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Building (or rebuilding) trust amid vaccine hesitancy
Nearly 10 months since the onset of the COVID-19 pandemic in the United States, ICUs across the country are reaching maximum capacity and hospitalizations are outnumbering the available providers and staff to care for them. Clinicians everywhere are becoming exhausted and frustrated, and the world is all asking when an end to this pandemic will be in sight? The Food and Drug Administration issued emergency authorization for two multidose COVID-19 vaccines that are now being deployed across the country.
At this writing, 2.8 million Americans have received their first COVID-19 vaccine dose, a number far short of the projected 100 million. The limited production capacity and tiered distribution are the main determinants of who gets the vaccine and when, but a third and extremely important factor in whether people will choose to get vaccinated is their level of awareness of and trust in the scientific and medical processes behind wide-scale vaccination.
As medical professionals, many of us wouldn’t hesitate to get vaccinated against a pandemic virus. Concerns about safety and the integrity of the COVID-19 vaccine development process in light of the “warp speed” of its production has many Americans concerned about getting vaccinated. We may not be able to relate to some patients’ reluctance to receive a vaccine that has been confirmed by phase 3 clinical trials with collectively over 66,000 participants (nearly 10% African American in each study) to have an effectiveness of over 90%. We are so intimately familiar with the vaccine development process, the medical terminology used to describe these results and the effectiveness of vaccines overall in eliminating infectious diseases like polio and smallpox. To many of us, receiving the COVID-19 vaccine may be considered a no-brainer. However, and especially for BIPOC (Black, Indigenous, and people of color) patients with sickle cell disease or other hematologic disorders, the history of medical racism and a pattern of negative health care experiences have sown a distrust of the medical research community that spurs vaccine hesitancy despite the far-reaching impact of this pandemic.
I asked an African American friend of mine who is a pediatrician if she would get the vaccine, to which she replied: “People of color are already aware of the experiments and trials performed on our communities without the knowledge and informed consent of those being tested – many of whom were children, impoverished or disenfranchised – so while I personally will get vaccinated, I understand why some wouldn’t be as trusting.”
In December 2020, a poll by the Kaiser Family Foundation found that a primary factor behind COVID-19 vaccine hesitancy among Black respondents was the fear of catching the virus from the vaccine.1 While this is an understandable concern for the general public, there needs to be a wide-reaching patient education effort to teach about the vaccine and how it was designed to work, (especially around the use of messenger RNA technology) so as to put such fears to rest and empower patients to go into this process as knowledgeable advocates for their own health.
With so many sources of information about the pandemic, there are just as many sources of misinformation being spouted by biased outlets on all sides of the political spectrum.
Physicians are most likely to influence their patients’ willingness to take the flu vaccine, accept treatment recommendations as well as potentially accept the COVID-19 vaccine. Our responsibility as care providers is to help our patients filter through the information and provide them with the tools, they need to understand what is fact and what is fiction. We are to answer their questions and concerns, correct any misunderstandings, and address their individual reasons for hesitancy. We must also pay particular attention to our BIPOC patient populations who may have unique reasons for declining the vaccine, compared with the general population. Our conversations should not only reassure patients that the vaccines currently available won’t give them COVID-19, but also address concerns about the efficacy and safety of the vaccine and reiterate that no corners were cut in the development and approval process.
As a hematologist I have had to become very comfortable with having uncomfortable conversations with my patients about the history of maltreatment and discrimination toward minorities in health care, while reassuring them of the current attempts to right those wrongs and the major wins we have had in research when it comes to adapting therapeutics to diverse populations for optimal outcomes.
The conversation about vaccine hesitancy should be held with patience and humility, acknowledging the past and validating patient concerns that will influence their decisions. We need to be more humane and relatable, and use real-world language to clearly share the facts without buzzwords and jargon that may confuse or even reinforce perceptions of lack of transparency.
I received my COVID-19 vaccine on Dec. 29, 2020, and my experience was similar to that of anyone else’s. I had the same concerns most of my patients and colleagues have expressed, but when I saw my sister share her “postvax selfie” on WhatsApp and discussed her experience with her, I felt more comfortable. I then spoke with my allergist, my primary care provider, my husband, and other people in my personal circles before I scheduled my appointment. After my first dose, I called my sister-in-law, a nurse in Canada, who expressed the same concerns that I had and was about to cancel her appointment for that afternoon. I shared my selfie, I shared my experience, and that afternoon she got her vaccine.
The best way to restore a fundamental trust in science and medicine in our patients is to relate to them as humans. Our patients need to know we have the same concerns and fears that they do and that sometimes we have just as many questions too. Communicating openly and authentically, not only with our patients but in all our spheres of influence, can help rebuild the relationship between the public and the health care system. By giving them a glimpse of our humanity, we can support each other as we hopefully eventually see an end to this pandemic.
Ifeyinwa (Ify) Osunkwo, MD, MPH, is a professor of medicine and the director of the Sickle Cell Disease Enterprise at the Levine Cancer Institute, Atrium Health, Charlotte, N.C. She is the editor in chief of Hematology News.
References
1. www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
Nearly 10 months since the onset of the COVID-19 pandemic in the United States, ICUs across the country are reaching maximum capacity and hospitalizations are outnumbering the available providers and staff to care for them. Clinicians everywhere are becoming exhausted and frustrated, and the world is all asking when an end to this pandemic will be in sight? The Food and Drug Administration issued emergency authorization for two multidose COVID-19 vaccines that are now being deployed across the country.
At this writing, 2.8 million Americans have received their first COVID-19 vaccine dose, a number far short of the projected 100 million. The limited production capacity and tiered distribution are the main determinants of who gets the vaccine and when, but a third and extremely important factor in whether people will choose to get vaccinated is their level of awareness of and trust in the scientific and medical processes behind wide-scale vaccination.
As medical professionals, many of us wouldn’t hesitate to get vaccinated against a pandemic virus. Concerns about safety and the integrity of the COVID-19 vaccine development process in light of the “warp speed” of its production has many Americans concerned about getting vaccinated. We may not be able to relate to some patients’ reluctance to receive a vaccine that has been confirmed by phase 3 clinical trials with collectively over 66,000 participants (nearly 10% African American in each study) to have an effectiveness of over 90%. We are so intimately familiar with the vaccine development process, the medical terminology used to describe these results and the effectiveness of vaccines overall in eliminating infectious diseases like polio and smallpox. To many of us, receiving the COVID-19 vaccine may be considered a no-brainer. However, and especially for BIPOC (Black, Indigenous, and people of color) patients with sickle cell disease or other hematologic disorders, the history of medical racism and a pattern of negative health care experiences have sown a distrust of the medical research community that spurs vaccine hesitancy despite the far-reaching impact of this pandemic.
I asked an African American friend of mine who is a pediatrician if she would get the vaccine, to which she replied: “People of color are already aware of the experiments and trials performed on our communities without the knowledge and informed consent of those being tested – many of whom were children, impoverished or disenfranchised – so while I personally will get vaccinated, I understand why some wouldn’t be as trusting.”
In December 2020, a poll by the Kaiser Family Foundation found that a primary factor behind COVID-19 vaccine hesitancy among Black respondents was the fear of catching the virus from the vaccine.1 While this is an understandable concern for the general public, there needs to be a wide-reaching patient education effort to teach about the vaccine and how it was designed to work, (especially around the use of messenger RNA technology) so as to put such fears to rest and empower patients to go into this process as knowledgeable advocates for their own health.
With so many sources of information about the pandemic, there are just as many sources of misinformation being spouted by biased outlets on all sides of the political spectrum.
Physicians are most likely to influence their patients’ willingness to take the flu vaccine, accept treatment recommendations as well as potentially accept the COVID-19 vaccine. Our responsibility as care providers is to help our patients filter through the information and provide them with the tools, they need to understand what is fact and what is fiction. We are to answer their questions and concerns, correct any misunderstandings, and address their individual reasons for hesitancy. We must also pay particular attention to our BIPOC patient populations who may have unique reasons for declining the vaccine, compared with the general population. Our conversations should not only reassure patients that the vaccines currently available won’t give them COVID-19, but also address concerns about the efficacy and safety of the vaccine and reiterate that no corners were cut in the development and approval process.
