PTSD and sexual assault as well as depression and substance abuse at all its primary care clinics nationwide. Thanks to comprehensive screening (at a level unknown in most other health care systems) even if a veteran doesn’t spontaneously report a trauma history or mental health distress, VA is able to identify the problem and offer help right in the primary care clinic. This one-stop shopping reduces the shame and stigma of having to make an appointment with a mental health provider, allows treatment to begin immediately, and reduces no shows at follow-up appointments.

Other health care systems are trying to copy the VA model of integrated primary and mental health care, but given our fragmented insurance system, it’s not easy to replicate.⁷ According to Suzanne Gordon coauthor of the VHPI study, “This VA innovation encourages veterans, socialized by the military to conceal serious mental health problems, to get immediate help. So do many other VA programs, like peer support groups and networks. Legislation needs to strengthen, not weaken, such programs that are almost impossible to reproduce in the private sector.” Outside of VA, mental health challenges faced by veterans likely go undetected, and many veterans will not receive the care that might change, or even save, their lives.

VA best practices include an unprecedented national training initiative on 16 evidence-based psychotherapies that has been in operation for more than a decade.⁸ These high-quality treatments target debilitating conditions such as depression, PTSD, substance use disorders, insomnia, and chronic pain.^9-13 More than 12,700 VA mental health providers have received training in these evidence-based psychotherapies.

“There is no way that non-VA health care systems can ever duplicate the quality of training and supervision that has now been provided, nationally, to VA mental health professionals,” Josef Ruzek, PhD, former Director of the VA National Center for PTSD Dissemination and Training Division told me in a phone conversation (January 14, 2021). “Their program of training and implementation in the very best treatments for veteran mental health conditions stands as an international model of a complex, well-executed, large-scale program to improve mental health service delivery and improve the outcomes of treatment.”

The VA not only paid for the training of these mental health providers, but also contributed substantial efforts to assist in the implementation and sustainability of such practices. These include policy changes mandating their availability at all VA facilities, designation of local evidence-based coordinators at each medical center, and even a nationwide PTSD mentoring program to help PTSD clinic managers make organizational changes and to guide the efforts of any VA clinician seeking advice on how to engage and work with a veteran living with PTSD.¹⁴ All these incredible dissemination and implementation endeavors have resulted in a substantial overall decrease in mental health symptoms and substance misuse behaviors and increase in functional outcomes, like improvement in relationship functioning and increase in quality of life for many veterans.

As a trauma psychologist and former VA employee, I urge lawmakers to assure that veterans are not sent to private sector providers who don’t understand their unique needs and aren’t trained to serve them well, and to similarly assure that systems of care are carefully designed to meet the specific needs of veterans.

A new report by the Veterans Healthcare Policy Institute (VHPI) documents how elements included in many bills passed on Capitol Hill have failed to improve the efficacy of mental health services for our nation’s former service members.¹ The authors argue that while these efforts may be well intended, they often compound problems by squandering precious financial resources and stretching an already overtaxed workforce. Clearly, there are shortcomings in the US Department of Veterans Affairs (VA), our nation’s largest integrated health care system, but rather than bash the VA, as the media and Congress tend to favor, let’s learn from its successes as we improve its services.

To do this we must avoid several policy pitfalls. Consider, for example, the VA MISSION Act (38 USC § 1703), which aimed to increase veteran access to quality health care outside the VA system. Studies confirmed that private sector mental health providers are not ready to deliver veteran-specific mental health care.^2,3 Indeed, a RAND report found that psychotherapists in the private sector were unlikely to have the requisite skills necessary to deliver high-quality mental health care to service members or veterans.⁴

The MISSION Act meant to fix this clinical deficit by directing that competency standards be set for non-VA mental health providers who treat veterans for posttraumatic stress disorder (PTSD), traumatic brain injury, and military sexual trauma. But to date, no minimum competency standards have been set for non-VA mental health providers who treat veterans’ common psychological conditions. A license is all they need.

Legislation like the MISSION Act and the newly passed Commander John Scott Hannon Act (38 USC § 101) also assume that veterans who are suicidal or have mental health problems and don’t go to the VA will seek care from private sector providers. Nothing is further from the truth. Many veterans are deeply resistant to seeking mental health care no matter where that care is delivered.^4,5 Sometimes veterans believe that mental health problems are a sign of weakness and are loathe to seek help.

To address this issue, the VA pioneered models of integrated mental health and primary care services.⁶ This means that if a veteran goes to an outpatient primary care clinic at a VA medical facility or community-based outpatient clinic and discusses a mental health or substance abuse problem, the veteran can get immediate care with a mental health provider without making a separate mental health appointment. In addition, the VA already provides routine, annual screening for PTSD and sexual assault as well as depression and substance abuse at all its primary care clinics nationwide. Thanks to comprehensive screening (at a level unknown in most other health care systems) even if a veteran doesn’t spontaneously report a trauma history or mental health distress, VA is able to identify the problem and offer help right in the primary care clinic. This one-stop shopping reduces the shame and stigma of having to make an appointment with a mental health provider, allows treatment to begin immediately, and reduces no shows at follow-up appointments.

Other health care systems are trying to copy the VA model of integrated primary and mental health care, but given our fragmented insurance system, it’s not easy to replicate.⁷ According to Suzanne Gordon coauthor of the VHPI study, “This VA innovation encourages veterans, socialized by the military to conceal serious mental health problems, to get immediate help. So do many other VA programs, like peer support groups and networks. Legislation needs to strengthen, not weaken, such programs that are almost impossible to reproduce in the private sector.” Outside of VA, mental health challenges faced by veterans likely go undetected, and many veterans will not receive the care that might change, or even save, their lives.

VA best practices include an unprecedented national training initiative on 16 evidence-based psychotherapies that has been in operation for more than a decade.⁸ These high-quality treatments target debilitating conditions such as depression, PTSD, substance use disorders, insomnia, and chronic pain.^9-13 More than 12,700 VA mental health providers have received training in these evidence-based psychotherapies.

“There is no way that non-VA health care systems can ever duplicate the quality of training and supervision that has now been provided, nationally, to VA mental health professionals,” Josef Ruzek, PhD, former Director of the VA National Center for PTSD Dissemination and Training Division told me in a phone conversation (January 14, 2021). “Their program of training and implementation in the very best treatments for veteran mental health conditions stands as an international model of a complex, well-executed, large-scale program to improve mental health service delivery and improve the outcomes of treatment.”

The VA not only paid for the training of these mental health providers, but also contributed substantial efforts to assist in the implementation and sustainability of such practices. These include policy changes mandating their availability at all VA facilities, designation of local evidence-based coordinators at each medical center, and even a nationwide PTSD mentoring program to help PTSD clinic managers make organizational changes and to guide the efforts of any VA clinician seeking advice on how to engage and work with a veteran living with PTSD.¹⁴ All these incredible dissemination and implementation endeavors have resulted in a substantial overall decrease in mental health symptoms and substance misuse behaviors and increase in functional outcomes, like improvement in relationship functioning and increase in quality of life for many veterans.

As a trauma psychologist and former VA employee, I urge lawmakers to assure that veterans are not sent to private sector providers who don’t understand their unique needs and aren’t trained to serve them well, and to similarly assure that systems of care are carefully designed to meet the specific needs of veterans.

The Journal of Family Practice rightfully places a high priority on evidence-based practice by including “strength of evidence” qualifiers to help physicians analyze scientific studies and emphasizing campaigns that encourage good stewardship of medical resources. The editorial “When patients don’t get the care they should” (J Fam Pract. 2020;69:427) struck on an often-neglected aspect of evidence-based practice: the increase in care provided by nonphysician practitioners.

Henry Silver, MD, created the first pediatric nurse practitioner (NP) training program at the University of Colorado in 1965. That same year, Eugene Stead, MD, created the first physician assistant (PA) program at Duke University. The goal of both professions was simple: to create physician extenders to reach medically needy patients in underserved areas. But over the past 20 years, NPs and PAs have increasingly sought—and legislatively gained—independent practice, the right to treat patients without physician supervision.

Studies show that nonphysician practitioners order more labs and radiographic tests and prescribe more medications— including antibiotics—than physicians.

Here’s where evidence-based practice comes in. Despite claims by NP advocates that “50 years of evidence” shows safe and effective practice, the truth is that there is no scientific evidence that nonphysicians can practice safely and effectively without physician supervision. The best meta-analysis of nurse practitioner care, a Cochrane review, found only 18 studies of adequate quality to analyze.¹ Of these, only 3 were performed in the United States, and every single study in the Cochrane review involved nurses working under physician supervision or following physician-­created protocols. Yes, even supposedly independent NPs in Mary Mundinger’s famous 2000 study were practicing under a collaborating physician, as required by New York statute at the time. In addition, NPs in the study were assigned a physician mentor and received an additional 9 months of training with medical residents.

Regarding the emphasis for physicians to “choose wisely,” research raises concerns about an overuse of health care resources by nonphysician practitioners.Studies show that nonphysician practitioners order more labs² and radiographic tests³ than physicians; prescribe more medications, including opioids,⁴ antipsychotics,⁴ and antibiotics⁵ than physicians; place lower-quality referrals than physicians⁶; and perform significantly more biopsies than physicians to diagnose malignant neoplasms in patients < 65 years.⁷ 

As the rate of nonphysician practitioners increases (significantly outpacing the growth of physicians), we must be cognizant of the rising risks to our patients in the absence of appropriate physician oversight.⁸ This issue is so concerning to me that I co-authored a book on the subject.⁸ I encourage all physicians to educate themselves on this topic and make practice decisions with the evidence in mind.

The Journal of Family Practice rightfully places a high priority on evidence-based practice by including “strength of evidence” qualifiers to help physicians analyze scientific studies and emphasizing campaigns that encourage good stewardship of medical resources. The editorial “When patients don’t get the care they should” (J Fam Pract. 2020;69:427) struck on an often-neglected aspect of evidence-based practice: the increase in care provided by nonphysician practitioners.

Henry Silver, MD, created the first pediatric nurse practitioner (NP) training program at the University of Colorado in 1965. That same year, Eugene Stead, MD, created the first physician assistant (PA) program at Duke University. The goal of both professions was simple: to create physician extenders to reach medically needy patients in underserved areas. But over the past 20 years, NPs and PAs have increasingly sought—and legislatively gained—independent practice, the right to treat patients without physician supervision.

Studies show that nonphysician practitioners order more labs and radiographic tests and prescribe more medications— including antibiotics—than physicians.

Here’s where evidence-based practice comes in. Despite claims by NP advocates that “50 years of evidence” shows safe and effective practice, the truth is that there is no scientific evidence that nonphysicians can practice safely and effectively without physician supervision. The best meta-analysis of nurse practitioner care, a Cochrane review, found only 18 studies of adequate quality to analyze.¹ Of these, only 3 were performed in the United States, and every single study in the Cochrane review involved nurses working under physician supervision or following physician-­created protocols. Yes, even supposedly independent NPs in Mary Mundinger’s famous 2000 study were practicing under a collaborating physician, as required by New York statute at the time. In addition, NPs in the study were assigned a physician mentor and received an additional 9 months of training with medical residents.

Regarding the emphasis for physicians to “choose wisely,” research raises concerns about an overuse of health care resources by nonphysician practitioners.Studies show that nonphysician practitioners order more labs² and radiographic tests³ than physicians; prescribe more medications, including opioids,⁴ antipsychotics,⁴ and antibiotics⁵ than physicians; place lower-quality referrals than physicians⁶; and perform significantly more biopsies than physicians to diagnose malignant neoplasms in patients < 65 years.⁷ 

As the rate of nonphysician practitioners increases (significantly outpacing the growth of physicians), we must be cognizant of the rising risks to our patients in the absence of appropriate physician oversight.⁸ This issue is so concerning to me that I co-authored a book on the subject.⁸ I encourage all physicians to educate themselves on this topic and make practice decisions with the evidence in mind.

The Journal of Family Practice rightfully places a high priority on evidence-based practice by including “strength of evidence” qualifiers to help physicians analyze scientific studies and emphasizing campaigns that encourage good stewardship of medical resources. The editorial “When patients don’t get the care they should” (J Fam Pract. 2020;69:427) struck on an often-neglected aspect of evidence-based practice: the increase in care provided by nonphysician practitioners.

Henry Silver, MD, created the first pediatric nurse practitioner (NP) training program at the University of Colorado in 1965. That same year, Eugene Stead, MD, created the first physician assistant (PA) program at Duke University. The goal of both professions was simple: to create physician extenders to reach medically needy patients in underserved areas. But over the past 20 years, NPs and PAs have increasingly sought—and legislatively gained—independent practice, the right to treat patients without physician supervision.

Studies show that nonphysician practitioners order more labs and radiographic tests and prescribe more medications— including antibiotics—than physicians.

Here’s where evidence-based practice comes in. Despite claims by NP advocates that “50 years of evidence” shows safe and effective practice, the truth is that there is no scientific evidence that nonphysicians can practice safely and effectively without physician supervision. The best meta-analysis of nurse practitioner care, a Cochrane review, found only 18 studies of adequate quality to analyze.¹ Of these, only 3 were performed in the United States, and every single study in the Cochrane review involved nurses working under physician supervision or following physician-­created protocols. Yes, even supposedly independent NPs in Mary Mundinger’s famous 2000 study were practicing under a collaborating physician, as required by New York statute at the time. In addition, NPs in the study were assigned a physician mentor and received an additional 9 months of training with medical residents.

Regarding the emphasis for physicians to “choose wisely,” research raises concerns about an overuse of health care resources by nonphysician practitioners.Studies show that nonphysician practitioners order more labs² and radiographic tests³ than physicians; prescribe more medications, including opioids,⁴ antipsychotics,⁴ and antibiotics⁵ than physicians; place lower-quality referrals than physicians⁶; and perform significantly more biopsies than physicians to diagnose malignant neoplasms in patients < 65 years.⁷ 

As the rate of nonphysician practitioners increases (significantly outpacing the growth of physicians), we must be cognizant of the rising risks to our patients in the absence of appropriate physician oversight.⁸ This issue is so concerning to me that I co-authored a book on the subject.⁸ I encourage all physicians to educate themselves on this topic and make practice decisions with the evidence in mind.

This transcript has been edited for clarity.