As a hematologist I have had to become very comfortable with having uncomfortable conversations with my patients about the history of maltreatment and discrimination toward minorities in health care, while reassuring them of the current attempts to right those wrongs and the major wins we have had in research when it comes to adapting therapeutics to diverse populations for optimal outcomes.
The conversation about vaccine hesitancy should be held with patience and humility, acknowledging the past and validating patient concerns that will influence their decisions. We need to be more humane and relatable, and use real-world language to clearly share the facts without buzzwords and jargon that may confuse or even reinforce perceptions of lack of transparency.
I received my COVID-19 vaccine on Dec. 29, 2020, and my experience was similar to that of anyone else’s. I had the same concerns most of my patients and colleagues have expressed, but when I saw my sister share her “postvax selfie” on WhatsApp and discussed her experience with her, I felt more comfortable. I then spoke with my allergist, my primary care provider, my husband, and other people in my personal circles before I scheduled my appointment. After my first dose, I called my sister-in-law, a nurse in Canada, who expressed the same concerns that I had and was about to cancel her appointment for that afternoon. I shared my selfie, I shared my experience, and that afternoon she got her vaccine.
The best way to restore a fundamental trust in science and medicine in our patients is to relate to them as humans. Our patients need to know we have the same concerns and fears that they do and that sometimes we have just as many questions too. Communicating openly and authentically, not only with our patients but in all our spheres of influence, can help rebuild the relationship between the public and the health care system. By giving them a glimpse of our humanity, we can support each other as we hopefully eventually see an end to this pandemic.
Ifeyinwa (Ify) Osunkwo, MD, MPH, is a professor of medicine and the director of the Sickle Cell Disease Enterprise at the Levine Cancer Institute, Atrium Health, Charlotte, N.C. She is the editor in chief of Hematology News.
References
1. www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
Nearly 10 months since the onset of the COVID-19 pandemic in the United States, ICUs across the country are reaching maximum capacity and hospitalizations are outnumbering the available providers and staff to care for them. Clinicians everywhere are becoming exhausted and frustrated, and the world is all asking when an end to this pandemic will be in sight? The Food and Drug Administration issued emergency authorization for two multidose COVID-19 vaccines that are now being deployed across the country.
At this writing, 2.8 million Americans have received their first COVID-19 vaccine dose, a number far short of the projected 100 million. The limited production capacity and tiered distribution are the main determinants of who gets the vaccine and when, but a third and extremely important factor in whether people will choose to get vaccinated is their level of awareness of and trust in the scientific and medical processes behind wide-scale vaccination.
As medical professionals, many of us wouldn’t hesitate to get vaccinated against a pandemic virus. Concerns about safety and the integrity of the COVID-19 vaccine development process in light of the “warp speed” of its production has many Americans concerned about getting vaccinated. We may not be able to relate to some patients’ reluctance to receive a vaccine that has been confirmed by phase 3 clinical trials with collectively over 66,000 participants (nearly 10% African American in each study) to have an effectiveness of over 90%. We are so intimately familiar with the vaccine development process, the medical terminology used to describe these results and the effectiveness of vaccines overall in eliminating infectious diseases like polio and smallpox. To many of us, receiving the COVID-19 vaccine may be considered a no-brainer. However, and especially for BIPOC (Black, Indigenous, and people of color) patients with sickle cell disease or other hematologic disorders, the history of medical racism and a pattern of negative health care experiences have sown a distrust of the medical research community that spurs vaccine hesitancy despite the far-reaching impact of this pandemic.
I asked an African American friend of mine who is a pediatrician if she would get the vaccine, to which she replied: “People of color are already aware of the experiments and trials performed on our communities without the knowledge and informed consent of those being tested – many of whom were children, impoverished or disenfranchised – so while I personally will get vaccinated, I understand why some wouldn’t be as trusting.”
In December 2020, a poll by the Kaiser Family Foundation found that a primary factor behind COVID-19 vaccine hesitancy among Black respondents was the fear of catching the virus from the vaccine.1 While this is an understandable concern for the general public, there needs to be a wide-reaching patient education effort to teach about the vaccine and how it was designed to work, (especially around the use of messenger RNA technology) so as to put such fears to rest and empower patients to go into this process as knowledgeable advocates for their own health.
With so many sources of information about the pandemic, there are just as many sources of misinformation being spouted by biased outlets on all sides of the political spectrum.
Physicians are most likely to influence their patients’ willingness to take the flu vaccine, accept treatment recommendations as well as potentially accept the COVID-19 vaccine. Our responsibility as care providers is to help our patients filter through the information and provide them with the tools, they need to understand what is fact and what is fiction. We are to answer their questions and concerns, correct any misunderstandings, and address their individual reasons for hesitancy. We must also pay particular attention to our BIPOC patient populations who may have unique reasons for declining the vaccine, compared with the general population. Our conversations should not only reassure patients that the vaccines currently available won’t give them COVID-19, but also address concerns about the efficacy and safety of the vaccine and reiterate that no corners were cut in the development and approval process.
As a hematologist I have had to become very comfortable with having uncomfortable conversations with my patients about the history of maltreatment and discrimination toward minorities in health care, while reassuring them of the current attempts to right those wrongs and the major wins we have had in research when it comes to adapting therapeutics to diverse populations for optimal outcomes.
The conversation about vaccine hesitancy should be held with patience and humility, acknowledging the past and validating patient concerns that will influence their decisions. We need to be more humane and relatable, and use real-world language to clearly share the facts without buzzwords and jargon that may confuse or even reinforce perceptions of lack of transparency.
I received my COVID-19 vaccine on Dec. 29, 2020, and my experience was similar to that of anyone else’s. I had the same concerns most of my patients and colleagues have expressed, but when I saw my sister share her “postvax selfie” on WhatsApp and discussed her experience with her, I felt more comfortable. I then spoke with my allergist, my primary care provider, my husband, and other people in my personal circles before I scheduled my appointment. After my first dose, I called my sister-in-law, a nurse in Canada, who expressed the same concerns that I had and was about to cancel her appointment for that afternoon. I shared my selfie, I shared my experience, and that afternoon she got her vaccine.
The best way to restore a fundamental trust in science and medicine in our patients is to relate to them as humans. Our patients need to know we have the same concerns and fears that they do and that sometimes we have just as many questions too. Communicating openly and authentically, not only with our patients but in all our spheres of influence, can help rebuild the relationship between the public and the health care system. By giving them a glimpse of our humanity, we can support each other as we hopefully eventually see an end to this pandemic.
Ifeyinwa (Ify) Osunkwo, MD, MPH, is a professor of medicine and the director of the Sickle Cell Disease Enterprise at the Levine Cancer Institute, Atrium Health, Charlotte, N.C. She is the editor in chief of Hematology News.
References
1. www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
Collective trauma could lead to posttraumatic growth
Reflections for 2021
When we went to medical school, how many of us thought we would practice through a pandemic? For most of us, 2020 was the most challenging professional year of our lives. As a psychiatrist, I found it particularly odd to be struggling with the same issues as all of my patients and to have all my patients in crisis at the same time. I was repeatedly asked by friends, “How are your patients doing?” My reply, “About the same as the rest of us.” After a period of adapting, I felt truly blessed to be able to practice online. I know many of my colleagues did not have that luxury, and the stress you endured is hard to fathom.
Yet, as Friedrich Nietzsche said in so many words, “What doesn’t kill you, makes you stronger,” and here we are in a new year. As we enter 2021, we know so much more about COVID-19 than we did mere months ago, and many of us have been fortunate enough to be vaccinated already.
We should be very proud of our medical and scientific community, which has worked so hard to prevent and treat COVID-19. It is indeed a miracle of modern medicine that two vaccines made their way through development to distribution in under a year. It is a great relief that health care workers are first in line: Of the 4 million vaccine doses given worldwide, 2 million were to U.S. medical personnel. We can now track the number of people vaccinated around the globe.