I’m Dr. Gregory Scott Brown, an Austin (Tex.)-based psychiatrist and an affiliate faculty member at the University of Texas Dell Medical School.

Recently, a patient of mine told me that, because of the political environment we find ourselves in, he’s avoiding conversations with some of his longtime friends. Because of this, he’s feeling even more isolated than before.

We’re all coming off the heels of a tough year, and many of us expected that when we entered 2021 we’d quickly turn the page and life would get a whole lot easier. Since the reality is that we’re still dealing with deep divisions, social injustices, and the politicization of evidence-based medicine, emotions are naturally running high.

In listening to my patients over the past few weeks, there’s definitely a sense of optimism about coronavirus vaccines and getting back to life as usual. But there’s also a lingering sense of uncertainty and fear, especially when it comes to the possibility of saying the wrong thing, offending our friends, or just having conversations with people we may disagree with. I’m hearing concerns from my patients that 2020 exposed a dormant hatred that was brewing in the underbelly of our society, in our politics, and in our institutions. Patients are telling me that these concerns are making them anxious and some are avoiding interacting with people they may disagree with altogether because they’re afraid of the difficult conversations that may follow.

Since, like many of my patients as well as many of you, I follow the news, including stories of COVID-related deaths, economic hardships, peaceful protests gone bad, and political vitriol, I’ve had to remind myself about the importance of intentional kindness for effective communication and for supporting mental health.

I was reminded of the paper “Hate in the Counter-Transference” by the well-known pediatrician and psychoanalyst Donald Winnicott. He focuses on how to manage and sort through the strong emotions that may be experienced even during an encounter between a therapist and a patient. Although some of what he has to say doesn’t translate well to modern times, his recommendation that we acknowledge and try to normalize some of our feelings does. And this is how I’ve been starting a conversation with my patients – just by normalizing things a bit.

The past year or so has brought with it a range of intense emotions, including frustration, exhaustion, and some degree of sadness for most of us. When we’re self-aware about our feelings, we can make sense of them early on so that they don’t evolve into maladaptive ones like unhinged anger or hatred. My patients and I actively discuss how our feelings don’t have to get in the way of our ability to live and to interact with each other as we’d like to.

Considering the basic tenets of kindness is a good place to start. I recently spoke with Kelli Harding, MD, a psychiatrist and author of The Rabbit Effect: Live Longer, Happier, and Healthier with the Groundbreaking Science of Kindness. She pointed to research suggesting that kindness can benefit multiple areas of our health, from reducing cardiovascular events to improving mood and anxiety. In her book, she notes that the major contributor to outcomes in health isn’t our genetics, as we might think, it’s other determinants, like our political and social environment.

I tell my patients that we can’t always change our environment, but we can definitely change how we respond to it. This doesn’t mean it’s always an easy process, but there are things we can do. First, we have to acknowledge that some degree of conflict or cordial disagreement is inevitable and it doesn’t have to disrupt our mood.

An interesting study on conflict management pointed out that healthy conflict is actually beneficial in some cases. For instance, in the work environment, conflict can help with team development and better group decision-making. But it’s rigid personality differences, poor communication, emotional stress, and lack of candor that may contribute to so-called high-tension events, and this is where conflict can go awry. These are the areas that we can all focus on improving, not only for performance benefits but for our overall health and well-being as well.

The authors also recommend an active style of engagement as a technique to manage conflict, but in a way that feels both natural and safe. Other authors agree that so-called engaged coping is associated with a higher sense of control and overall improved psychological well-being. What this means is that avoidance may be necessary in the short term, but over time it may lead to more emotional stress and anxiety.

Overcoming the tendency to avoid requires both motivation and self-awareness. We need to know about patterns in our own behavior and how the behavior of others can push our buttons and spiral a healthy disagreement into a heated argument.

I like to recommend the hunger, angry, lonely, tired (HALT) model, which is often used as a self-care gauge in addiction treatment and to reduce medication errors. But I think it’s also a useful way to assess personal readiness for having a difficult conversation. I tell my patients to ask themselves in this moment: “Am I hungry, angry, lonely, or tired?” And if they are, perhaps it’s not the best time for the conversation.

Because 2020 brought with it a new set of challenges, it also forced many of us to focus on things that we just didn’t pay as much attention to before, including checking in on our feelings and the feelings of those around us. It also taught us to pay attention to the way and manner in which we communicate. I think that kindness is much easier to carry into difficult conversations if we approach them with a sense of curiosity before judgment. Ultimately, kindness is one of the best tools for balancing the intense emotions that many of us are feeling right now.

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

This transcript has been edited for clarity.

I’m Dr. Gregory Scott Brown, an Austin (Tex.)-based psychiatrist and an affiliate faculty member at the University of Texas Dell Medical School.

Recently, a patient of mine told me that, because of the political environment we find ourselves in, he’s avoiding conversations with some of his longtime friends. Because of this, he’s feeling even more isolated than before.

We’re all coming off the heels of a tough year, and many of us expected that when we entered 2021 we’d quickly turn the page and life would get a whole lot easier. Since the reality is that we’re still dealing with deep divisions, social injustices, and the politicization of evidence-based medicine, emotions are naturally running high.

In listening to my patients over the past few weeks, there’s definitely a sense of optimism about coronavirus vaccines and getting back to life as usual. But there’s also a lingering sense of uncertainty and fear, especially when it comes to the possibility of saying the wrong thing, offending our friends, or just having conversations with people we may disagree with. I’m hearing concerns from my patients that 2020 exposed a dormant hatred that was brewing in the underbelly of our society, in our politics, and in our institutions. Patients are telling me that these concerns are making them anxious and some are avoiding interacting with people they may disagree with altogether because they’re afraid of the difficult conversations that may follow.

Since, like many of my patients as well as many of you, I follow the news, including stories of COVID-related deaths, economic hardships, peaceful protests gone bad, and political vitriol, I’ve had to remind myself about the importance of intentional kindness for effective communication and for supporting mental health.

I was reminded of the paper “Hate in the Counter-Transference” by the well-known pediatrician and psychoanalyst Donald Winnicott. He focuses on how to manage and sort through the strong emotions that may be experienced even during an encounter between a therapist and a patient. Although some of what he has to say doesn’t translate well to modern times, his recommendation that we acknowledge and try to normalize some of our feelings does. And this is how I’ve been starting a conversation with my patients – just by normalizing things a bit.

The past year or so has brought with it a range of intense emotions, including frustration, exhaustion, and some degree of sadness for most of us. When we’re self-aware about our feelings, we can make sense of them early on so that they don’t evolve into maladaptive ones like unhinged anger or hatred. My patients and I actively discuss how our feelings don’t have to get in the way of our ability to live and to interact with each other as we’d like to.

Considering the basic tenets of kindness is a good place to start. I recently spoke with Kelli Harding, MD, a psychiatrist and author of The Rabbit Effect: Live Longer, Happier, and Healthier with the Groundbreaking Science of Kindness. She pointed to research suggesting that kindness can benefit multiple areas of our health, from reducing cardiovascular events to improving mood and anxiety. In her book, she notes that the major contributor to outcomes in health isn’t our genetics, as we might think, it’s other determinants, like our political and social environment.

I tell my patients that we can’t always change our environment, but we can definitely change how we respond to it. This doesn’t mean it’s always an easy process, but there are things we can do. First, we have to acknowledge that some degree of conflict or cordial disagreement is inevitable and it doesn’t have to disrupt our mood.

An interesting study on conflict management pointed out that healthy conflict is actually beneficial in some cases. For instance, in the work environment, conflict can help with team development and better group decision-making. But it’s rigid personality differences, poor communication, emotional stress, and lack of candor that may contribute to so-called high-tension events, and this is where conflict can go awry. These are the areas that we can all focus on improving, not only for performance benefits but for our overall health and well-being as well.

The authors also recommend an active style of engagement as a technique to manage conflict, but in a way that feels both natural and safe. Other authors agree that so-called engaged coping is associated with a higher sense of control and overall improved psychological well-being. What this means is that avoidance may be necessary in the short term, but over time it may lead to more emotional stress and anxiety.

Overcoming the tendency to avoid requires both motivation and self-awareness. We need to know about patterns in our own behavior and how the behavior of others can push our buttons and spiral a healthy disagreement into a heated argument.

I like to recommend the hunger, angry, lonely, tired (HALT) model, which is often used as a self-care gauge in addiction treatment and to reduce medication errors. But I think it’s also a useful way to assess personal readiness for having a difficult conversation. I tell my patients to ask themselves in this moment: “Am I hungry, angry, lonely, or tired?” And if they are, perhaps it’s not the best time for the conversation.

Because 2020 brought with it a new set of challenges, it also forced many of us to focus on things that we just didn’t pay as much attention to before, including checking in on our feelings and the feelings of those around us. It also taught us to pay attention to the way and manner in which we communicate. I think that kindness is much easier to carry into difficult conversations if we approach them with a sense of curiosity before judgment. Ultimately, kindness is one of the best tools for balancing the intense emotions that many of us are feeling right now.

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

This transcript has been edited for clarity.

I’m Dr. Gregory Scott Brown, an Austin (Tex.)-based psychiatrist and an affiliate faculty member at the University of Texas Dell Medical School.

Recently, a patient of mine told me that, because of the political environment we find ourselves in, he’s avoiding conversations with some of his longtime friends. Because of this, he’s feeling even more isolated than before.

We’re all coming off the heels of a tough year, and many of us expected that when we entered 2021 we’d quickly turn the page and life would get a whole lot easier. Since the reality is that we’re still dealing with deep divisions, social injustices, and the politicization of evidence-based medicine, emotions are naturally running high.

In listening to my patients over the past few weeks, there’s definitely a sense of optimism about coronavirus vaccines and getting back to life as usual. But there’s also a lingering sense of uncertainty and fear, especially when it comes to the possibility of saying the wrong thing, offending our friends, or just having conversations with people we may disagree with. I’m hearing concerns from my patients that 2020 exposed a dormant hatred that was brewing in the underbelly of our society, in our politics, and in our institutions. Patients are telling me that these concerns are making them anxious and some are avoiding interacting with people they may disagree with altogether because they’re afraid of the difficult conversations that may follow.

Since, like many of my patients as well as many of you, I follow the news, including stories of COVID-related deaths, economic hardships, peaceful protests gone bad, and political vitriol, I’ve had to remind myself about the importance of intentional kindness for effective communication and for supporting mental health.

I was reminded of the paper “Hate in the Counter-Transference” by the well-known pediatrician and psychoanalyst Donald Winnicott. He focuses on how to manage and sort through the strong emotions that may be experienced even during an encounter between a therapist and a patient. Although some of what he has to say doesn’t translate well to modern times, his recommendation that we acknowledge and try to normalize some of our feelings does. And this is how I’ve been starting a conversation with my patients – just by normalizing things a bit.

The past year or so has brought with it a range of intense emotions, including frustration, exhaustion, and some degree of sadness for most of us. When we’re self-aware about our feelings, we can make sense of them early on so that they don’t evolve into maladaptive ones like unhinged anger or hatred. My patients and I actively discuss how our feelings don’t have to get in the way of our ability to live and to interact with each other as we’d like to.

Considering the basic tenets of kindness is a good place to start. I recently spoke with Kelli Harding, MD, a psychiatrist and author of The Rabbit Effect: Live Longer, Happier, and Healthier with the Groundbreaking Science of Kindness. She pointed to research suggesting that kindness can benefit multiple areas of our health, from reducing cardiovascular events to improving mood and anxiety. In her book, she notes that the major contributor to outcomes in health isn’t our genetics, as we might think, it’s other determinants, like our political and social environment.

I tell my patients that we can’t always change our environment, but we can definitely change how we respond to it. This doesn’t mean it’s always an easy process, but there are things we can do. First, we have to acknowledge that some degree of conflict or cordial disagreement is inevitable and it doesn’t have to disrupt our mood.

An interesting study on conflict management pointed out that healthy conflict is actually beneficial in some cases. For instance, in the work environment, conflict can help with team development and better group decision-making. But it’s rigid personality differences, poor communication, emotional stress, and lack of candor that may contribute to so-called high-tension events, and this is where conflict can go awry. These are the areas that we can all focus on improving, not only for performance benefits but for our overall health and well-being as well.

The authors also recommend an active style of engagement as a technique to manage conflict, but in a way that feels both natural and safe. Other authors agree that so-called engaged coping is associated with a higher sense of control and overall improved psychological well-being. What this means is that avoidance may be necessary in the short term, but over time it may lead to more emotional stress and anxiety.

Overcoming the tendency to avoid requires both motivation and self-awareness. We need to know about patterns in our own behavior and how the behavior of others can push our buttons and spiral a healthy disagreement into a heated argument.

I like to recommend the hunger, angry, lonely, tired (HALT) model, which is often used as a self-care gauge in addiction treatment and to reduce medication errors. But I think it’s also a useful way to assess personal readiness for having a difficult conversation. I tell my patients to ask themselves in this moment: “Am I hungry, angry, lonely, or tired?” And if they are, perhaps it’s not the best time for the conversation.

Because 2020 brought with it a new set of challenges, it also forced many of us to focus on things that we just didn’t pay as much attention to before, including checking in on our feelings and the feelings of those around us. It also taught us to pay attention to the way and manner in which we communicate. I think that kindness is much easier to carry into difficult conversations if we approach them with a sense of curiosity before judgment. Ultimately, kindness is one of the best tools for balancing the intense emotions that many of us are feeling right now.

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

A 16-year-old patient sits in front of you and says, “I think I’m transgender.”

Origovisualis/Getty Images

What do you do?

Whether you are an endocrinologist, family physician, pediatrician, or emergency physician, it’s probably a situation for which medical school education did not sufficiently prepare you. What you know is that you want to do your best to guide your patient and offer every resource necessary for a healthy and happy life. The good news is that your patient trusted you enough to disclose this information to you.

Sadly, this isn’t always the case. About 23% of transgender adults responding to the 2015 U.S. Transgender Survey put off necessary health care because they fear being mistreated or disrespected. Nearly one-third (31%) of survey respondents reported that none of their health care providers knew they were transgender.

Now that your patient feels comfortable enough with you to share this information, you must make sure you do everything in your power to continue to earn your patient’s trust.
 

Language matters

First, make sure that you are respectful with your terminology. Ask the patient for their name, pronouns, and gender identity. For example: “My name is Dr. Pine, and my pronouns are she/her. What are your pronouns? How do you describe your gender identity?” Each person may have terminology that is specific to their own experience, so allowing people to use their own language is the most respectful method.

People may identify as male, female, transwoman, transman, gender fluid, nonbinary, agender, neutrois, pangender, two-spirit, or other options not listed here. Physicians can be supportive by ensuring that their paperwork or electronic medical systems are sensitive to the needs of the transgender community. Having an option for the patient’s chosen name is courteous to all patients, regardless of gender identity; not everyone uses their legal name in everyday conversation.

Paperwork and electronic medical systems should ask for gender identity and sex assigned at birth, allow write-in options for issues of gender and sexual orientation, and ask for an anatomical inventory or organ inventory so that cancer screening can be conducted for the appropriate body parts.
 

Questions to ask

Ask patients about their gender journey: How long have they felt this way? How did they come to understand themselves and their gender? When did they start to disclose their experience with others? With pediatric patients, I ask if they have discussed this with their parents/guardians, and if they would like to have that conversation together.

Ask how you can support the patient on their journey. Are they interested in therapy, puberty blockers, hormones, or surgery? People may seek therapy for help coping with internalized transphobia, family rejection, or stigma. They may also want information or support with accessing hormones or surgery. In addition to individual therapy, there are numerous support groups for children, individuals, parents/guardians, and partners, such as PFLAG.org and Genderspectrum.org.

If you are the right kind of doctor and ready to prescribe, you can begin counseling. If not, you should know how to find local resources. The World Professional Association for Transgender Health has a directory of providers, and there are other resources listed below.
 

What does gender transitioning entail?

There are many components to gender transition. Some transitions may consist primarily of a social transition, with people using a different name, pronouns, and external expression, such as hairstyle and clothing. For others, there may be a medical component.

Mental health care is also an important component of gender transition for children, adolescents, adults, and family members. Mental health concerns are significantly greater in transgender and gender-nonconforming people, with higher rates of depression, anxiety, suicidal ideation, self-harm, substance abuse, eating disorders, and neurodiversity on the autism spectrum. In a study of more than 6,400 transgender people in the United States, 41% reported attempting suicide – a rate 25 times higher than that of the general population. Numerous studies show that hormonal treatment decreases depression, suicidal ideation, and anxiety, and also improves quality of life.

One common misperception, especially when working with children, is that youth transition involves a “sex change” (an outdated term) or any type of surgery. In reality, the main intervention before puberty is psychological support and social transition. The use of a chosen name at school, home, work, and with friends was shown to be associated with lower depression, suicidal ideation, and suicidal behavior. Another study demonstrated that children supported in their identities have mental health similar to that of cisgender siblings and peers.

When puberty approaches, if there is distress around natal pubertal development, then gonadotropin-releasing hormone agonists or “puberty blockers” may be used to temporarily pause the pubertal process, but only after Tanner stage II-III is reached. These medications have been safely used for decades for patients with central precocious puberty. Access to puberty-blocking medication in adolescence (when desired) has been associated with lower rates of suicidal ideation in adulthood and can truly be a lifesaving intervention.

When teens are older, they may choose to take gender-affirming hormone therapy to go through the puberty that is concordant with their affirmed gender. Adults who decide to transition medically may decide to take hormone therapy and may have gender-confirmation surgery, if desired, to align the body with their gender identity and alleviate gender dysphoria. Overall, access to medical care and hormone therapy have been shown to decrease depression, anxiety, and suicidality, and improve quality of life.
 

Sexuality and fertility

It is important to understand that sexuality is separate from gender identity, and that attraction and sexual activity cannot be assumed. Take a sensitive romantic and sexual history from your patient to get the information necessary to counsel patients about safe relationships and sexual practices. It is important not to make assumptions; a patient who is asexual may still be having sex, and a transgender man may be having receptive vaginal intercourse and may need information about contraception and family planning.

Also, be careful about using clinical language. Some people may want to use anatomical terms, but others may be uncomfortable or triggered by them. For instance, a transgender man may use “chest” for breasts, or “genital canal,” and “junk,” “dick,” or “front hole” for the vagina. Ask patients what terms they prefer to use.

It is also important to consider the impact that medical and surgical interventions may have on fertility, especially when discussing the topic with children and adolescents who may not have spent much time thinking about family planning. Be careful not to make assumptions about plans for parenthood, and remember that there are many paths to becoming a parent.
 

What does the patient need right now?

When I was a fourth-year medical student on my outpatient child psychiatry rotation, a 5-year-old child assigned male at birth was guarded and frightened of me until their mother said: “It’s okay, Dr. Elyse likes girl things too,” at which point the child became animated and happy while chatting with me about Barbie dolls. My patient had already endured teasing about gender nonconformity, starting in kindergarten; it was unclear to my patient whether I would be a safe person or a bully.

The mother was kind and affirming, but she also wanted answers. Would her child grow up to be a gay man? Or a transgender woman? Would her child be able to live freely, or would they always be quiet around others, scared of what people might say? Would her child be safe?

We can’t predict the future, but as doctors, we want to use all of our knowledge and tools to help our patients live healthy lives. In this case, it meant helping the mother know how to support her child’s identity, how to advocate for a safe school and community, where to connect with other gender-creative children, and how to tolerate ambiguity and celebrate the child she has, not the child she expected.

We know that people with higher support and higher self-esteem can have greater resilience and greater success. This family may need medical resources for puberty blockers, hormone therapy, and even surgery someday, but reassurance is what was needed in the moment. When your patient comes out to you, they are trusting you. It is your obligation and privilege as a medical professional to help them begin a journey to an authentic life.

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

A 16-year-old patient sits in front of you and says, “I think I’m transgender.”

Origovisualis/Getty Images

What do you do?

Whether you are an endocrinologist, family physician, pediatrician, or emergency physician, it’s probably a situation for which medical school education did not sufficiently prepare you. What you know is that you want to do your best to guide your patient and offer every resource necessary for a healthy and happy life. The good news is that your patient trusted you enough to disclose this information to you.

Sadly, this isn’t always the case. About 23% of transgender adults responding to the 2015 U.S. Transgender Survey put off necessary health care because they fear being mistreated or disrespected. Nearly one-third (31%) of survey respondents reported that none of their health care providers knew they were transgender.

Now that your patient feels comfortable enough with you to share this information, you must make sure you do everything in your power to continue to earn your patient’s trust.
 

Language matters

First, make sure that you are respectful with your terminology. Ask the patient for their name, pronouns, and gender identity. For example: “My name is Dr. Pine, and my pronouns are she/her. What are your pronouns? How do you describe your gender identity?” Each person may have terminology that is specific to their own experience, so allowing people to use their own language is the most respectful method.

People may identify as male, female, transwoman, transman, gender fluid, nonbinary, agender, neutrois, pangender, two-spirit, or other options not listed here. Physicians can be supportive by ensuring that their paperwork or electronic medical systems are sensitive to the needs of the transgender community. Having an option for the patient’s chosen name is courteous to all patients, regardless of gender identity; not everyone uses their legal name in everyday conversation.

Paperwork and electronic medical systems should ask for gender identity and sex assigned at birth, allow write-in options for issues of gender and sexual orientation, and ask for an anatomical inventory or organ inventory so that cancer screening can be conducted for the appropriate body parts.
 

Questions to ask

Ask patients about their gender journey: How long have they felt this way? How did they come to understand themselves and their gender? When did they start to disclose their experience with others? With pediatric patients, I ask if they have discussed this with their parents/guardians, and if they would like to have that conversation together.

Ask how you can support the patient on their journey. Are they interested in therapy, puberty blockers, hormones, or surgery? People may seek therapy for help coping with internalized transphobia, family rejection, or stigma. They may also want information or support with accessing hormones or surgery. In addition to individual therapy, there are numerous support groups for children, individuals, parents/guardians, and partners, such as PFLAG.org and Genderspectrum.org.

If you are the right kind of doctor and ready to prescribe, you can begin counseling. If not, you should know how to find local resources. The World Professional Association for Transgender Health has a directory of providers, and there are other resources listed below.
 

What does gender transitioning entail?

There are many components to gender transition. Some transitions may consist primarily of a social transition, with people using a different name, pronouns, and external expression, such as hairstyle and clothing. For others, there may be a medical component.

Mental health care is also an important component of gender transition for children, adolescents, adults, and family members. Mental health concerns are significantly greater in transgender and gender-nonconforming people, with higher rates of depression, anxiety, suicidal ideation, self-harm, substance abuse, eating disorders, and neurodiversity on the autism spectrum. In a study of more than 6,400 transgender people in the United States, 41% reported attempting suicide – a rate 25 times higher than that of the general population. Numerous studies show that hormonal treatment decreases depression, suicidal ideation, and anxiety, and also improves quality of life.

One common misperception, especially when working with children, is that youth transition involves a “sex change” (an outdated term) or any type of surgery. In reality, the main intervention before puberty is psychological support and social transition. The use of a chosen name at school, home, work, and with friends was shown to be associated with lower depression, suicidal ideation, and suicidal behavior. Another study demonstrated that children supported in their identities have mental health similar to that of cisgender siblings and peers.

When puberty approaches, if there is distress around natal pubertal development, then gonadotropin-releasing hormone agonists or “puberty blockers” may be used to temporarily pause the pubertal process, but only after Tanner stage II-III is reached. These medications have been safely used for decades for patients with central precocious puberty. Access to puberty-blocking medication in adolescence (when desired) has been associated with lower rates of suicidal ideation in adulthood and can truly be a lifesaving intervention.

When teens are older, they may choose to take gender-affirming hormone therapy to go through the puberty that is concordant with their affirmed gender. Adults who decide to transition medically may decide to take hormone therapy and may have gender-confirmation surgery, if desired, to align the body with their gender identity and alleviate gender dysphoria. Overall, access to medical care and hormone therapy have been shown to decrease depression, anxiety, and suicidality, and improve quality of life.
 

Sexuality and fertility

It is important to understand that sexuality is separate from gender identity, and that attraction and sexual activity cannot be assumed. Take a sensitive romantic and sexual history from your patient to get the information necessary to counsel patients about safe relationships and sexual practices. It is important not to make assumptions; a patient who is asexual may still be having sex, and a transgender man may be having receptive vaginal intercourse and may need information about contraception and family planning.

Also, be careful about using clinical language. Some people may want to use anatomical terms, but others may be uncomfortable or triggered by them. For instance, a transgender man may use “chest” for breasts, or “genital canal,” and “junk,” “dick,” or “front hole” for the vagina. Ask patients what terms they prefer to use.

It is also important to consider the impact that medical and surgical interventions may have on fertility, especially when discussing the topic with children and adolescents who may not have spent much time thinking about family planning. Be careful not to make assumptions about plans for parenthood, and remember that there are many paths to becoming a parent.
 

What does the patient need right now?

When I was a fourth-year medical student on my outpatient child psychiatry rotation, a 5-year-old child assigned male at birth was guarded and frightened of me until their mother said: “It’s okay, Dr. Elyse likes girl things too,” at which point the child became animated and happy while chatting with me about Barbie dolls. My patient had already endured teasing about gender nonconformity, starting in kindergarten; it was unclear to my patient whether I would be a safe person or a bully.

The mother was kind and affirming, but she also wanted answers. Would her child grow up to be a gay man? Or a transgender woman? Would her child be able to live freely, or would they always be quiet around others, scared of what people might say? Would her child be safe?

We can’t predict the future, but as doctors, we want to use all of our knowledge and tools to help our patients live healthy lives. In this case, it meant helping the mother know how to support her child’s identity, how to advocate for a safe school and community, where to connect with other gender-creative children, and how to tolerate ambiguity and celebrate the child she has, not the child she expected.

We know that people with higher support and higher self-esteem can have greater resilience and greater success. This family may need medical resources for puberty blockers, hormone therapy, and even surgery someday, but reassurance is what was needed in the moment. When your patient comes out to you, they are trusting you. It is your obligation and privilege as a medical professional to help them begin a journey to an authentic life.

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

A 16-year-old patient sits in front of you and says, “I think I’m transgender.”

Origovisualis/Getty Images

What do you do?

Whether you are an endocrinologist, family physician, pediatrician, or emergency physician, it’s probably a situation for which medical school education did not sufficiently prepare you. What you know is that you want to do your best to guide your patient and offer every resource necessary for a healthy and happy life. The good news is that your patient trusted you enough to disclose this information to you.

Sadly, this isn’t always the case. About 23% of transgender adults responding to the 2015 U.S. Transgender Survey put off necessary health care because they fear being mistreated or disrespected. Nearly one-third (31%) of survey respondents reported that none of their health care providers knew they were transgender.

Now that your patient feels comfortable enough with you to share this information, you must make sure you do everything in your power to continue to earn your patient’s trust.
 

Language matters

First, make sure that you are respectful with your terminology. Ask the patient for their name, pronouns, and gender identity. For example: “My name is Dr. Pine, and my pronouns are she/her. What are your pronouns? How do you describe your gender identity?” Each person may have terminology that is specific to their own experience, so allowing people to use their own language is the most respectful method.

People may identify as male, female, transwoman, transman, gender fluid, nonbinary, agender, neutrois, pangender, two-spirit, or other options not listed here. Physicians can be supportive by ensuring that their paperwork or electronic medical systems are sensitive to the needs of the transgender community. Having an option for the patient’s chosen name is courteous to all patients, regardless of gender identity; not everyone uses their legal name in everyday conversation.

Paperwork and electronic medical systems should ask for gender identity and sex assigned at birth, allow write-in options for issues of gender and sexual orientation, and ask for an anatomical inventory or organ inventory so that cancer screening can be conducted for the appropriate body parts.
 

Questions to ask

Ask patients about their gender journey: How long have they felt this way? How did they come to understand themselves and their gender? When did they start to disclose their experience with others? With pediatric patients, I ask if they have discussed this with their parents/guardians, and if they would like to have that conversation together.

Ask how you can support the patient on their journey. Are they interested in therapy, puberty blockers, hormones, or surgery? People may seek therapy for help coping with internalized transphobia, family rejection, or stigma. They may also want information or support with accessing hormones or surgery. In addition to individual therapy, there are numerous support groups for children, individuals, parents/guardians, and partners, such as PFLAG.org and Genderspectrum.org.