Yet, “the darkest hour is just before the dawn.” We are currently in the riskiest part of the pandemic, and we must continue to work hard.
As 2021 progresses, we can expect to begin the long recovery process. We know we are innately wired to adapt to adversity and are therefore resilient. The key is to tap into this wiring by developing behaviors, habits, and strategies that support us.
Posttraumatic growth (PTG) is a theory in mental health that explains a kind of transformation following trauma. It was developed by psychologists Richard Tedeschi, PhD, and Lawrence Calhoun, PhD, in the mid-1990s. They studied how people experienced positive growth following adversity. Dr. Tedeschi has said: “People develop new understandings of themselves, the world they live in, how to relate to other people, the kind of future they might have and a better understanding of how to live life.” One-half to two-thirds of individuals experiencing trauma will experience PTG. Given that our entire profession has gone through this collective trauma, far better times may indeed be ahead.
Resilience expert Eva Selhub, MD, suggests cultivating these six pillars:
- Physical vitality: The toll of 2020 has been enormous. If we are to rebound, we must care for ourselves. In our training, we were taught to put our health aside and work grueling hours. But to recover from trauma, we must attend to our own needs. Even after we are vaccinated, we must keep our nutritional status and immunity functioning at optimal levels. Let’s not get COVID-19 complacency. Clearly, health matters most. Ours included!
- Mental toughness: We made it through an incredibly grueling year, and we had to “build it as we sailed.” We figured out how to save as many lives as we could and simultaneously keep ourselves and our families safe. We have seen things previously unimaginable. We have adjusted to telemedicine. We have lived with far fewer pleasures. We have cultivated multiple ways to tame our anxieties. The year 2020 is one we can be proud of for ourselves and our colleagues. We have come a long way in a short time.
- Emotional balance: Anxiety and depression were easy to fall into in 2020. But as the pandemic subsides, the pendulum will swing the other way. The 1918 pandemic gave rise to the Roaring Twenties. What will the next chapter in our civilization bring?
- Loving and strong connections. Our relationships are what give depth and meaning to our lives, and these relationships are crucial now so we can heal. How can we nourish our connections? What toll has the pandemic taken on those closest to you? Did some friends or family step up and help? Can we move out of our caretaker role and allow others to care for us?
- Spiritual connection: Facing so much grief and suffering, we have had an opportunity to look at our own lives from a different perspective. It has been an important year for reflection. How can we cultivate a deeper appreciation recognizing that every day is truly a gift? Did you find more purpose in your work last year? What sustained you in your time of need?
- Inspiring leadership: As health care professionals, we must set an example. We must show our patients and our families how resilient we can be. Let’s grow from trauma and avoid succumbing to depression, self-destructive tendencies, and divisiveness. We must continue to care for ourselves, our patients, and our community and work together to ensure a brighter and safer future for all.
Wishing you a safe, happy and healthy 2021.
“I am not what happened to me, I am what I choose to become.”
– Carl Jung, PhD
Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Mimosa Publishing, 2018). She has no conflicts of interest.
Reflections for 2021
Reflections for 2021
When we went to medical school, how many of us thought we would practice through a pandemic? For most of us, 2020 was the most challenging professional year of our lives. As a psychiatrist, I found it particularly odd to be struggling with the same issues as all of my patients and to have all my patients in crisis at the same time. I was repeatedly asked by friends, “How are your patients doing?” My reply, “About the same as the rest of us.” After a period of adapting, I felt truly blessed to be able to practice online. I know many of my colleagues did not have that luxury, and the stress you endured is hard to fathom.
Yet, as Friedrich Nietzsche said in so many words, “What doesn’t kill you, makes you stronger,” and here we are in a new year. As we enter 2021, we know so much more about COVID-19 than we did mere months ago, and many of us have been fortunate enough to be vaccinated already.
We should be very proud of our medical and scientific community, which has worked so hard to prevent and treat COVID-19. It is indeed a miracle of modern medicine that two vaccines made their way through development to distribution in under a year. It is a great relief that health care workers are first in line: Of the 4 million vaccine doses given worldwide, 2 million were to U.S. medical personnel. We can now track the number of people vaccinated around the globe.
Yet, “the darkest hour is just before the dawn.” We are currently in the riskiest part of the pandemic, and we must continue to work hard.
As 2021 progresses, we can expect to begin the long recovery process. We know we are innately wired to adapt to adversity and are therefore resilient. The key is to tap into this wiring by developing behaviors, habits, and strategies that support us.
Posttraumatic growth (PTG) is a theory in mental health that explains a kind of transformation following trauma. It was developed by psychologists Richard Tedeschi, PhD, and Lawrence Calhoun, PhD, in the mid-1990s. They studied how people experienced positive growth following adversity. Dr. Tedeschi has said: “People develop new understandings of themselves, the world they live in, how to relate to other people, the kind of future they might have and a better understanding of how to live life.” One-half to two-thirds of individuals experiencing trauma will experience PTG. Given that our entire profession has gone through this collective trauma, far better times may indeed be ahead.
Resilience expert Eva Selhub, MD, suggests cultivating these six pillars:
- Physical vitality: The toll of 2020 has been enormous. If we are to rebound, we must care for ourselves. In our training, we were taught to put our health aside and work grueling hours. But to recover from trauma, we must attend to our own needs. Even after we are vaccinated, we must keep our nutritional status and immunity functioning at optimal levels. Let’s not get COVID-19 complacency. Clearly, health matters most. Ours included!
- Mental toughness: We made it through an incredibly grueling year, and we had to “build it as we sailed.” We figured out how to save as many lives as we could and simultaneously keep ourselves and our families safe. We have seen things previously unimaginable. We have adjusted to telemedicine. We have lived with far fewer pleasures. We have cultivated multiple ways to tame our anxieties. The year 2020 is one we can be proud of for ourselves and our colleagues. We have come a long way in a short time.
- Emotional balance: Anxiety and depression were easy to fall into in 2020. But as the pandemic subsides, the pendulum will swing the other way. The 1918 pandemic gave rise to the Roaring Twenties. What will the next chapter in our civilization bring?
- Loving and strong connections. Our relationships are what give depth and meaning to our lives, and these relationships are crucial now so we can heal. How can we nourish our connections? What toll has the pandemic taken on those closest to you? Did some friends or family step up and help? Can we move out of our caretaker role and allow others to care for us?
- Spiritual connection: Facing so much grief and suffering, we have had an opportunity to look at our own lives from a different perspective. It has been an important year for reflection. How can we cultivate a deeper appreciation recognizing that every day is truly a gift? Did you find more purpose in your work last year? What sustained you in your time of need?
- Inspiring leadership: As health care professionals, we must set an example. We must show our patients and our families how resilient we can be. Let’s grow from trauma and avoid succumbing to depression, self-destructive tendencies, and divisiveness. We must continue to care for ourselves, our patients, and our community and work together to ensure a brighter and safer future for all.
Wishing you a safe, happy and healthy 2021.
“I am not what happened to me, I am what I choose to become.”
– Carl Jung, PhD
Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Mimosa Publishing, 2018). She has no conflicts of interest.
When we went to medical school, how many of us thought we would practice through a pandemic? For most of us, 2020 was the most challenging professional year of our lives. As a psychiatrist, I found it particularly odd to be struggling with the same issues as all of my patients and to have all my patients in crisis at the same time. I was repeatedly asked by friends, “How are your patients doing?” My reply, “About the same as the rest of us.” After a period of adapting, I felt truly blessed to be able to practice online. I know many of my colleagues did not have that luxury, and the stress you endured is hard to fathom.
Yet, as Friedrich Nietzsche said in so many words, “What doesn’t kill you, makes you stronger,” and here we are in a new year. As we enter 2021, we know so much more about COVID-19 than we did mere months ago, and many of us have been fortunate enough to be vaccinated already.
We should be very proud of our medical and scientific community, which has worked so hard to prevent and treat COVID-19. It is indeed a miracle of modern medicine that two vaccines made their way through development to distribution in under a year. It is a great relief that health care workers are first in line: Of the 4 million vaccine doses given worldwide, 2 million were to U.S. medical personnel. We can now track the number of people vaccinated around the globe.
Yet, “the darkest hour is just before the dawn.” We are currently in the riskiest part of the pandemic, and we must continue to work hard.
As 2021 progresses, we can expect to begin the long recovery process. We know we are innately wired to adapt to adversity and are therefore resilient. The key is to tap into this wiring by developing behaviors, habits, and strategies that support us.
Posttraumatic growth (PTG) is a theory in mental health that explains a kind of transformation following trauma. It was developed by psychologists Richard Tedeschi, PhD, and Lawrence Calhoun, PhD, in the mid-1990s. They studied how people experienced positive growth following adversity. Dr. Tedeschi has said: “People develop new understandings of themselves, the world they live in, how to relate to other people, the kind of future they might have and a better understanding of how to live life.” One-half to two-thirds of individuals experiencing trauma will experience PTG. Given that our entire profession has gone through this collective trauma, far better times may indeed be ahead.
Resilience expert Eva Selhub, MD, suggests cultivating these six pillars:
- Physical vitality: The toll of 2020 has been enormous. If we are to rebound, we must care for ourselves. In our training, we were taught to put our health aside and work grueling hours. But to recover from trauma, we must attend to our own needs. Even after we are vaccinated, we must keep our nutritional status and immunity functioning at optimal levels. Let’s not get COVID-19 complacency. Clearly, health matters most. Ours included!
- Mental toughness: We made it through an incredibly grueling year, and we had to “build it as we sailed.” We figured out how to save as many lives as we could and simultaneously keep ourselves and our families safe. We have seen things previously unimaginable. We have adjusted to telemedicine. We have lived with far fewer pleasures. We have cultivated multiple ways to tame our anxieties. The year 2020 is one we can be proud of for ourselves and our colleagues. We have come a long way in a short time.
- Emotional balance: Anxiety and depression were easy to fall into in 2020. But as the pandemic subsides, the pendulum will swing the other way. The 1918 pandemic gave rise to the Roaring Twenties. What will the next chapter in our civilization bring?
- Loving and strong connections. Our relationships are what give depth and meaning to our lives, and these relationships are crucial now so we can heal. How can we nourish our connections? What toll has the pandemic taken on those closest to you? Did some friends or family step up and help? Can we move out of our caretaker role and allow others to care for us?
- Spiritual connection: Facing so much grief and suffering, we have had an opportunity to look at our own lives from a different perspective. It has been an important year for reflection. How can we cultivate a deeper appreciation recognizing that every day is truly a gift? Did you find more purpose in your work last year? What sustained you in your time of need?
- Inspiring leadership: As health care professionals, we must set an example. We must show our patients and our families how resilient we can be. Let’s grow from trauma and avoid succumbing to depression, self-destructive tendencies, and divisiveness. We must continue to care for ourselves, our patients, and our community and work together to ensure a brighter and safer future for all.
Wishing you a safe, happy and healthy 2021.
“I am not what happened to me, I am what I choose to become.”
– Carl Jung, PhD
Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Mimosa Publishing, 2018). She has no conflicts of interest.
Happy New Year! May 2021 be better
As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.
I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.
I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.
Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.
Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.
“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson
John I. Allen, MD, MBA, AGAF
Editor in Chief
As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.
I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.
I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.
Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.
Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.
“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson
John I. Allen, MD, MBA, AGAF
Editor in Chief
As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.
I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.
I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.
Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.
Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.
“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson
John I. Allen, MD, MBA, AGAF
Editor in Chief
Zoom Zoom Zoom: An end-of-year update from a virtual psychiatrist
In mid-April, a month into pandemic life with a stay-at-home order, I wrote about my experiences as a virtual outpatient psychiatrist in private practice. It’s been 10 months now and with this tragic year drawing to a close, it seems like a good time for an update.
In that April column, I describe how I created a makeshift home office. This entailed pushing my son’s baseball card collection and dusty sports trophies to the side of the room, bringing in a desk and a rug, a house plant, and a statue of a Buddha. I enjoyed watching out the window behind my computer screen as the neighbors and their dogs walked by, and I loved seeing the tree out the window blossom into gorgeous flowers.
With time, my physical space has changed. The remnants of my son’s childhood have all been moved to a closet, artwork has been added to the wall behind me, and the space is now clearly an office, though my laptop remains propped on a pile of books so that no one is looking up my nose. The room, with four large windows facing north and west, has issues with temperature control. In an old house, the heat works all too well in the adjacent bedroom (while the rest of the occupants in other rooms freeze), but the office itself has no heat: I have added both a fan and a space heater, and there are some very cold days where I’ve propped open one of the windows. And with the shortened days, large windows on two walls have presented a challenge as the sun changes positions throughout the day – there are times when the sun’s rays streak across my face in such a way that I look rather ethereal, and between sessions I have lowered, raised, and adjusted the blinds to avoid this. I finally pulled off the thin metal venetian blinds and took them to Lowe’s, where a partially masked young woman cut me new blinds with larger slats. An ergonomic office chair has replaced the wicker Ikea chair I was using, and between all these machinations, I am now physically comfortable most of the time. I believe I am still a bit too pixelated on the screen, but my patients are not complaining, and when the natural lighting fades at 4:30 p.m., the overhead lighting is all wrong again. These all are things I never considered – or long ago addressed – in my real-life practice of psychiatry in a office I have loved for years.
With time, I’ve grown more comfortable working from home on a screen and there are things about this life I’ve grown to like. My husband no longer travels, my daughter – my gift of the pandemic – returned home from New York City where she was in her final months of graduate school, and these unexpected months with her (and her cat) have been a pleasure. There is something nice about being trapped at home with people I love, even if we are all in our respective places, in front of our separate screens. There has been time for long walks, trips to the beach, and long bike rides. And as my daughter now prepares to move to Denver, I have been heartened by the hope of vaccines, and the knowledge that I will likely be able to see her again in the coming months. The people are not the only ones who have benefited from this time at home together – I have no idea how we would have managed with our elderly dog if we were not home to care for him.
My life has become more efficient. I used to find myself aggravated when patients forgot their appointments, a not-infrequent occurrence. People no longer get caught in traffic, they come on time, and they don’t complain about my crowded parking lot. When there is down time, I use it more efficiently at home – a load of laundry gets done, I get a chance to turn on the news or exercise, or make dinner early. And because I have two other family members working from home, I am not the only one mixing work with chores or exercise.
While my medical colleagues who work in settings where they must see patients in person have struggled or functioned in some state of denial, I have felt safe and protected, a bit cocooned with my family in a house big enough to give us all space, in a neighborhood with sidewalks and places to walk, and to protect my sanity, I am lucky to have a patio that has now been equipped with lights, patio heaters, a fire pit, and socially distanced tables so that I can still see friends outside.
Telemedicine has added a new dimension to treatment. I’ve had family sessions with multiple people joining a zoom link from different locations – so much easier than coordinating a time when everyone can travel to my office. I’ve had patients call in from cars and from closets in search of privacy, and from their gardens and poolsides. I’ve met spouses, children, many a dog and cat, plus the more unusual of pets and farm animals, including a goat, ferret, lizard, African grey parrot, and guinea pigs.
These are the good things, and while I wish I could say it was all good, so much of what remains is laden with anxiety. My son lives nearby, but he has shared a house with a hospital worker for much of the past year and there were COVID scares, months at a time without so much as a hug, and my husband has not seen his parents or brother for a year now. There are the awkward waves or salutes with friends I once gave carefree hugs, the constant thoughts of how far away is that person standing, and each person’s “beliefs” about what is safe when we still don’t fully understand how this virus spreads. I worry for myself, I worry for my family and friends, and I worry for my patients when they tell me about behaviors that clearly are not safe.