If you are the right kind of doctor and ready to prescribe, you can begin counseling. If not, you should know how to find local resources. The World Professional Association for Transgender Health has a directory of providers, and there are other resources listed below.
 

What does gender transitioning entail?

There are many components to gender transition. Some transitions may consist primarily of a social transition, with people using a different name, pronouns, and external expression, such as hairstyle and clothing. For others, there may be a medical component.

Mental health care is also an important component of gender transition for children, adolescents, adults, and family members. Mental health concerns are significantly greater in transgender and gender-nonconforming people, with higher rates of depression, anxiety, suicidal ideation, self-harm, substance abuse, eating disorders, and neurodiversity on the autism spectrum. In a study of more than 6,400 transgender people in the United States, 41% reported attempting suicide – a rate 25 times higher than that of the general population. Numerous studies show that hormonal treatment decreases depression, suicidal ideation, and anxiety, and also improves quality of life.

One common misperception, especially when working with children, is that youth transition involves a “sex change” (an outdated term) or any type of surgery. In reality, the main intervention before puberty is psychological support and social transition. The use of a chosen name at school, home, work, and with friends was shown to be associated with lower depression, suicidal ideation, and suicidal behavior. Another study demonstrated that children supported in their identities have mental health similar to that of cisgender siblings and peers.

When puberty approaches, if there is distress around natal pubertal development, then gonadotropin-releasing hormone agonists or “puberty blockers” may be used to temporarily pause the pubertal process, but only after Tanner stage II-III is reached. These medications have been safely used for decades for patients with central precocious puberty. Access to puberty-blocking medication in adolescence (when desired) has been associated with lower rates of suicidal ideation in adulthood and can truly be a lifesaving intervention.

When teens are older, they may choose to take gender-affirming hormone therapy to go through the puberty that is concordant with their affirmed gender. Adults who decide to transition medically may decide to take hormone therapy and may have gender-confirmation surgery, if desired, to align the body with their gender identity and alleviate gender dysphoria. Overall, access to medical care and hormone therapy have been shown to decrease depression, anxiety, and suicidality, and improve quality of life.
 

Sexuality and fertility

It is important to understand that sexuality is separate from gender identity, and that attraction and sexual activity cannot be assumed. Take a sensitive romantic and sexual history from your patient to get the information necessary to counsel patients about safe relationships and sexual practices. It is important not to make assumptions; a patient who is asexual may still be having sex, and a transgender man may be having receptive vaginal intercourse and may need information about contraception and family planning.

Also, be careful about using clinical language. Some people may want to use anatomical terms, but others may be uncomfortable or triggered by them. For instance, a transgender man may use “chest” for breasts, or “genital canal,” and “junk,” “dick,” or “front hole” for the vagina. Ask patients what terms they prefer to use.

It is also important to consider the impact that medical and surgical interventions may have on fertility, especially when discussing the topic with children and adolescents who may not have spent much time thinking about family planning. Be careful not to make assumptions about plans for parenthood, and remember that there are many paths to becoming a parent.
 

What does the patient need right now?

When I was a fourth-year medical student on my outpatient child psychiatry rotation, a 5-year-old child assigned male at birth was guarded and frightened of me until their mother said: “It’s okay, Dr. Elyse likes girl things too,” at which point the child became animated and happy while chatting with me about Barbie dolls. My patient had already endured teasing about gender nonconformity, starting in kindergarten; it was unclear to my patient whether I would be a safe person or a bully.

The mother was kind and affirming, but she also wanted answers. Would her child grow up to be a gay man? Or a transgender woman? Would her child be able to live freely, or would they always be quiet around others, scared of what people might say? Would her child be safe?

We can’t predict the future, but as doctors, we want to use all of our knowledge and tools to help our patients live healthy lives. In this case, it meant helping the mother know how to support her child’s identity, how to advocate for a safe school and community, where to connect with other gender-creative children, and how to tolerate ambiguity and celebrate the child she has, not the child she expected.

We know that people with higher support and higher self-esteem can have greater resilience and greater success. This family may need medical resources for puberty blockers, hormone therapy, and even surgery someday, but reassurance is what was needed in the moment. When your patient comes out to you, they are trusting you. It is your obligation and privilege as a medical professional to help them begin a journey to an authentic life.

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

What happened to Hasan Gokal, MD, should stick painfully in the craws of all physicians. It should serve as a call to action, because Dr. Gokal is sitting at home today without a job and under threat of further legal action while we continue about our day.

Dr. Gokal’s “crime” is that he vaccinated 10 strangers and acquaintances with soon-to-expire doses of the Moderna COVID-19 vaccine. He drove to the homes of some in the dark of night and injected others on his Sugar Land, Texas, lawn. He spent hours in a frantic search for willing recipients to beat the expiration clock. With minutes to spare, he gave the last dose to his at-risk wife, who has symptomatic pulmonary sarcoidosis, but whose age meant she did not fall into a vaccine priority tier.

According to the New York Times, Dr. Gokal’s wife was hesitant, afraid he might get into trouble. But why would she be hesitant? He wasn’t doing anything immoral. Perhaps she knew how far physicians have fallen and how bitterly they both could suffer.

In Barren County, Ky., where I live, a state of emergency was declared by our judge executive because of inclement weather. This directive allows our emergency management to “waive procedures and formalities otherwise required by the law.” It’s too bad that the same courtesy was not afforded to Dr. Gokal in Texas. It’s a shame that ice and snow didn’t drive his actions. Perhaps that would have protected him against the harsh criticism. Rather, it was his oath to patients and dedication to his fellow humans that motivated him, and for that, he was made to suffer.

Dr. Gokal was right to think that pouring the last 10 vaccine doses down the toilet would be an egregious act. But he was wrong in thinking his decision to find takers for the vaccine would be viewed as expedient. Instead, he was accused of graft and even nepotism. And there is the rub. That he was fired and charged with the theft of $137 worth of vaccines says everything about how physicians are treated in the year 2021. Dr. Gokal’s lawyer says the charge carried a maximum penalty of 1 year in prison and a fine of nearly $4,000.

Thank God a sage judge threw out the case and “rebuked” the office of District Attorney Kim Ogg. That hasn’t stopped her from threatening to bring the case to a grand jury. That threat invites anyone faced with the same scenario to flush the extra vaccine doses into the septic system. It encourages us to choose the toilet handle to avoid a mug shot.

And we can’t ignore the racial slant to this story. The Times reported that Dr. Gokal asked the officials, “Are you suggesting that there were too many Indian names in this group?”

“Exactly” was the answer. Let that sink in.

None of this would have happened 20 years ago. Back then, no one would have questioned the wisdom a physician gains from all our years of training and residency. In an age when anyone who conducts an office visit is now called “doctor,” respect for the letters “MD” has been leveled. We physicians have lost our autonomy and been cowed into submission.

But whatever his profession, Hasan Gokal was fired for being a good human. Today, the sun rose on 10 individuals who now enjoy better protection against a deadly pandemic. They include a bed-bound nonagenarian. A woman in her 80s with dementia. A mother with a child who uses a ventilator. All now have antibodies against SARS-CoV2 because of the tireless actions of Dr. Gokal.

Yet Dr. Gokal’s future is uncertain. Will we help him, or will we leave him to the wolves? In an email exchange with his lawyer’s office, I learned that Dr. Gokal has received offers of employment but is unable to entertain them because the actions by the Harris County District Attorney triggered an automatic review by the Texas Medical Board. A GoFundMe page was launched, but an appreciative Dr. Gokal stated publicly that he’d rather the money go to a needy charity.

 In the last paragraph of the Times article, Dr. Gokal asks, “How can I take it back?” referencing stories about “the Pakistani doctor in Houston who stole all those vaccines.”

Let’s help him take back his story. In helping him, perhaps we can take back a little control. We could start with letters of support that could be mailed to his lawyer, Paul Doyle, Esq., of Houston, or tweet, respectfully of course, to the district attorney @Kimoggforda.

We can also let the Harris County Public Health Department in Houston know what we think of their actions.

On Martin Luther King Day, Kim Ogg, the district attorney who charged Dr. Gokal, tweeted MLK’s famous quote: “Injustice anywhere is a threat to justice everywhere.”

Let that motivate us to action.

Melissa Walton-Shirley, MD, is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband, daughters and parents, and sidelines as a backing vocalist for local rock bands. A version of this article first appeared on Medscape.com.

What happened to Hasan Gokal, MD, should stick painfully in the craws of all physicians. It should serve as a call to action, because Dr. Gokal is sitting at home today without a job and under threat of further legal action while we continue about our day.

Dr. Gokal’s “crime” is that he vaccinated 10 strangers and acquaintances with soon-to-expire doses of the Moderna COVID-19 vaccine. He drove to the homes of some in the dark of night and injected others on his Sugar Land, Texas, lawn. He spent hours in a frantic search for willing recipients to beat the expiration clock. With minutes to spare, he gave the last dose to his at-risk wife, who has symptomatic pulmonary sarcoidosis, but whose age meant she did not fall into a vaccine priority tier.

According to the New York Times, Dr. Gokal’s wife was hesitant, afraid he might get into trouble. But why would she be hesitant? He wasn’t doing anything immoral. Perhaps she knew how far physicians have fallen and how bitterly they both could suffer.

In Barren County, Ky., where I live, a state of emergency was declared by our judge executive because of inclement weather. This directive allows our emergency management to “waive procedures and formalities otherwise required by the law.” It’s too bad that the same courtesy was not afforded to Dr. Gokal in Texas. It’s a shame that ice and snow didn’t drive his actions. Perhaps that would have protected him against the harsh criticism. Rather, it was his oath to patients and dedication to his fellow humans that motivated him, and for that, he was made to suffer.

Dr. Gokal was right to think that pouring the last 10 vaccine doses down the toilet would be an egregious act. But he was wrong in thinking his decision to find takers for the vaccine would be viewed as expedient. Instead, he was accused of graft and even nepotism. And there is the rub. That he was fired and charged with the theft of $137 worth of vaccines says everything about how physicians are treated in the year 2021. Dr. Gokal’s lawyer says the charge carried a maximum penalty of 1 year in prison and a fine of nearly $4,000.

Thank God a sage judge threw out the case and “rebuked” the office of District Attorney Kim Ogg. That hasn’t stopped her from threatening to bring the case to a grand jury. That threat invites anyone faced with the same scenario to flush the extra vaccine doses into the septic system. It encourages us to choose the toilet handle to avoid a mug shot.

And we can’t ignore the racial slant to this story. The Times reported that Dr. Gokal asked the officials, “Are you suggesting that there were too many Indian names in this group?”

“Exactly” was the answer. Let that sink in.

None of this would have happened 20 years ago. Back then, no one would have questioned the wisdom a physician gains from all our years of training and residency. In an age when anyone who conducts an office visit is now called “doctor,” respect for the letters “MD” has been leveled. We physicians have lost our autonomy and been cowed into submission.

But whatever his profession, Hasan Gokal was fired for being a good human. Today, the sun rose on 10 individuals who now enjoy better protection against a deadly pandemic. They include a bed-bound nonagenarian. A woman in her 80s with dementia. A mother with a child who uses a ventilator. All now have antibodies against SARS-CoV2 because of the tireless actions of Dr. Gokal.

Yet Dr. Gokal’s future is uncertain. Will we help him, or will we leave him to the wolves? In an email exchange with his lawyer’s office, I learned that Dr. Gokal has received offers of employment but is unable to entertain them because the actions by the Harris County District Attorney triggered an automatic review by the Texas Medical Board. A GoFundMe page was launched, but an appreciative Dr. Gokal stated publicly that he’d rather the money go to a needy charity.

 In the last paragraph of the Times article, Dr. Gokal asks, “How can I take it back?” referencing stories about “the Pakistani doctor in Houston who stole all those vaccines.”

Let’s help him take back his story. In helping him, perhaps we can take back a little control. We could start with letters of support that could be mailed to his lawyer, Paul Doyle, Esq., of Houston, or tweet, respectfully of course, to the district attorney @Kimoggforda.

We can also let the Harris County Public Health Department in Houston know what we think of their actions.

On Martin Luther King Day, Kim Ogg, the district attorney who charged Dr. Gokal, tweeted MLK’s famous quote: “Injustice anywhere is a threat to justice everywhere.”

Let that motivate us to action.

Melissa Walton-Shirley, MD, is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband, daughters and parents, and sidelines as a backing vocalist for local rock bands. A version of this article first appeared on Medscape.com.

What happened to Hasan Gokal, MD, should stick painfully in the craws of all physicians. It should serve as a call to action, because Dr. Gokal is sitting at home today without a job and under threat of further legal action while we continue about our day.

Dr. Gokal’s “crime” is that he vaccinated 10 strangers and acquaintances with soon-to-expire doses of the Moderna COVID-19 vaccine. He drove to the homes of some in the dark of night and injected others on his Sugar Land, Texas, lawn. He spent hours in a frantic search for willing recipients to beat the expiration clock. With minutes to spare, he gave the last dose to his at-risk wife, who has symptomatic pulmonary sarcoidosis, but whose age meant she did not fall into a vaccine priority tier.

According to the New York Times, Dr. Gokal’s wife was hesitant, afraid he might get into trouble. But why would she be hesitant? He wasn’t doing anything immoral. Perhaps she knew how far physicians have fallen and how bitterly they both could suffer.

In Barren County, Ky., where I live, a state of emergency was declared by our judge executive because of inclement weather. This directive allows our emergency management to “waive procedures and formalities otherwise required by the law.” It’s too bad that the same courtesy was not afforded to Dr. Gokal in Texas. It’s a shame that ice and snow didn’t drive his actions. Perhaps that would have protected him against the harsh criticism. Rather, it was his oath to patients and dedication to his fellow humans that motivated him, and for that, he was made to suffer.

Dr. Gokal was right to think that pouring the last 10 vaccine doses down the toilet would be an egregious act. But he was wrong in thinking his decision to find takers for the vaccine would be viewed as expedient. Instead, he was accused of graft and even nepotism. And there is the rub. That he was fired and charged with the theft of $137 worth of vaccines says everything about how physicians are treated in the year 2021. Dr. Gokal’s lawyer says the charge carried a maximum penalty of 1 year in prison and a fine of nearly $4,000.

Thank God a sage judge threw out the case and “rebuked” the office of District Attorney Kim Ogg. That hasn’t stopped her from threatening to bring the case to a grand jury. That threat invites anyone faced with the same scenario to flush the extra vaccine doses into the septic system. It encourages us to choose the toilet handle to avoid a mug shot.

And we can’t ignore the racial slant to this story. The Times reported that Dr. Gokal asked the officials, “Are you suggesting that there were too many Indian names in this group?”

“Exactly” was the answer. Let that sink in.

None of this would have happened 20 years ago. Back then, no one would have questioned the wisdom a physician gains from all our years of training and residency. In an age when anyone who conducts an office visit is now called “doctor,” respect for the letters “MD” has been leveled. We physicians have lost our autonomy and been cowed into submission.

But whatever his profession, Hasan Gokal was fired for being a good human. Today, the sun rose on 10 individuals who now enjoy better protection against a deadly pandemic. They include a bed-bound nonagenarian. A woman in her 80s with dementia. A mother with a child who uses a ventilator. All now have antibodies against SARS-CoV2 because of the tireless actions of Dr. Gokal.

Yet Dr. Gokal’s future is uncertain. Will we help him, or will we leave him to the wolves? In an email exchange with his lawyer’s office, I learned that Dr. Gokal has received offers of employment but is unable to entertain them because the actions by the Harris County District Attorney triggered an automatic review by the Texas Medical Board. A GoFundMe page was launched, but an appreciative Dr. Gokal stated publicly that he’d rather the money go to a needy charity.

 In the last paragraph of the Times article, Dr. Gokal asks, “How can I take it back?” referencing stories about “the Pakistani doctor in Houston who stole all those vaccines.”

Let’s help him take back his story. In helping him, perhaps we can take back a little control. We could start with letters of support that could be mailed to his lawyer, Paul Doyle, Esq., of Houston, or tweet, respectfully of course, to the district attorney @Kimoggforda.

We can also let the Harris County Public Health Department in Houston know what we think of their actions.

On Martin Luther King Day, Kim Ogg, the district attorney who charged Dr. Gokal, tweeted MLK’s famous quote: “Injustice anywhere is a threat to justice everywhere.”

Let that motivate us to action.

Melissa Walton-Shirley, MD, is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband, daughters and parents, and sidelines as a backing vocalist for local rock bands. A version of this article first appeared on Medscape.com.

Two themes have emerged recently in my psychotherapy practice, and in the mirror: relief and exhaustion. Some peace in the public discourse, or at least a pause in the ominous discord, has had the effect of a lightening, an unburdening. Some release from a contracted sense of tension around the specifics of violence and a broader sense of civil fracture has been palpable like a big, deep breath, exhaled. No sensible person would mistake this for being out of the metaphoric woods. A virus menaces and mutates, economic woes follow, and lots of us don’t get along. But, yes, there is some relief, some good change.

But even good change, even a downshift into relief, can pose some challenges to look for and overcome.

Consider for a moment the notion that every change represents a loss, a metaphoric “death” of the prior state of things. This is true of big, painful losses, like the death of a loved one, and small ones, like finding an empty cookie jar. It’s also true in changes we associate with benefit or relief: a refund check, a job promotion, a resolving migraine, or the breaking out of some civility.

In changes of all sorts, the world outside of one’s mind has shifted – at odds, momentarily, with our inner, now obsolete understanding of that changed world. The inside of the head does not match the outside. How we make that adjustment, so “inside = outside,” is a clinically familiar process: it’s grieving, with a sequence famously elaborated upon by Elisabeth Kübler-Ross, MD,¹ and others.

We all likely know the steps: shock/denial, anger, “bargaining,” depression, and acceptance. A quick review: Our initial anxious/threat reaction leads to grievous judgment, to rationalizing “woulda/coulda/shoulda’s,” then to truly landing in the disappointment of a loss or change, and the accepting of a new steady state. Inside proceeds to match outside.

So, what then of relief? How do we process “good” change? I think we still must move from “in ≠ out” to “in = out,” navigating some pitfalls along the way.

Initial threat often remains; apprehension of the “new” still can generate energy, and even a sense of threat, regardless of a kiss or a shove. Our brainstems run roughshod over this first phase.

Step two is about judgment. We can move past the threat to, “How do I feel about it?” Here’s where grievous feeling gets swapped out for something more peak-positive – joy, or relief if the change represents an ending of a state of suffering, tension, or uncertainty.

The “bargaining” step still happens, but often around a kind of testing regimen: Is this too good to be true? Is it really different? We run scenarios.

The thud of disappointment also gets a makeover. It’s a settling into the beneficial change and its associations: gratitude, a sense of energy shifting.

The bookend “OK” seems anodyne here – why would anyone not accept relief, some good change?² But it can nevertheless represent a challenge for many. The receding tension of the last year could open into a burst of energy, but I’m finding that exhaustion is just as or more common. That’s not illness, but a weary exhaling from the longest of held breaths.

One other twist: What happens when one of those steps is an individual obstacle, trigger, or hard-to-hold state? Especially for those with deep experience in disappointment or even trauma, buying into acceptance of a new normal can feel like a fool’s game. This is an especially complex spot for individuals who won’t quite allow for joyful acceptance to break out, lest it reveals itself as a humiliating trick or a too-brief respite from the “usual.”

Mindfulness practices, such as meditation, are helpful in managing this process. Committed time and optimal conditions to witness and adapt to the various inner states that ebb and flow generate a clear therapeutic benefit. Incorporating meditation training into my work with psychotherapy patients also becomes a kind of diagnostic force multiplier. Patients improve their identification of somatic manifestations, emotional reactions, and cycling ruminations of thought. What generates distraction and loss of mindful attention becomes better recognized. Contemplative work in between sessions becomes more productive.

What else do I advise?³ Patience, and some compassion for ourselves in this unusual time. Grief, and relief, are complex but truly human processes that generate not just one state of experience, but a cascade of them. While that cascade can hurt, it’s actually normal, not illness. But it can be exhausting.
 

Dr. Sazima is a Northern California psychiatrist, educator, and author. He is senior behavioral faculty at the Stanford-O’Connor Family Medicine Residency Program in San José, Calif. His latest book is “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021. Dr. Sazima disclosed no relevant financial relationships.

References

1. Kübler-Ross E. “On Death And Dying,” New York: Simon & Schuster, 1969.

2. Selye H. “Stress Without Distress,” New York: Lippincott, Williams & Wilkins, 1974.

3. Sazima G. “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021.

Two themes have emerged recently in my psychotherapy practice, and in the mirror: relief and exhaustion. Some peace in the public discourse, or at least a pause in the ominous discord, has had the effect of a lightening, an unburdening. Some release from a contracted sense of tension around the specifics of violence and a broader sense of civil fracture has been palpable like a big, deep breath, exhaled. No sensible person would mistake this for being out of the metaphoric woods. A virus menaces and mutates, economic woes follow, and lots of us don’t get along. But, yes, there is some relief, some good change.

But even good change, even a downshift into relief, can pose some challenges to look for and overcome.

Consider for a moment the notion that every change represents a loss, a metaphoric “death” of the prior state of things. This is true of big, painful losses, like the death of a loved one, and small ones, like finding an empty cookie jar. It’s also true in changes we associate with benefit or relief: a refund check, a job promotion, a resolving migraine, or the breaking out of some civility.

In changes of all sorts, the world outside of one’s mind has shifted – at odds, momentarily, with our inner, now obsolete understanding of that changed world. The inside of the head does not match the outside. How we make that adjustment, so “inside = outside,” is a clinically familiar process: it’s grieving, with a sequence famously elaborated upon by Elisabeth Kübler-Ross, MD,¹ and others.

We all likely know the steps: shock/denial, anger, “bargaining,” depression, and acceptance. A quick review: Our initial anxious/threat reaction leads to grievous judgment, to rationalizing “woulda/coulda/shoulda’s,” then to truly landing in the disappointment of a loss or change, and the accepting of a new steady state. Inside proceeds to match outside.

So, what then of relief? How do we process “good” change? I think we still must move from “in ≠ out” to “in = out,” navigating some pitfalls along the way.

Initial threat often remains; apprehension of the “new” still can generate energy, and even a sense of threat, regardless of a kiss or a shove. Our brainstems run roughshod over this first phase.

Step two is about judgment. We can move past the threat to, “How do I feel about it?” Here’s where grievous feeling gets swapped out for something more peak-positive – joy, or relief if the change represents an ending of a state of suffering, tension, or uncertainty.

The “bargaining” step still happens, but often around a kind of testing regimen: Is this too good to be true? Is it really different? We run scenarios.

The thud of disappointment also gets a makeover. It’s a settling into the beneficial change and its associations: gratitude, a sense of energy shifting.

The bookend “OK” seems anodyne here – why would anyone not accept relief, some good change?² But it can nevertheless represent a challenge for many. The receding tension of the last year could open into a burst of energy, but I’m finding that exhaustion is just as or more common. That’s not illness, but a weary exhaling from the longest of held breaths.

One other twist: What happens when one of those steps is an individual obstacle, trigger, or hard-to-hold state? Especially for those with deep experience in disappointment or even trauma, buying into acceptance of a new normal can feel like a fool’s game. This is an especially complex spot for individuals who won’t quite allow for joyful acceptance to break out, lest it reveals itself as a humiliating trick or a too-brief respite from the “usual.”

Mindfulness practices, such as meditation, are helpful in managing this process. Committed time and optimal conditions to witness and adapt to the various inner states that ebb and flow generate a clear therapeutic benefit. Incorporating meditation training into my work with psychotherapy patients also becomes a kind of diagnostic force multiplier. Patients improve their identification of somatic manifestations, emotional reactions, and cycling ruminations of thought. What generates distraction and loss of mindful attention becomes better recognized. Contemplative work in between sessions becomes more productive.

What else do I advise?³ Patience, and some compassion for ourselves in this unusual time. Grief, and relief, are complex but truly human processes that generate not just one state of experience, but a cascade of them. While that cascade can hurt, it’s actually normal, not illness. But it can be exhausting.
 

Dr. Sazima is a Northern California psychiatrist, educator, and author. He is senior behavioral faculty at the Stanford-O’Connor Family Medicine Residency Program in San José, Calif. His latest book is “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021. Dr. Sazima disclosed no relevant financial relationships.

References

1. Kübler-Ross E. “On Death And Dying,” New York: Simon & Schuster, 1969.

2. Selye H. “Stress Without Distress,” New York: Lippincott, Williams & Wilkins, 1974.

3. Sazima G. “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021.

Two themes have emerged recently in my psychotherapy practice, and in the mirror: relief and exhaustion. Some peace in the public discourse, or at least a pause in the ominous discord, has had the effect of a lightening, an unburdening. Some release from a contracted sense of tension around the specifics of violence and a broader sense of civil fracture has been palpable like a big, deep breath, exhaled. No sensible person would mistake this for being out of the metaphoric woods. A virus menaces and mutates, economic woes follow, and lots of us don’t get along. But, yes, there is some relief, some good change.

But even good change, even a downshift into relief, can pose some challenges to look for and overcome.

Consider for a moment the notion that every change represents a loss, a metaphoric “death” of the prior state of things. This is true of big, painful losses, like the death of a loved one, and small ones, like finding an empty cookie jar. It’s also true in changes we associate with benefit or relief: a refund check, a job promotion, a resolving migraine, or the breaking out of some civility.

In changes of all sorts, the world outside of one’s mind has shifted – at odds, momentarily, with our inner, now obsolete understanding of that changed world. The inside of the head does not match the outside. How we make that adjustment, so “inside = outside,” is a clinically familiar process: it’s grieving, with a sequence famously elaborated upon by Elisabeth Kübler-Ross, MD,¹ and others.

We all likely know the steps: shock/denial, anger, “bargaining,” depression, and acceptance. A quick review: Our initial anxious/threat reaction leads to grievous judgment, to rationalizing “woulda/coulda/shoulda’s,” then to truly landing in the disappointment of a loss or change, and the accepting of a new steady state. Inside proceeds to match outside.

So, what then of relief? How do we process “good” change? I think we still must move from “in ≠ out” to “in = out,” navigating some pitfalls along the way.

Initial threat often remains; apprehension of the “new” still can generate energy, and even a sense of threat, regardless of a kiss or a shove. Our brainstems run roughshod over this first phase.

Step two is about judgment. We can move past the threat to, “How do I feel about it?” Here’s where grievous feeling gets swapped out for something more peak-positive – joy, or relief if the change represents an ending of a state of suffering, tension, or uncertainty.

The “bargaining” step still happens, but often around a kind of testing regimen: Is this too good to be true? Is it really different? We run scenarios.

The thud of disappointment also gets a makeover. It’s a settling into the beneficial change and its associations: gratitude, a sense of energy shifting.

The bookend “OK” seems anodyne here – why would anyone not accept relief, some good change?² But it can nevertheless represent a challenge for many. The receding tension of the last year could open into a burst of energy, but I’m finding that exhaustion is just as or more common. That’s not illness, but a weary exhaling from the longest of held breaths.

One other twist: What happens when one of those steps is an individual obstacle, trigger, or hard-to-hold state? Especially for those with deep experience in disappointment or even trauma, buying into acceptance of a new normal can feel like a fool’s game. This is an especially complex spot for individuals who won’t quite allow for joyful acceptance to break out, lest it reveals itself as a humiliating trick or a too-brief respite from the “usual.”

Mindfulness practices, such as meditation, are helpful in managing this process. Committed time and optimal conditions to witness and adapt to the various inner states that ebb and flow generate a clear therapeutic benefit. Incorporating meditation training into my work with psychotherapy patients also becomes a kind of diagnostic force multiplier. Patients improve their identification of somatic manifestations, emotional reactions, and cycling ruminations of thought. What generates distraction and loss of mindful attention becomes better recognized. Contemplative work in between sessions becomes more productive.

What else do I advise?³ Patience, and some compassion for ourselves in this unusual time. Grief, and relief, are complex but truly human processes that generate not just one state of experience, but a cascade of them. While that cascade can hurt, it’s actually normal, not illness. But it can be exhausting.
 

Dr. Sazima is a Northern California psychiatrist, educator, and author. He is senior behavioral faculty at the Stanford-O’Connor Family Medicine Residency Program in San José, Calif. His latest book is “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021. Dr. Sazima disclosed no relevant financial relationships.