At first, I found my work as a telepsychiatrist to be exhausting, and I assumed it was because my patients were now just faces, inches from my own eyes, and no longer diffused by a visual field that included my whole office and the opportunity to break eye contact while I still listened with full attention. This has gotten much better – I’ve adjusted to my on-screen relationships, but what has not gotten better is both the acuity, and sometimes the boredom.
Patients are struggling; they are sad, lonely, and missing the richness of their former lives. They miss friends, meeting new people, cultural experiences, diversity in how they spend their time, and travel. They have all the same human experiences of loss, illness, and grief, but with the added burden of struggling alone or within the confines of pandemic life that has destroyed our ability to mark events with social and religious customs that guide healing. People who had done well for years are now needing more, and those who were not doing well are doing worse. It makes for long days.
I mentioned boredom: With less time spent with other people, so many sessions are about COVID – who has it, who might have it, what people are doing to avoid it, and still, how they get their groceries. The second most popular psychotherapy topic includes what they are watching on Netflix, and as human beings trudging through this together, I have appreciated my patients’ suggestions as much as they have appreciated mine.* Life for all of us has come to be more about survival, and less about self-discovery and striving. Many sessions have started to feel the same from 1 hour to the next, in ways they never did before.
There are other aspects to telepsychiatry that I have found difficult. The site I have used most – Doxy.me – works well with some patients, but with others there are technical problems. Sessions freeze, the sound goes in or out, and we end up switching to another platform, which may or may not work better. Sometimes patients have the camera at odd angles, or they bounce a laptop on their knees to the point that I get seasick. One of my family members has said that I can sometimes be overheard, so I now have a radio playing classical music outside my door, and I often use earbuds so that the patient can’t be overheard and I speak more softly with them – this has all been good in terms of improving privacy, but after a while I find that it’s stressful to have people talking to me inside my own ears! These are little kinks, but when you do it for hours a day, they add up to a sense of being stressed in ways that in-person psychiatry does not lend itself to.
Finally, three seasons into my work-at-home life, I still have not found a new rhythm for some of the logistical aspects of private practice that came so easily in my office. My mail still goes to the office, the plants there still need water, my files and computer are there, but tasks that were once a seamless part of my work day now spill into my time off and I go into the office each week to file, log medications, and attend to the business of my practice. My smartphone, with its ability to e-prescribe, invoice, and fax, has made it possible for me to manage and certainly, outpatient psychiatrists are very lucky that we have the option to continue our work with patients remotely during such difficult times.
I have sent people for virtual intensive substance treatment, and to virtual couples’ counseling, and these remote treatments have been useful. The one treatment that has been very difficult for patients to negotiate has been outpatient electroconvulsive therapy – this requires coordination with another person to drive the patient to treatments (and to wait outside in the parking lot), and also for separate weekly COVID testing. Transcranial magnetic stimulation, which also is still being done in person, has not been any different – patients can drive themselves and the one center I referred to has not required preprocedure COVID testing.
What does the future hold? Will we ever go back to practicing the way we did? While some of my patients miss real-life therapy, most do not; they too like the added efficiency, getting treatment from the comfort of their home without the stress of finding the time to travel. I’ve taken on new patients during this time, and while I anticipated that it would be difficult, it has gone surprisingly well – people I have never met in real life talk to me with ease, and both psychotherapy and medication management have gone well. The one area that I have found most difficult is assessing tremors and dyskinesias, and one patient mentioned she has gained nearly 50 pounds over the past year – something I certainly would have noticed and attended to sooner in real life. I have mixed feelings about returning to a completely live practice. I think I would like a combination where I see all my patients in person once in a while, but would like to be able to offer some times where I see people virtually from home at least one day a week.
Time will tell how that plays out with insurers. My best guess is that, with the lowered no-show rates that everyone is seeing and the higher levels of depression and anxiety that people are having, this may have been a costly time for mental health care. At the same time, inpatient psychiatric units have decreased their capacity, and perhaps more efficient delivery of outpatient care has lowered the overall cost. I suppose we will wait to hear, but for many, the transition to virtual care has allowed many people to get treatment who would have otherwise gone without care.
In my April article, I mentioned that I was having daily Facetime check-in visits with a distressed patient who was on a COVID unit with pneumonia. Since then, I have had several more patients contract COVID, and many of my patients have had family members who have tested positive or become symptomatic with COVID. It has been nice to have sessions with people during this time, and thankfully, I have not had any more patients who have required hospitalization for the virus.
I still catch myself thinking that, of all the things I have worried about over the years, “pandemic” was never on my list. It seems so strange that I left my office on a Friday with no idea that I would not be returning to work the following Monday, or that life would change in such a radical way. As we leave this awful year behind and greet the new one with the hope that vaccines and a new administration might offer solutions, I’d like to wish my readers the best for a healthy, safe, and gentle New Year.
*My top viewing picks for now are “The Queen’s Gambit” (Netflix), and “A Place to Call Home” (Acorn).
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.
In mid-April, a month into pandemic life with a stay-at-home order, I wrote about my experiences as a virtual outpatient psychiatrist in private practice. It’s been 10 months now and with this tragic year drawing to a close, it seems like a good time for an update.
In that April column, I describe how I created a makeshift home office. This entailed pushing my son’s baseball card collection and dusty sports trophies to the side of the room, bringing in a desk and a rug, a house plant, and a statue of a Buddha. I enjoyed watching out the window behind my computer screen as the neighbors and their dogs walked by, and I loved seeing the tree out the window blossom into gorgeous flowers.
With time, my physical space has changed. The remnants of my son’s childhood have all been moved to a closet, artwork has been added to the wall behind me, and the space is now clearly an office, though my laptop remains propped on a pile of books so that no one is looking up my nose. The room, with four large windows facing north and west, has issues with temperature control. In an old house, the heat works all too well in the adjacent bedroom (while the rest of the occupants in other rooms freeze), but the office itself has no heat: I have added both a fan and a space heater, and there are some very cold days where I’ve propped open one of the windows. And with the shortened days, large windows on two walls have presented a challenge as the sun changes positions throughout the day – there are times when the sun’s rays streak across my face in such a way that I look rather ethereal, and between sessions I have lowered, raised, and adjusted the blinds to avoid this. I finally pulled off the thin metal venetian blinds and took them to Lowe’s, where a partially masked young woman cut me new blinds with larger slats. An ergonomic office chair has replaced the wicker Ikea chair I was using, and between all these machinations, I am now physically comfortable most of the time. I believe I am still a bit too pixelated on the screen, but my patients are not complaining, and when the natural lighting fades at 4:30 p.m., the overhead lighting is all wrong again. These all are things I never considered – or long ago addressed – in my real-life practice of psychiatry in a office I have loved for years.
With time, I’ve grown more comfortable working from home on a screen and there are things about this life I’ve grown to like. My husband no longer travels, my daughter – my gift of the pandemic – returned home from New York City where she was in her final months of graduate school, and these unexpected months with her (and her cat) have been a pleasure. There is something nice about being trapped at home with people I love, even if we are all in our respective places, in front of our separate screens. There has been time for long walks, trips to the beach, and long bike rides. And as my daughter now prepares to move to Denver, I have been heartened by the hope of vaccines, and the knowledge that I will likely be able to see her again in the coming months. The people are not the only ones who have benefited from this time at home together – I have no idea how we would have managed with our elderly dog if we were not home to care for him.
My life has become more efficient. I used to find myself aggravated when patients forgot their appointments, a not-infrequent occurrence. People no longer get caught in traffic, they come on time, and they don’t complain about my crowded parking lot. When there is down time, I use it more efficiently at home – a load of laundry gets done, I get a chance to turn on the news or exercise, or make dinner early. And because I have two other family members working from home, I am not the only one mixing work with chores or exercise.
While my medical colleagues who work in settings where they must see patients in person have struggled or functioned in some state of denial, I have felt safe and protected, a bit cocooned with my family in a house big enough to give us all space, in a neighborhood with sidewalks and places to walk, and to protect my sanity, I am lucky to have a patio that has now been equipped with lights, patio heaters, a fire pit, and socially distanced tables so that I can still see friends outside.