References

1. Kübler-Ross E. “On Death And Dying,” New York: Simon & Schuster, 1969.

2. Selye H. “Stress Without Distress,” New York: Lippincott, Williams & Wilkins, 1974.

3. Sazima G. “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021.

Editor’s note: Readers’ Forum is a new department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.

Since the completion of the human genome project, the role of pharmacogenomics in treating mental health disorders has become more prevalent. Recently discovered genetic polymorphisms and mutations in the methylenetetrahydrofolate reductase (MTHFR) gene have led clinicians to seek out new therapeutic approaches to personalize mental health care. MTHFR is a key enzyme of folate metabolism, and changes in its gene can result in reduced enzyme activity, which has been associated with psychiatric illnesses such as schizophrenia, major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), and autism.¹ Supplementation with L-methylfolate, the active form of folate, has been found to improve clinical and social recovery in patients with psychiatric illnesses such as schizophrenia and MDD.² While L-methylfolate is classified as an FDA-approved medicinal food for patients with depression and schizophrenia, its role in ADHD remains controversial.³ L-methylfolate modulates the synthesis of monoamines such as dopamine and norepinephrine, which are pivotal in reducing inattentiveness and hyperactivity in patients with ADHD.^4,5 As a result, it could play an important role in the management of ADHD in patients with MTHFR deficiency.

Despite its high prevalence in many children, ADHD can persist into adulthood with impairing symptoms that have long-term social and economic impacts. Conventional methods of treating ADHD include stimulant medications such as methylphenidate, which can increase the levels of dopamine and norepinephrine in the brain. Unfortunately, stimulants’ cost, adverse effect profile, and high potential for abuse can hinder their use and contribute to treatment resistance.⁶ Because L-methylfolate can cross the blood-brain barrier and lacks the adverse effect profile of stimulants, it represents an alternative that could improve the quality of life for ADHD patients, particularly those with MTHFR polymorphisms or mutations.

Conflicting evidence

Several researchers have investigated the role of L-methylfolate as a supplement or alternative to stimulant therapy for patients with ADHD. While some preliminary studies have found some benefit, others have not. Here we describe 2 studies with differing results.

Quilliin⁷ (2013). In an open-label study at a children’s hospital in Texas, Quillin⁷ investi­gated L-methylfolate for alleviating attention-deficit disorder/ADHD symptoms in 59 patients age 5 to 18. Twenty-seven patients received stimulant therapy. All patients were treated with L-methylfolate, 0.2 mg/kg/d in a chewable tablet form, for 6 weeks. The primary endpoint was change on the average Vanderbilt Assessment Scale Total Symptom Score (TSS), which was 30 at baseline. At the study’s conclusion, the average TSS score was 22, a 27% reduction. Patients who were taking only L-methylfolate had an average score of 21 at the end of the study, which was a 34% improvement, compared with an average TSS score of 23 in those who were taking stimulants.

Surman et al³ (2019). In this 12-week, double-blind, placebo-controlled clinical trial, researchers assessed the efficacy and tolerability of L-methylfolate when added to osmotic-release oral system methylphenidate (OROS-MPH).³ Surman et al³ randomized 44 adult patients (age 18 to 55) who met the DSM-5 criteria for ADHD to a placebo group or an active group. The placebo group was treated with placebo plus OROS-MPH, while the active group received L-methylfolate, 15 mg/d, plus OROS-MPH. OROS-MPH was started at 36 mg/d and titrated to optimal response. The primary endpoint was change in score from baseline on the Adult ADHD Investigator Symptom Report scale. Although it was well tolerated, L-methylfolate was not associated with a significant change in measures of ADHD or mental health function.³ However, researchers noticed that patients who received L-methylfolate needed to receive higher doses of methylphenidate over time. This suggests that supplementation with L-methylfolate could reduce the effectiveness of methylphenidate in adult patients with ADHD.³

While more research is needed, the contradictory results of these studies suggests that the relationship between L-methylfolate and ADHD could be impacted by dosing, as well as by differences in adult and childhood ADHD that are not yet fully understood.

Continue to: An area warranting future research

An area warranting future research

The growth of pharmacogenomics represents an important opportunity to bridge the gap between our understanding of psychiatric illnesses and new ways to treat them. Using L-methylfolate to treat ADHD might help bridge this gap. For this to occur, psychiatrists need to use evidence-based pharmacogenetic research to inform their decision-making. The differing results in studies evaluating the use of L-methylfolate in adult and pediatric patients pose interesting questions that will require more robust research to answer. Clinicians should be cautious in the use of L-methylfolate and recognize the importance of evaluating every patient with ADHD for MTHFR deficiency. This could help personalize care in ways that may improve the quality of life for patients and their families.

Editor’s note: Readers’ Forum is a new department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.

Since the completion of the human genome project, the role of pharmacogenomics in treating mental health disorders has become more prevalent. Recently discovered genetic polymorphisms and mutations in the methylenetetrahydrofolate reductase (MTHFR) gene have led clinicians to seek out new therapeutic approaches to personalize mental health care. MTHFR is a key enzyme of folate metabolism, and changes in its gene can result in reduced enzyme activity, which has been associated with psychiatric illnesses such as schizophrenia, major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), and autism.¹ Supplementation with L-methylfolate, the active form of folate, has been found to improve clinical and social recovery in patients with psychiatric illnesses such as schizophrenia and MDD.² While L-methylfolate is classified as an FDA-approved medicinal food for patients with depression and schizophrenia, its role in ADHD remains controversial.³ L-methylfolate modulates the synthesis of monoamines such as dopamine and norepinephrine, which are pivotal in reducing inattentiveness and hyperactivity in patients with ADHD.^4,5 As a result, it could play an important role in the management of ADHD in patients with MTHFR deficiency.

Despite its high prevalence in many children, ADHD can persist into adulthood with impairing symptoms that have long-term social and economic impacts. Conventional methods of treating ADHD include stimulant medications such as methylphenidate, which can increase the levels of dopamine and norepinephrine in the brain. Unfortunately, stimulants’ cost, adverse effect profile, and high potential for abuse can hinder their use and contribute to treatment resistance.⁶ Because L-methylfolate can cross the blood-brain barrier and lacks the adverse effect profile of stimulants, it represents an alternative that could improve the quality of life for ADHD patients, particularly those with MTHFR polymorphisms or mutations.

Conflicting evidence

Several researchers have investigated the role of L-methylfolate as a supplement or alternative to stimulant therapy for patients with ADHD. While some preliminary studies have found some benefit, others have not. Here we describe 2 studies with differing results.

Quilliin⁷ (2013). In an open-label study at a children’s hospital in Texas, Quillin⁷ investi­gated L-methylfolate for alleviating attention-deficit disorder/ADHD symptoms in 59 patients age 5 to 18. Twenty-seven patients received stimulant therapy. All patients were treated with L-methylfolate, 0.2 mg/kg/d in a chewable tablet form, for 6 weeks. The primary endpoint was change on the average Vanderbilt Assessment Scale Total Symptom Score (TSS), which was 30 at baseline. At the study’s conclusion, the average TSS score was 22, a 27% reduction. Patients who were taking only L-methylfolate had an average score of 21 at the end of the study, which was a 34% improvement, compared with an average TSS score of 23 in those who were taking stimulants.

Surman et al³ (2019). In this 12-week, double-blind, placebo-controlled clinical trial, researchers assessed the efficacy and tolerability of L-methylfolate when added to osmotic-release oral system methylphenidate (OROS-MPH).³ Surman et al³ randomized 44 adult patients (age 18 to 55) who met the DSM-5 criteria for ADHD to a placebo group or an active group. The placebo group was treated with placebo plus OROS-MPH, while the active group received L-methylfolate, 15 mg/d, plus OROS-MPH. OROS-MPH was started at 36 mg/d and titrated to optimal response. The primary endpoint was change in score from baseline on the Adult ADHD Investigator Symptom Report scale. Although it was well tolerated, L-methylfolate was not associated with a significant change in measures of ADHD or mental health function.³ However, researchers noticed that patients who received L-methylfolate needed to receive higher doses of methylphenidate over time. This suggests that supplementation with L-methylfolate could reduce the effectiveness of methylphenidate in adult patients with ADHD.³

While more research is needed, the contradictory results of these studies suggests that the relationship between L-methylfolate and ADHD could be impacted by dosing, as well as by differences in adult and childhood ADHD that are not yet fully understood.

Continue to: An area warranting future research

An area warranting future research

The growth of pharmacogenomics represents an important opportunity to bridge the gap between our understanding of psychiatric illnesses and new ways to treat them. Using L-methylfolate to treat ADHD might help bridge this gap. For this to occur, psychiatrists need to use evidence-based pharmacogenetic research to inform their decision-making. The differing results in studies evaluating the use of L-methylfolate in adult and pediatric patients pose interesting questions that will require more robust research to answer. Clinicians should be cautious in the use of L-methylfolate and recognize the importance of evaluating every patient with ADHD for MTHFR deficiency. This could help personalize care in ways that may improve the quality of life for patients and their families.

Editor’s note: Readers’ Forum is a new department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.

Since the completion of the human genome project, the role of pharmacogenomics in treating mental health disorders has become more prevalent. Recently discovered genetic polymorphisms and mutations in the methylenetetrahydrofolate reductase (MTHFR) gene have led clinicians to seek out new therapeutic approaches to personalize mental health care. MTHFR is a key enzyme of folate metabolism, and changes in its gene can result in reduced enzyme activity, which has been associated with psychiatric illnesses such as schizophrenia, major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), and autism.¹ Supplementation with L-methylfolate, the active form of folate, has been found to improve clinical and social recovery in patients with psychiatric illnesses such as schizophrenia and MDD.² While L-methylfolate is classified as an FDA-approved medicinal food for patients with depression and schizophrenia, its role in ADHD remains controversial.³ L-methylfolate modulates the synthesis of monoamines such as dopamine and norepinephrine, which are pivotal in reducing inattentiveness and hyperactivity in patients with ADHD.^4,5 As a result, it could play an important role in the management of ADHD in patients with MTHFR deficiency.

Despite its high prevalence in many children, ADHD can persist into adulthood with impairing symptoms that have long-term social and economic impacts. Conventional methods of treating ADHD include stimulant medications such as methylphenidate, which can increase the levels of dopamine and norepinephrine in the brain. Unfortunately, stimulants’ cost, adverse effect profile, and high potential for abuse can hinder their use and contribute to treatment resistance.⁶ Because L-methylfolate can cross the blood-brain barrier and lacks the adverse effect profile of stimulants, it represents an alternative that could improve the quality of life for ADHD patients, particularly those with MTHFR polymorphisms or mutations.

Conflicting evidence

Several researchers have investigated the role of L-methylfolate as a supplement or alternative to stimulant therapy for patients with ADHD. While some preliminary studies have found some benefit, others have not. Here we describe 2 studies with differing results.

Quilliin⁷ (2013). In an open-label study at a children’s hospital in Texas, Quillin⁷ investi­gated L-methylfolate for alleviating attention-deficit disorder/ADHD symptoms in 59 patients age 5 to 18. Twenty-seven patients received stimulant therapy. All patients were treated with L-methylfolate, 0.2 mg/kg/d in a chewable tablet form, for 6 weeks. The primary endpoint was change on the average Vanderbilt Assessment Scale Total Symptom Score (TSS), which was 30 at baseline. At the study’s conclusion, the average TSS score was 22, a 27% reduction. Patients who were taking only L-methylfolate had an average score of 21 at the end of the study, which was a 34% improvement, compared with an average TSS score of 23 in those who were taking stimulants.

Surman et al³ (2019). In this 12-week, double-blind, placebo-controlled clinical trial, researchers assessed the efficacy and tolerability of L-methylfolate when added to osmotic-release oral system methylphenidate (OROS-MPH).³ Surman et al³ randomized 44 adult patients (age 18 to 55) who met the DSM-5 criteria for ADHD to a placebo group or an active group. The placebo group was treated with placebo plus OROS-MPH, while the active group received L-methylfolate, 15 mg/d, plus OROS-MPH. OROS-MPH was started at 36 mg/d and titrated to optimal response. The primary endpoint was change in score from baseline on the Adult ADHD Investigator Symptom Report scale. Although it was well tolerated, L-methylfolate was not associated with a significant change in measures of ADHD or mental health function.³ However, researchers noticed that patients who received L-methylfolate needed to receive higher doses of methylphenidate over time. This suggests that supplementation with L-methylfolate could reduce the effectiveness of methylphenidate in adult patients with ADHD.³

While more research is needed, the contradictory results of these studies suggests that the relationship between L-methylfolate and ADHD could be impacted by dosing, as well as by differences in adult and childhood ADHD that are not yet fully understood.

Continue to: An area warranting future research

An area warranting future research

The growth of pharmacogenomics represents an important opportunity to bridge the gap between our understanding of psychiatric illnesses and new ways to treat them. Using L-methylfolate to treat ADHD might help bridge this gap. For this to occur, psychiatrists need to use evidence-based pharmacogenetic research to inform their decision-making. The differing results in studies evaluating the use of L-methylfolate in adult and pediatric patients pose interesting questions that will require more robust research to answer. Clinicians should be cautious in the use of L-methylfolate and recognize the importance of evaluating every patient with ADHD for MTHFR deficiency. This could help personalize care in ways that may improve the quality of life for patients and their families.

The coronavirus disease 2019 pandemic, which as of mid-February 2021 had caused more than 486,000 deaths in the United States, has changed our lives forever. Elders and Black, Indigenous, and People of Color (BIPOC) have been overrepresented among those lost. That, when juxtaposed with the civil unrest that followed the brutal killing of George Floyd, an unarmed Black man, by a White law enforcement officer on May 25, 2020, have compelled us to talk about US race relations in unprecedented ways. These and other traumas disproportionately affect the quality of life and health of minority and underserved individuals. The international outcry about racism, serial trauma, and health disparities left the medical profession well positioned to promulgate changes that are conducive to achieving health equity.

Race is a social construct

In November 2020, the American Medical Association (AMA) Board of Trustees made several public acknowledgments about race.¹ First, race is a social, nonbiological classification that is different from biology, ethnicity, or genetic ancestry.¹ Next, race contributes to health disparities and poor health outcomes for minorities and members of underserved communities.¹ Also, racism, which includes disproportionate police brutality against Black and Indigenous people, is a driver of health inequity for them and people in marginalized communities.¹

The AMA also commented on how serial trauma and racism can affect one’s health. The AMA acknowledged that exposure to serial trauma throughout one’s life can have a cumulative effect that is “associated with chronic stress, higher rates of comorbidities and lower life expectancy” and results in increased health care costs and decreased quality of life for those who are affected.¹ Also, the AMA proclaimed that racism is a threat to public health and pledged to dismantle discriminatory practices and policies in health care, including medical education and research.²

Diversity and inclusion in psychiatry

While the AMA has been striving to reduce bias in health care systems, psychiatry has been forging its path. In March 2015, the American Psychiatric Association’s (APA) Board of Trustees approved the APA’s Strategic Initiative, which has 4 goals: 1) advancing the integration of psychiatry in health care; 2) supporting research; 3) supporting education; and 4) promoting diversity and inclusion in psychiatry.³ The latter goal includes advocating for antiracist policies that promote cultural competence and health equity in education, research and psychiatric care; increased recruitment and retention of psychiatrists from groups that historically have been underrepresented in medicine and medical leadership; and ensuring representation of these groups in APA governance at all levels.³

The APA’s antiracism agenda

In March 2020, outgoing APA President Bruce Schwartz concurred with Board members that diversity and inclusion in the APA warranted a closer review. On May 5, 2020, APA President Jeff Geller committed to authorizing a systematic study of diversity and inclusion in various branches of the APA, including councils and governance. By the end of May, with civil unrest in full swing in the United States, President Geller decided to expand the APA’s diversity agenda.

President Geller appointed the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry (SR Task Force), which had its virtual inaugural meeting on June 27, 2020.⁴ The SR Task Force exists to focus on structural racism (aka institutional racism) in organized psychiatry, psychiatric patients, and those who provide psychiatric services to patients. The charge, which is subject to revision, if warranted, is clear: provide resources and education on the history of structural racism in the APA and psychiatry, explain how structural racism impacts psychiatric patients and the profession, craft actionable recommendations to dismantle structural racism in the APA and psychiatry, report those findings to the APA’s Board of Trustees, and implement a quality assurance protocol to ensure that the Task Force’s work is consistent with its charge. President Geller decided to have the Task Force focus on anti-Black racism in its inaugural year and believes that the outcome will benefit all psychiatrists, other mental health professionals, and patients who identify as members of minority and underserved groups in the United States and the profession of psychiatry.⁵

Presidential Task Forces in APA

Presidential Task Forces report directly to the Board of Trustees, which expedites the review of progress reports and deliberation on and, when favorable, implementation of recommendations. Also, Presidential Task Forces are afforded additional APA resources. For example, the SR Task Force has 16 APA staff members who have been appointed or volunteered to assist the Task Force in some way. Many APA staff have graduate degrees in law, education, and other subjects. The skill sets, networks, institutional memory, and commitment that they bring to the project are conducive to advancing the SR Task Force’s agenda at a brisk pace.

Continue to: The APA President...

The APA President decides whom to appoint to each Task Force. President Geller propitiously appointed subject matter experts and members of the Board of Trustees to serve on the SR Task Force. Subject matter experts contribute historical and contemporary content about racism, including anti-Black racism, to the discussion. The data are used to craft research questions that may yield pertinent data. (Note that not all subject matter experts are Black, nor are all Board members White.) APA staff support the Task Force by sharing their expertise, compiling data, coordinating meetings, collaborating on program development, disseminating the work product to APA members and the media, and other important tasks.

The SR Task Force’s work

The SR Task Force strives for transparency in a process that is informed by APA members. The group immediately set up a web hub that is used to communicate with APA members.⁵ Individual members also use social media to alert members to SR Task Force activities and events. Member input has been solicited by posting several brief surveys on the SR Task Force web hub. Topics have included the effect of structural racism on patient care, psychiatric practice, and organized psychiatry, including the APA. The responses, which collectively totaled >1,600, were reviewed and used to inform Task Force priorities while working within the scope of the charge.⁵

Based on member feedback, the first large project of the SR Task Force has been to examine structural racism in the APA. The SR Task Force formed workgroups to study data pertaining to diversity and inclusion in the APA Assembly, governance (the Board of Trustees), Councils and Committees, and Scientific Program Committee. As APA Publishing and the DSM Steering Committee have internal processes to address structural racism, the SR Task Force did not convene workgroups to study this. However, the SR Task Force will be meeting with leaders of those groups to learn about their protocols and will request that information be made available to APA members.

The SR Task Force reviews and interprets data that are compiled by each workgroup, deliberates on its significance, and when appropriate, drafts achievable recommendations to improve diversity and inclusion in the APA. This is where Trustee involvement is invaluable to the SR Task Force, because the report and recommendations will be presented to the Board of Trustees.

There is no guarantee that the recommendations contained in a report that is accepted by the Board of Trustees will be implemented unless they are approved. It is imperative, therefore, that SR Task Force recommendations to the Board take into consideration Board structure, processes, goals, efficiency, history, and other matters. The learning curve can be steep, especially when the first major report was due 3 months after the SR Task Force was appointed. Clarity and efficiency are key in report preparation. For example, during the Winter 2020 Board of Trustees meeting, the SR Task Force presented its report, answered questions, and offered 7 action items to the Board for deliberation and voting. The endeavor, which was completed in 20 minutes, resulted in the Board supporting 6 of the recommendations and deferring the deliberation of the seventh recommendation to the spring Board meeting, due to logistical concerns.

Continue to: Thus far, the SR Task Force Workgroups...

Thus far, the SR Task Force Workgroups on the Assembly and Governance have presented their reports. ⁵ The SR Task Force reports on the Scientific Program Committee and Councils and Committees are scheduled to be presented to the Board during the Spring 2021 meeting.

The SR Task Force has been fulfilling the commitment to provide relevant educational materials to members in several ways. There have been 4 virtual Structural Racism Town Hall meetings that featured subject matter experts. The first Town Hall session addressed the initial steps towards dismantling structural racism and included President Geller’s announcement about appointing a SR Task Force. The next Town Hall meeting addressed structural racism in medicine and psychiatry, its effect on children and individuals who identify as transgender, and its intersectionality (the cumulative effect of discrimination on a person who belongs to 2 non-dominant groups.) The panel in the third Town Hall meeting reviewed the impact of structural racism, including intersectionality, on transgenerational trauma in several minority groups. The meeting ended with an update of Task Force activities. The February 2021 Town Hall meeting focused on how structural racism affects recruitment and retention of minority psychiatry residents, and how this can undermine efforts to grow a diverse workforce. Recordings of these and other events can be accessed on the SR Task Force web hub.⁵ The SR Task Force members plan to present a review of the year’s work during the next Town Hall meeting, which is scheduled to occur on Saturday, May 1, 2021, during the APA’s Annual Meeting.

The SR Task Force web hub contains other resources, including APA position statements, press releases, and news articles, and a glossary of relevant terms. It also includes internet links to President Geller’s 9-part series on the history of Structural Racism in the APA. There are CME and other webinars, a curated list of references, videos, podcasts, and other media.⁴

The SR Task Force believes that much of the antiracism work needs to occur beyond APA headquarters. Consequently, President Geller challenged all APA Councils to work on an antiracism project to support the APA’s antiracism agenda. APA committees and caucuses have been encouraged to do the same. The SR Task Force has asked APA District Branches and Allied Organizations to share information about what they are doing to educate members about structural racism and what they are doing for input regarding their antiracist activities. Additionally, Task Force members have been speaking with these and other groups to inform them about the APA’s antiracism work.

APA’s Board of Trustees actions

It would be inappropriate for the APA to task groups with focusing on antiracism unless the organization was doing its part. In July 2020, the Board of Trustees had a 2-hour round table discussion during which each member spoke about the problem and how the APA should address it. Next, President Geller appointed a Board Workgroup to clarify the definitions of “minority” and “underrepresented.” Although the APA Assembly has defined the terms, the APA has not. Additionally, the APA Board of Trustees retained a consultant to assess all aspects of how it functions as a Board. The Board’s management of matters pertaining to diversity and inclusion was part of the examination. The recommendations are being reviewed and the Board will undergo diversity training.

Continue to: President Geller's study...

President Geller’s study of racism in the APA, which involved a review of past APA presidential addresses, brought to light a long-term pattern of racism in the organization.⁵ On January 18, 2021, Martin Luther King, Jr. Day, the APA acknowledged and apologized to psychiatrists, patients, and the public for its history of engaging in and passively condoning racist behavior.⁶ The APA has committed to being better informed about diversity and inclusion at every level. Lastly, hired consultants with expertise in diversity and inclusion are working with APA staff at every level so that the environment can be a welcoming and comfortable workspace for recruiting and retaining a diverse workforce.

Although it may seem that the APA has engaged in many antiracist activities in a brief period, there is much more to accomplish. The Task Force hopes that the work will speak for itself and will be sustained over time. It’s long overdue.

The coronavirus disease 2019 pandemic, which as of mid-February 2021 had caused more than 486,000 deaths in the United States, has changed our lives forever. Elders and Black, Indigenous, and People of Color (BIPOC) have been overrepresented among those lost. That, when juxtaposed with the civil unrest that followed the brutal killing of George Floyd, an unarmed Black man, by a White law enforcement officer on May 25, 2020, have compelled us to talk about US race relations in unprecedented ways. These and other traumas disproportionately affect the quality of life and health of minority and underserved individuals. The international outcry about racism, serial trauma, and health disparities left the medical profession well positioned to promulgate changes that are conducive to achieving health equity.

Race is a social construct

In November 2020, the American Medical Association (AMA) Board of Trustees made several public acknowledgments about race.¹ First, race is a social, nonbiological classification that is different from biology, ethnicity, or genetic ancestry.¹ Next, race contributes to health disparities and poor health outcomes for minorities and members of underserved communities.¹ Also, racism, which includes disproportionate police brutality against Black and Indigenous people, is a driver of health inequity for them and people in marginalized communities.¹

The AMA also commented on how serial trauma and racism can affect one’s health. The AMA acknowledged that exposure to serial trauma throughout one’s life can have a cumulative effect that is “associated with chronic stress, higher rates of comorbidities and lower life expectancy” and results in increased health care costs and decreased quality of life for those who are affected.¹ Also, the AMA proclaimed that racism is a threat to public health and pledged to dismantle discriminatory practices and policies in health care, including medical education and research.²

Diversity and inclusion in psychiatry

While the AMA has been striving to reduce bias in health care systems, psychiatry has been forging its path. In March 2015, the American Psychiatric Association’s (APA) Board of Trustees approved the APA’s Strategic Initiative, which has 4 goals: 1) advancing the integration of psychiatry in health care; 2) supporting research; 3) supporting education; and 4) promoting diversity and inclusion in psychiatry.³ The latter goal includes advocating for antiracist policies that promote cultural competence and health equity in education, research and psychiatric care; increased recruitment and retention of psychiatrists from groups that historically have been underrepresented in medicine and medical leadership; and ensuring representation of these groups in APA governance at all levels.³

The APA’s antiracism agenda

In March 2020, outgoing APA President Bruce Schwartz concurred with Board members that diversity and inclusion in the APA warranted a closer review. On May 5, 2020, APA President Jeff Geller committed to authorizing a systematic study of diversity and inclusion in various branches of the APA, including councils and governance. By the end of May, with civil unrest in full swing in the United States, President Geller decided to expand the APA’s diversity agenda.

President Geller appointed the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry (SR Task Force), which had its virtual inaugural meeting on June 27, 2020.⁴ The SR Task Force exists to focus on structural racism (aka institutional racism) in organized psychiatry, psychiatric patients, and those who provide psychiatric services to patients. The charge, which is subject to revision, if warranted, is clear: provide resources and education on the history of structural racism in the APA and psychiatry, explain how structural racism impacts psychiatric patients and the profession, craft actionable recommendations to dismantle structural racism in the APA and psychiatry, report those findings to the APA’s Board of Trustees, and implement a quality assurance protocol to ensure that the Task Force’s work is consistent with its charge. President Geller decided to have the Task Force focus on anti-Black racism in its inaugural year and believes that the outcome will benefit all psychiatrists, other mental health professionals, and patients who identify as members of minority and underserved groups in the United States and the profession of psychiatry.⁵

Presidential Task Forces in APA

Presidential Task Forces report directly to the Board of Trustees, which expedites the review of progress reports and deliberation on and, when favorable, implementation of recommendations. Also, Presidential Task Forces are afforded additional APA resources. For example, the SR Task Force has 16 APA staff members who have been appointed or volunteered to assist the Task Force in some way. Many APA staff have graduate degrees in law, education, and other subjects. The skill sets, networks, institutional memory, and commitment that they bring to the project are conducive to advancing the SR Task Force’s agenda at a brisk pace.

Continue to: The APA President...

The APA President decides whom to appoint to each Task Force. President Geller propitiously appointed subject matter experts and members of the Board of Trustees to serve on the SR Task Force. Subject matter experts contribute historical and contemporary content about racism, including anti-Black racism, to the discussion. The data are used to craft research questions that may yield pertinent data. (Note that not all subject matter experts are Black, nor are all Board members White.) APA staff support the Task Force by sharing their expertise, compiling data, coordinating meetings, collaborating on program development, disseminating the work product to APA members and the media, and other important tasks.

The SR Task Force’s work

The SR Task Force strives for transparency in a process that is informed by APA members. The group immediately set up a web hub that is used to communicate with APA members.⁵ Individual members also use social media to alert members to SR Task Force activities and events. Member input has been solicited by posting several brief surveys on the SR Task Force web hub. Topics have included the effect of structural racism on patient care, psychiatric practice, and organized psychiatry, including the APA. The responses, which collectively totaled >1,600, were reviewed and used to inform Task Force priorities while working within the scope of the charge.⁵

Based on member feedback, the first large project of the SR Task Force has been to examine structural racism in the APA. The SR Task Force formed workgroups to study data pertaining to diversity and inclusion in the APA Assembly, governance (the Board of Trustees), Councils and Committees, and Scientific Program Committee. As APA Publishing and the DSM Steering Committee have internal processes to address structural racism, the SR Task Force did not convene workgroups to study this. However, the SR Task Force will be meeting with leaders of those groups to learn about their protocols and will request that information be made available to APA members.