Telemedicine has added a new dimension to treatment. I’ve had family sessions with multiple people joining a zoom link from different locations – so much easier than coordinating a time when everyone can travel to my office. I’ve had patients call in from cars and from closets in search of privacy, and from their gardens and poolsides. I’ve met spouses, children, many a dog and cat, plus the more unusual of pets and farm animals, including a goat, ferret, lizard, African grey parrot, and guinea pigs.
These are the good things, and while I wish I could say it was all good, so much of what remains is laden with anxiety. My son lives nearby, but he has shared a house with a hospital worker for much of the past year and there were COVID scares, months at a time without so much as a hug, and my husband has not seen his parents or brother for a year now. There are the awkward waves or salutes with friends I once gave carefree hugs, the constant thoughts of how far away is that person standing, and each person’s “beliefs” about what is safe when we still don’t fully understand how this virus spreads. I worry for myself, I worry for my family and friends, and I worry for my patients when they tell me about behaviors that clearly are not safe.
At first, I found my work as a telepsychiatrist to be exhausting, and I assumed it was because my patients were now just faces, inches from my own eyes, and no longer diffused by a visual field that included my whole office and the opportunity to break eye contact while I still listened with full attention. This has gotten much better – I’ve adjusted to my on-screen relationships, but what has not gotten better is both the acuity, and sometimes the boredom.
Patients are struggling; they are sad, lonely, and missing the richness of their former lives. They miss friends, meeting new people, cultural experiences, diversity in how they spend their time, and travel. They have all the same human experiences of loss, illness, and grief, but with the added burden of struggling alone or within the confines of pandemic life that has destroyed our ability to mark events with social and religious customs that guide healing. People who had done well for years are now needing more, and those who were not doing well are doing worse. It makes for long days.
I mentioned boredom: With less time spent with other people, so many sessions are about COVID – who has it, who might have it, what people are doing to avoid it, and still, how they get their groceries. The second most popular psychotherapy topic includes what they are watching on Netflix, and as human beings trudging through this together, I have appreciated my patients’ suggestions as much as they have appreciated mine.* Life for all of us has come to be more about survival, and less about self-discovery and striving. Many sessions have started to feel the same from 1 hour to the next, in ways they never did before.
There are other aspects to telepsychiatry that I have found difficult. The site I have used most – Doxy.me – works well with some patients, but with others there are technical problems. Sessions freeze, the sound goes in or out, and we end up switching to another platform, which may or may not work better. Sometimes patients have the camera at odd angles, or they bounce a laptop on their knees to the point that I get seasick. One of my family members has said that I can sometimes be overheard, so I now have a radio playing classical music outside my door, and I often use earbuds so that the patient can’t be overheard and I speak more softly with them – this has all been good in terms of improving privacy, but after a while I find that it’s stressful to have people talking to me inside my own ears! These are little kinks, but when you do it for hours a day, they add up to a sense of being stressed in ways that in-person psychiatry does not lend itself to.
Finally, three seasons into my work-at-home life, I still have not found a new rhythm for some of the logistical aspects of private practice that came so easily in my office. My mail still goes to the office, the plants there still need water, my files and computer are there, but tasks that were once a seamless part of my work day now spill into my time off and I go into the office each week to file, log medications, and attend to the business of my practice. My smartphone, with its ability to e-prescribe, invoice, and fax, has made it possible for me to manage and certainly, outpatient psychiatrists are very lucky that we have the option to continue our work with patients remotely during such difficult times.
I have sent people for virtual intensive substance treatment, and to virtual couples’ counseling, and these remote treatments have been useful. The one treatment that has been very difficult for patients to negotiate has been outpatient electroconvulsive therapy – this requires coordination with another person to drive the patient to treatments (and to wait outside in the parking lot), and also for separate weekly COVID testing. Transcranial magnetic stimulation, which also is still being done in person, has not been any different – patients can drive themselves and the one center I referred to has not required preprocedure COVID testing.
What does the future hold? Will we ever go back to practicing the way we did? While some of my patients miss real-life therapy, most do not; they too like the added efficiency, getting treatment from the comfort of their home without the stress of finding the time to travel. I’ve taken on new patients during this time, and while I anticipated that it would be difficult, it has gone surprisingly well – people I have never met in real life talk to me with ease, and both psychotherapy and medication management have gone well. The one area that I have found most difficult is assessing tremors and dyskinesias, and one patient mentioned she has gained nearly 50 pounds over the past year – something I certainly would have noticed and attended to sooner in real life. I have mixed feelings about returning to a completely live practice. I think I would like a combination where I see all my patients in person once in a while, but would like to be able to offer some times where I see people virtually from home at least one day a week.
Time will tell how that plays out with insurers. My best guess is that, with the lowered no-show rates that everyone is seeing and the higher levels of depression and anxiety that people are having, this may have been a costly time for mental health care. At the same time, inpatient psychiatric units have decreased their capacity, and perhaps more efficient delivery of outpatient care has lowered the overall cost. I suppose we will wait to hear, but for many, the transition to virtual care has allowed many people to get treatment who would have otherwise gone without care.
In my April article, I mentioned that I was having daily Facetime check-in visits with a distressed patient who was on a COVID unit with pneumonia. Since then, I have had several more patients contract COVID, and many of my patients have had family members who have tested positive or become symptomatic with COVID. It has been nice to have sessions with people during this time, and thankfully, I have not had any more patients who have required hospitalization for the virus.
I still catch myself thinking that, of all the things I have worried about over the years, “pandemic” was never on my list. It seems so strange that I left my office on a Friday with no idea that I would not be returning to work the following Monday, or that life would change in such a radical way. As we leave this awful year behind and greet the new one with the hope that vaccines and a new administration might offer solutions, I’d like to wish my readers the best for a healthy, safe, and gentle New Year.
*My top viewing picks for now are “The Queen’s Gambit” (Netflix), and “A Place to Call Home” (Acorn).
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.
In mid-April, a month into pandemic life with a stay-at-home order, I wrote about my experiences as a virtual outpatient psychiatrist in private practice. It’s been 10 months now and with this tragic year drawing to a close, it seems like a good time for an update.
In that April column, I describe how I created a makeshift home office. This entailed pushing my son’s baseball card collection and dusty sports trophies to the side of the room, bringing in a desk and a rug, a house plant, and a statue of a Buddha. I enjoyed watching out the window behind my computer screen as the neighbors and their dogs walked by, and I loved seeing the tree out the window blossom into gorgeous flowers.
With time, my physical space has changed. The remnants of my son’s childhood have all been moved to a closet, artwork has been added to the wall behind me, and the space is now clearly an office, though my laptop remains propped on a pile of books so that no one is looking up my nose. The room, with four large windows facing north and west, has issues with temperature control. In an old house, the heat works all too well in the adjacent bedroom (while the rest of the occupants in other rooms freeze), but the office itself has no heat: I have added both a fan and a space heater, and there are some very cold days where I’ve propped open one of the windows. And with the shortened days, large windows on two walls have presented a challenge as the sun changes positions throughout the day – there are times when the sun’s rays streak across my face in such a way that I look rather ethereal, and between sessions I have lowered, raised, and adjusted the blinds to avoid this. I finally pulled off the thin metal venetian blinds and took them to Lowe’s, where a partially masked young woman cut me new blinds with larger slats. An ergonomic office chair has replaced the wicker Ikea chair I was using, and between all these machinations, I am now physically comfortable most of the time. I believe I am still a bit too pixelated on the screen, but my patients are not complaining, and when the natural lighting fades at 4:30 p.m., the overhead lighting is all wrong again. These all are things I never considered – or long ago addressed – in my real-life practice of psychiatry in a office I have loved for years.
With time, I’ve grown more comfortable working from home on a screen and there are things about this life I’ve grown to like. My husband no longer travels, my daughter – my gift of the pandemic – returned home from New York City where she was in her final months of graduate school, and these unexpected months with her (and her cat) have been a pleasure. There is something nice about being trapped at home with people I love, even if we are all in our respective places, in front of our separate screens. There has been time for long walks, trips to the beach, and long bike rides. And as my daughter now prepares to move to Denver, I have been heartened by the hope of vaccines, and the knowledge that I will likely be able to see her again in the coming months. The people are not the only ones who have benefited from this time at home together – I have no idea how we would have managed with our elderly dog if we were not home to care for him.
My life has become more efficient. I used to find myself aggravated when patients forgot their appointments, a not-infrequent occurrence. People no longer get caught in traffic, they come on time, and they don’t complain about my crowded parking lot. When there is down time, I use it more efficiently at home – a load of laundry gets done, I get a chance to turn on the news or exercise, or make dinner early. And because I have two other family members working from home, I am not the only one mixing work with chores or exercise.
While my medical colleagues who work in settings where they must see patients in person have struggled or functioned in some state of denial, I have felt safe and protected, a bit cocooned with my family in a house big enough to give us all space, in a neighborhood with sidewalks and places to walk, and to protect my sanity, I am lucky to have a patio that has now been equipped with lights, patio heaters, a fire pit, and socially distanced tables so that I can still see friends outside.
Telemedicine has added a new dimension to treatment. I’ve had family sessions with multiple people joining a zoom link from different locations – so much easier than coordinating a time when everyone can travel to my office. I’ve had patients call in from cars and from closets in search of privacy, and from their gardens and poolsides. I’ve met spouses, children, many a dog and cat, plus the more unusual of pets and farm animals, including a goat, ferret, lizard, African grey parrot, and guinea pigs.
These are the good things, and while I wish I could say it was all good, so much of what remains is laden with anxiety. My son lives nearby, but he has shared a house with a hospital worker for much of the past year and there were COVID scares, months at a time without so much as a hug, and my husband has not seen his parents or brother for a year now. There are the awkward waves or salutes with friends I once gave carefree hugs, the constant thoughts of how far away is that person standing, and each person’s “beliefs” about what is safe when we still don’t fully understand how this virus spreads. I worry for myself, I worry for my family and friends, and I worry for my patients when they tell me about behaviors that clearly are not safe.
At first, I found my work as a telepsychiatrist to be exhausting, and I assumed it was because my patients were now just faces, inches from my own eyes, and no longer diffused by a visual field that included my whole office and the opportunity to break eye contact while I still listened with full attention. This has gotten much better – I’ve adjusted to my on-screen relationships, but what has not gotten better is both the acuity, and sometimes the boredom.
Patients are struggling; they are sad, lonely, and missing the richness of their former lives. They miss friends, meeting new people, cultural experiences, diversity in how they spend their time, and travel. They have all the same human experiences of loss, illness, and grief, but with the added burden of struggling alone or within the confines of pandemic life that has destroyed our ability to mark events with social and religious customs that guide healing. People who had done well for years are now needing more, and those who were not doing well are doing worse. It makes for long days.
I mentioned boredom: With less time spent with other people, so many sessions are about COVID – who has it, who might have it, what people are doing to avoid it, and still, how they get their groceries. The second most popular psychotherapy topic includes what they are watching on Netflix, and as human beings trudging through this together, I have appreciated my patients’ suggestions as much as they have appreciated mine.* Life for all of us has come to be more about survival, and less about self-discovery and striving. Many sessions have started to feel the same from 1 hour to the next, in ways they never did before.
There are other aspects to telepsychiatry that I have found difficult. The site I have used most – Doxy.me – works well with some patients, but with others there are technical problems. Sessions freeze, the sound goes in or out, and we end up switching to another platform, which may or may not work better. Sometimes patients have the camera at odd angles, or they bounce a laptop on their knees to the point that I get seasick. One of my family members has said that I can sometimes be overheard, so I now have a radio playing classical music outside my door, and I often use earbuds so that the patient can’t be overheard and I speak more softly with them – this has all been good in terms of improving privacy, but after a while I find that it’s stressful to have people talking to me inside my own ears! These are little kinks, but when you do it for hours a day, they add up to a sense of being stressed in ways that in-person psychiatry does not lend itself to.
Finally, three seasons into my work-at-home life, I still have not found a new rhythm for some of the logistical aspects of private practice that came so easily in my office. My mail still goes to the office, the plants there still need water, my files and computer are there, but tasks that were once a seamless part of my work day now spill into my time off and I go into the office each week to file, log medications, and attend to the business of my practice. My smartphone, with its ability to e-prescribe, invoice, and fax, has made it possible for me to manage and certainly, outpatient psychiatrists are very lucky that we have the option to continue our work with patients remotely during such difficult times.
I have sent people for virtual intensive substance treatment, and to virtual couples’ counseling, and these remote treatments have been useful. The one treatment that has been very difficult for patients to negotiate has been outpatient electroconvulsive therapy – this requires coordination with another person to drive the patient to treatments (and to wait outside in the parking lot), and also for separate weekly COVID testing. Transcranial magnetic stimulation, which also is still being done in person, has not been any different – patients can drive themselves and the one center I referred to has not required preprocedure COVID testing.
What does the future hold? Will we ever go back to practicing the way we did? While some of my patients miss real-life therapy, most do not; they too like the added efficiency, getting treatment from the comfort of their home without the stress of finding the time to travel. I’ve taken on new patients during this time, and while I anticipated that it would be difficult, it has gone surprisingly well – people I have never met in real life talk to me with ease, and both psychotherapy and medication management have gone well. The one area that I have found most difficult is assessing tremors and dyskinesias, and one patient mentioned she has gained nearly 50 pounds over the past year – something I certainly would have noticed and attended to sooner in real life. I have mixed feelings about returning to a completely live practice. I think I would like a combination where I see all my patients in person once in a while, but would like to be able to offer some times where I see people virtually from home at least one day a week.
Time will tell how that plays out with insurers. My best guess is that, with the lowered no-show rates that everyone is seeing and the higher levels of depression and anxiety that people are having, this may have been a costly time for mental health care. At the same time, inpatient psychiatric units have decreased their capacity, and perhaps more efficient delivery of outpatient care has lowered the overall cost. I suppose we will wait to hear, but for many, the transition to virtual care has allowed many people to get treatment who would have otherwise gone without care.
In my April article, I mentioned that I was having daily Facetime check-in visits with a distressed patient who was on a COVID unit with pneumonia. Since then, I have had several more patients contract COVID, and many of my patients have had family members who have tested positive or become symptomatic with COVID. It has been nice to have sessions with people during this time, and thankfully, I have not had any more patients who have required hospitalization for the virus.
I still catch myself thinking that, of all the things I have worried about over the years, “pandemic” was never on my list. It seems so strange that I left my office on a Friday with no idea that I would not be returning to work the following Monday, or that life would change in such a radical way. As we leave this awful year behind and greet the new one with the hope that vaccines and a new administration might offer solutions, I’d like to wish my readers the best for a healthy, safe, and gentle New Year.
*My top viewing picks for now are “The Queen’s Gambit” (Netflix), and “A Place to Call Home” (Acorn).
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.
Reducing COVID-19 opioid deaths
Editor's Note: Due to updated statistics from the CDC, the online version of this article has been modified from the version that appears in the printed edition of the January 2021 issue of Current Psychiatry.
Individuals with mental health and substance use disorders (SUDs) are particularly susceptible to negative effects of the coronavirus disease 2019 (COVID-19) pandemic. The collision of the COVID-19 pandemic and the drug overdose epidemic has highlighted the urgent need for physicians, policymakers, and health care professionals to optimize care for individuals with SUDs because they may be particularly vulnerable to the effects of the virus due to compromised respiratory and immune function, and poor social support.1 In this commentary, we highlight the challenges of the drug overdose epidemic, and recommend strategies to mitigate the impact of the COVID-19 pandemic among patients with SUDs.