The SR Task Force reviews and interprets data that are compiled by each workgroup, deliberates on its significance, and when appropriate, drafts achievable recommendations to improve diversity and inclusion in the APA. This is where Trustee involvement is invaluable to the SR Task Force, because the report and recommendations will be presented to the Board of Trustees.

There is no guarantee that the recommendations contained in a report that is accepted by the Board of Trustees will be implemented unless they are approved. It is imperative, therefore, that SR Task Force recommendations to the Board take into consideration Board structure, processes, goals, efficiency, history, and other matters. The learning curve can be steep, especially when the first major report was due 3 months after the SR Task Force was appointed. Clarity and efficiency are key in report preparation. For example, during the Winter 2020 Board of Trustees meeting, the SR Task Force presented its report, answered questions, and offered 7 action items to the Board for deliberation and voting. The endeavor, which was completed in 20 minutes, resulted in the Board supporting 6 of the recommendations and deferring the deliberation of the seventh recommendation to the spring Board meeting, due to logistical concerns.

Continue to: Thus far, the SR Task Force Workgroups...

Thus far, the SR Task Force Workgroups on the Assembly and Governance have presented their reports. ⁵ The SR Task Force reports on the Scientific Program Committee and Councils and Committees are scheduled to be presented to the Board during the Spring 2021 meeting.

The SR Task Force has been fulfilling the commitment to provide relevant educational materials to members in several ways. There have been 4 virtual Structural Racism Town Hall meetings that featured subject matter experts. The first Town Hall session addressed the initial steps towards dismantling structural racism and included President Geller’s announcement about appointing a SR Task Force. The next Town Hall meeting addressed structural racism in medicine and psychiatry, its effect on children and individuals who identify as transgender, and its intersectionality (the cumulative effect of discrimination on a person who belongs to 2 non-dominant groups.) The panel in the third Town Hall meeting reviewed the impact of structural racism, including intersectionality, on transgenerational trauma in several minority groups. The meeting ended with an update of Task Force activities. The February 2021 Town Hall meeting focused on how structural racism affects recruitment and retention of minority psychiatry residents, and how this can undermine efforts to grow a diverse workforce. Recordings of these and other events can be accessed on the SR Task Force web hub.⁵ The SR Task Force members plan to present a review of the year’s work during the next Town Hall meeting, which is scheduled to occur on Saturday, May 1, 2021, during the APA’s Annual Meeting.

The SR Task Force web hub contains other resources, including APA position statements, press releases, and news articles, and a glossary of relevant terms. It also includes internet links to President Geller’s 9-part series on the history of Structural Racism in the APA. There are CME and other webinars, a curated list of references, videos, podcasts, and other media.⁴

The SR Task Force believes that much of the antiracism work needs to occur beyond APA headquarters. Consequently, President Geller challenged all APA Councils to work on an antiracism project to support the APA’s antiracism agenda. APA committees and caucuses have been encouraged to do the same. The SR Task Force has asked APA District Branches and Allied Organizations to share information about what they are doing to educate members about structural racism and what they are doing for input regarding their antiracist activities. Additionally, Task Force members have been speaking with these and other groups to inform them about the APA’s antiracism work.

APA’s Board of Trustees actions

It would be inappropriate for the APA to task groups with focusing on antiracism unless the organization was doing its part. In July 2020, the Board of Trustees had a 2-hour round table discussion during which each member spoke about the problem and how the APA should address it. Next, President Geller appointed a Board Workgroup to clarify the definitions of “minority” and “underrepresented.” Although the APA Assembly has defined the terms, the APA has not. Additionally, the APA Board of Trustees retained a consultant to assess all aspects of how it functions as a Board. The Board’s management of matters pertaining to diversity and inclusion was part of the examination. The recommendations are being reviewed and the Board will undergo diversity training.

Continue to: President Geller's study...

President Geller’s study of racism in the APA, which involved a review of past APA presidential addresses, brought to light a long-term pattern of racism in the organization.⁵ On January 18, 2021, Martin Luther King, Jr. Day, the APA acknowledged and apologized to psychiatrists, patients, and the public for its history of engaging in and passively condoning racist behavior.⁶ The APA has committed to being better informed about diversity and inclusion at every level. Lastly, hired consultants with expertise in diversity and inclusion are working with APA staff at every level so that the environment can be a welcoming and comfortable workspace for recruiting and retaining a diverse workforce.

Although it may seem that the APA has engaged in many antiracist activities in a brief period, there is much more to accomplish. The Task Force hopes that the work will speak for itself and will be sustained over time. It’s long overdue.

The coronavirus disease 2019 pandemic, which as of mid-February 2021 had caused more than 486,000 deaths in the United States, has changed our lives forever. Elders and Black, Indigenous, and People of Color (BIPOC) have been overrepresented among those lost. That, when juxtaposed with the civil unrest that followed the brutal killing of George Floyd, an unarmed Black man, by a White law enforcement officer on May 25, 2020, have compelled us to talk about US race relations in unprecedented ways. These and other traumas disproportionately affect the quality of life and health of minority and underserved individuals. The international outcry about racism, serial trauma, and health disparities left the medical profession well positioned to promulgate changes that are conducive to achieving health equity.

Race is a social construct

In November 2020, the American Medical Association (AMA) Board of Trustees made several public acknowledgments about race.¹ First, race is a social, nonbiological classification that is different from biology, ethnicity, or genetic ancestry.¹ Next, race contributes to health disparities and poor health outcomes for minorities and members of underserved communities.¹ Also, racism, which includes disproportionate police brutality against Black and Indigenous people, is a driver of health inequity for them and people in marginalized communities.¹

The AMA also commented on how serial trauma and racism can affect one’s health. The AMA acknowledged that exposure to serial trauma throughout one’s life can have a cumulative effect that is “associated with chronic stress, higher rates of comorbidities and lower life expectancy” and results in increased health care costs and decreased quality of life for those who are affected.¹ Also, the AMA proclaimed that racism is a threat to public health and pledged to dismantle discriminatory practices and policies in health care, including medical education and research.²

Diversity and inclusion in psychiatry

While the AMA has been striving to reduce bias in health care systems, psychiatry has been forging its path. In March 2015, the American Psychiatric Association’s (APA) Board of Trustees approved the APA’s Strategic Initiative, which has 4 goals: 1) advancing the integration of psychiatry in health care; 2) supporting research; 3) supporting education; and 4) promoting diversity and inclusion in psychiatry.³ The latter goal includes advocating for antiracist policies that promote cultural competence and health equity in education, research and psychiatric care; increased recruitment and retention of psychiatrists from groups that historically have been underrepresented in medicine and medical leadership; and ensuring representation of these groups in APA governance at all levels.³

The APA’s antiracism agenda

In March 2020, outgoing APA President Bruce Schwartz concurred with Board members that diversity and inclusion in the APA warranted a closer review. On May 5, 2020, APA President Jeff Geller committed to authorizing a systematic study of diversity and inclusion in various branches of the APA, including councils and governance. By the end of May, with civil unrest in full swing in the United States, President Geller decided to expand the APA’s diversity agenda.

President Geller appointed the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry (SR Task Force), which had its virtual inaugural meeting on June 27, 2020.⁴ The SR Task Force exists to focus on structural racism (aka institutional racism) in organized psychiatry, psychiatric patients, and those who provide psychiatric services to patients. The charge, which is subject to revision, if warranted, is clear: provide resources and education on the history of structural racism in the APA and psychiatry, explain how structural racism impacts psychiatric patients and the profession, craft actionable recommendations to dismantle structural racism in the APA and psychiatry, report those findings to the APA’s Board of Trustees, and implement a quality assurance protocol to ensure that the Task Force’s work is consistent with its charge. President Geller decided to have the Task Force focus on anti-Black racism in its inaugural year and believes that the outcome will benefit all psychiatrists, other mental health professionals, and patients who identify as members of minority and underserved groups in the United States and the profession of psychiatry.⁵

Presidential Task Forces in APA

Presidential Task Forces report directly to the Board of Trustees, which expedites the review of progress reports and deliberation on and, when favorable, implementation of recommendations. Also, Presidential Task Forces are afforded additional APA resources. For example, the SR Task Force has 16 APA staff members who have been appointed or volunteered to assist the Task Force in some way. Many APA staff have graduate degrees in law, education, and other subjects. The skill sets, networks, institutional memory, and commitment that they bring to the project are conducive to advancing the SR Task Force’s agenda at a brisk pace.

Continue to: The APA President...

The APA President decides whom to appoint to each Task Force. President Geller propitiously appointed subject matter experts and members of the Board of Trustees to serve on the SR Task Force. Subject matter experts contribute historical and contemporary content about racism, including anti-Black racism, to the discussion. The data are used to craft research questions that may yield pertinent data. (Note that not all subject matter experts are Black, nor are all Board members White.) APA staff support the Task Force by sharing their expertise, compiling data, coordinating meetings, collaborating on program development, disseminating the work product to APA members and the media, and other important tasks.

The SR Task Force’s work

The SR Task Force strives for transparency in a process that is informed by APA members. The group immediately set up a web hub that is used to communicate with APA members.⁵ Individual members also use social media to alert members to SR Task Force activities and events. Member input has been solicited by posting several brief surveys on the SR Task Force web hub. Topics have included the effect of structural racism on patient care, psychiatric practice, and organized psychiatry, including the APA. The responses, which collectively totaled >1,600, were reviewed and used to inform Task Force priorities while working within the scope of the charge.⁵

Based on member feedback, the first large project of the SR Task Force has been to examine structural racism in the APA. The SR Task Force formed workgroups to study data pertaining to diversity and inclusion in the APA Assembly, governance (the Board of Trustees), Councils and Committees, and Scientific Program Committee. As APA Publishing and the DSM Steering Committee have internal processes to address structural racism, the SR Task Force did not convene workgroups to study this. However, the SR Task Force will be meeting with leaders of those groups to learn about their protocols and will request that information be made available to APA members.

The SR Task Force reviews and interprets data that are compiled by each workgroup, deliberates on its significance, and when appropriate, drafts achievable recommendations to improve diversity and inclusion in the APA. This is where Trustee involvement is invaluable to the SR Task Force, because the report and recommendations will be presented to the Board of Trustees.

There is no guarantee that the recommendations contained in a report that is accepted by the Board of Trustees will be implemented unless they are approved. It is imperative, therefore, that SR Task Force recommendations to the Board take into consideration Board structure, processes, goals, efficiency, history, and other matters. The learning curve can be steep, especially when the first major report was due 3 months after the SR Task Force was appointed. Clarity and efficiency are key in report preparation. For example, during the Winter 2020 Board of Trustees meeting, the SR Task Force presented its report, answered questions, and offered 7 action items to the Board for deliberation and voting. The endeavor, which was completed in 20 minutes, resulted in the Board supporting 6 of the recommendations and deferring the deliberation of the seventh recommendation to the spring Board meeting, due to logistical concerns.

Continue to: Thus far, the SR Task Force Workgroups...

Thus far, the SR Task Force Workgroups on the Assembly and Governance have presented their reports. ⁵ The SR Task Force reports on the Scientific Program Committee and Councils and Committees are scheduled to be presented to the Board during the Spring 2021 meeting.

The SR Task Force has been fulfilling the commitment to provide relevant educational materials to members in several ways. There have been 4 virtual Structural Racism Town Hall meetings that featured subject matter experts. The first Town Hall session addressed the initial steps towards dismantling structural racism and included President Geller’s announcement about appointing a SR Task Force. The next Town Hall meeting addressed structural racism in medicine and psychiatry, its effect on children and individuals who identify as transgender, and its intersectionality (the cumulative effect of discrimination on a person who belongs to 2 non-dominant groups.) The panel in the third Town Hall meeting reviewed the impact of structural racism, including intersectionality, on transgenerational trauma in several minority groups. The meeting ended with an update of Task Force activities. The February 2021 Town Hall meeting focused on how structural racism affects recruitment and retention of minority psychiatry residents, and how this can undermine efforts to grow a diverse workforce. Recordings of these and other events can be accessed on the SR Task Force web hub.⁵ The SR Task Force members plan to present a review of the year’s work during the next Town Hall meeting, which is scheduled to occur on Saturday, May 1, 2021, during the APA’s Annual Meeting.

The SR Task Force web hub contains other resources, including APA position statements, press releases, and news articles, and a glossary of relevant terms. It also includes internet links to President Geller’s 9-part series on the history of Structural Racism in the APA. There are CME and other webinars, a curated list of references, videos, podcasts, and other media.⁴

The SR Task Force believes that much of the antiracism work needs to occur beyond APA headquarters. Consequently, President Geller challenged all APA Councils to work on an antiracism project to support the APA’s antiracism agenda. APA committees and caucuses have been encouraged to do the same. The SR Task Force has asked APA District Branches and Allied Organizations to share information about what they are doing to educate members about structural racism and what they are doing for input regarding their antiracist activities. Additionally, Task Force members have been speaking with these and other groups to inform them about the APA’s antiracism work.

APA’s Board of Trustees actions

It would be inappropriate for the APA to task groups with focusing on antiracism unless the organization was doing its part. In July 2020, the Board of Trustees had a 2-hour round table discussion during which each member spoke about the problem and how the APA should address it. Next, President Geller appointed a Board Workgroup to clarify the definitions of “minority” and “underrepresented.” Although the APA Assembly has defined the terms, the APA has not. Additionally, the APA Board of Trustees retained a consultant to assess all aspects of how it functions as a Board. The Board’s management of matters pertaining to diversity and inclusion was part of the examination. The recommendations are being reviewed and the Board will undergo diversity training.

Continue to: President Geller's study...

President Geller’s study of racism in the APA, which involved a review of past APA presidential addresses, brought to light a long-term pattern of racism in the organization.⁵ On January 18, 2021, Martin Luther King, Jr. Day, the APA acknowledged and apologized to psychiatrists, patients, and the public for its history of engaging in and passively condoning racist behavior.⁶ The APA has committed to being better informed about diversity and inclusion at every level. Lastly, hired consultants with expertise in diversity and inclusion are working with APA staff at every level so that the environment can be a welcoming and comfortable workspace for recruiting and retaining a diverse workforce.

Although it may seem that the APA has engaged in many antiracist activities in a brief period, there is much more to accomplish. The Task Force hopes that the work will speak for itself and will be sustained over time. It’s long overdue.