A crisis exacerbated by COVID-19
The current drug overdose epidemic has become an American public health nightmare. According to preliminary data released by the CDC on December 17, 2020, there were more than 81,000 drug overdose deaths in the United States in the 12 months ending May 2020.2,3 This is the highest number of overdose deaths ever recorded in a 12-month period. The CDC also noted that while overdose deaths were already increasing in the months preceding the COVID-19 pandemic, the latest numbers suggest an acceleration of overdose deaths during the pandemic.
What is causing this significant loss of life? Prescription opioids and illegal opioids such as heroin and illicitly manufactured fentanyl are the main agents associated with overdose deaths. These opioids were responsible for 61% (28,647) of drug overdose deaths in the United States in 2014.4 In 2015, the opioid overdose death rate increased by 15.6%.5
The increase in the number of opioid overdose deaths in part coincides with a sharp increase in the availability and use of heroin. Heroin overdose deaths have more than tripled since 2010, but heroin is not the only opiate involved. Fentanyl, a synthetic, short-acting opioid that is approved for managing pain in patients with advanced cancers, is 50 times more potent than heroin. The abuse of prescribed fentanyl has been accelerating over the past decade, as is the use of illicitly produced fentanyl. Evidence from US Drug Enforcement Administration (DEA) seizure records shows heroin is being adulterated with illicit fentanyl to enhance the potency of the heroin.6,7 Mixing illicit fentanyl with heroin may be contributing to the recent increase in heroin overdose fatalities. According to the CDC, overdose deaths related to synthetic opioids increased 38.4% from the 12-month period leading up to June 2019 compared with the 12-month period leading up to May 2020.2,3 Postmortem studies of individuals who died from a heroin overdose have frequently found the presence of fentanyl along with heroin.8 Overdose deaths involving heroin may be occurring because individuals may be unknowingly using heroin adulterated with fentanyl.9 In addition, carfentanil, a powerful new synthetic fentanyl, has been recently identified in heroin mixtures. Carfentanil is 10,000 times stronger than morphine. Even in miniscule amounts, carfentanil can suppress breathing to the degree that multiple doses of naloxone are needed to restore respirations.
Initial studies indicate that the COVID-19 pandemic has been exacerbating this situation. Wainwright et al10 conducted an analysis of urine drug test results of patients with SUDs from 4 months before and 4 months after COVID-19 was declared a national emergency on March 13, 2020. Compared with before COVID-19, the proportion of specimens testing positive since COVID-19 increased from 3.80% to 7.32% for fentanyl and from 1.29% to 2.09% for heroin.10
A similar drug testing study found that during the pandemic, the proportion of positive results (positivity) increased by 35% for non-prescribed fentanyl and 44% for heroin.11 Positivity for non-prescribed fentanyl increased significantly among patients who tested positive for other drugs, including by 89% for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (P < .1 for all).11
In a review of electronic medical records, Ochalek et al12 found that the number of nonfatal opioid overdoses in an emergency department in Virginia increased from 102 in March-June 2019 to 227 in March-June 2020. In an issue brief published on October 31, 2020, the American Medical Association reported increase in opioid and other drug-related overdoses in more than 40 states during the COVID-19 pandemic.13
Continue to: Strategies for intervention...
Strategies for intervention
A multi-dimensional approach is needed to protect the public from this growing opioid overdose epidemic. To address this challenging task, we recommend several strategies:
Enhance access to virtual treatment
Even when in-person treatment cannot take place due to COVID-19-related restrictions, it is vital that services are accessible to patients with SUDs during this pandemic. Examples of virtual treatment include:
- Telehealth for medication-assisted treatment (MAT) using buprenorphine (recently updated guidance from the US DEA and Substance Abuse and Mental Health Services Administration [SAMHSA] allows this method of prescribing)
- Teletherapy to prevent relapse
- Remote drug screens by sending saliva or urine kits to patients' homes, visiting patients to collect fluid samples, or asking patients to come to a "drive-through" facility to provide samples
- Virtual (online) Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery, and similar meetings to provide support in the absence of in-person meetings.
The American Society of Addiction Medicine (ASAM) offers guidance to treatment programs to focus on infection control and mitigation. The Table14 summarizes the ASAM recommendations for office-based opioid treatment during COVID-19.
Expand access to treatment
This includes access to MAT (such as buprenorphine/naloxone, methadone, naltrexone, and depot naltrexone) and, equally important, to psychosocial treatment, counseling, and/or recovery services. Recent legislative changes have increased the number of patients that a qualified physician can treat with buprenorphine/naloxone from 100 to 275, and allowed physician extenders to prescribe buprenorphine/naloxone in office-based settings. A recent population-based, retrospective Canadian study showed that opioid agonist treatment decreased the risk of mortality among opioid users, and the protective effects of this treatment increased as fentanyl and other synthetic opioids became common in the illicit drug supply.15 However, because of the shortage of psychiatrists and addiction medicine specialists in several regions of the United States, access to treatment is extremely limited and often inadequate. This constitutes a major public health crisis and contributes to our inability to intervene effectively in the opioid epidemic. Telepsychiatry programs can bring needed services to underserved areas, but they need additional support and development. Further, involving other specialties is paramount for treating this epidemic. Integrating MAT in primary care settings can improve access to treatment. Harm-reduction approaches, such as syringe exchange programs, can play an important role in reducing the adverse consequences associated with heroin use and establish health care relationships with at-risk individuals. Syringe exchange programs can also reduce the rate of infections associated with IV drug use, such as human immunodeficiency virus and hepatitis C virus.
Continue to: Increase education on naloxone...
Increase education on naloxone
Naloxone is a safe and effective opioid antagonist used to treat opioid overdoses. Timely access to naloxone is of the essence when treating opioid-related overdoses. Many states have enacted laws allowing health care professionals, law enforcement officers, and patients and relatives to obtain naloxone without a physician's prescription. It appears this approach may be yielding results. For example, the North Carolina Harm Reduction Coalition distributed >101,000 free overdose rescue kits that included naloxone and recorded 13,392 confirmed cases of overdose rescue with naloxone from 2013 to 2019.16
Divert patients with SUDs from the criminal justice system to treatment
We need to develop programs to divert patients with SUDs from the criminal justice system, which is focused on punishment, to interventions that focus on treatment. Data indicates high recidivism rates for incarcerated individuals with SUDs who do not have access to treatment after they are released. Recognizing this, communities are developing programs that divert low-level offenders from the criminal justice system into treatment. For instance, in Seattle, the Law Enforcement Assisted Diversion is a pilot program developed to divert low-level drug and prostitution offenders into community-based treatment and support services. This helps provide housing, health care, job training, treatment, and mental health support. Innovative programs are needed to provide SUD treatment in the rehabilitation programs of correctional facilities and ensure case managers and discharge planners can transition participants to community treatment programs upon their release.
Develop early identification and prevention programs
These programs should focus on individuals at high risk, such as patients with comorbid SUDs and psychiatric disorders, those with chronic pain, and at-risk children whose parents abuse opiates. Traditional addiction treatment programs typically do not address patients with complex conditions or special populations, such as adolescents or pregnant women with substance use issues. Evidence-based approaches such as Screening, Brief Intervention, and Referral to Treatment (SBIRT), Integrated Dual Diagnosis Treatment (IDDT), and prevention approaches that target students in middle schools and high schools need to be more widely available.
Improve education on opioid prescribing
Responsible opioid prescribing for clinicians should include education about the regular use of prescription drug monitoring programs, urine drug screening, avoiding co-prescription of opioids with sedative-hypnotic medications, and better linkage with addiction treatment.
Treat comorbid psychiatric conditions
It is critical to both identify and effectively treat underlying affective, anxiety, and psychotic disorders in patients with SUDs. Anxiety, depression, and emotional dysregulation often contribute to worsening substance abuse, abuse of prescription drugs, diversion of prescribed drugs, and an increased risk of overdoses and suicides. Effective treatment of comorbid psychiatric conditions also may reduce relapses.
Increase research on causes and treatments
Through research, we must expand our knowledge to better understand the factors that contribute to this epidemic and develop better treatments. These efforts may allow for the development of prevention mechanisms. For example, a recent study found that the continued use of opioid medications after an overdose was associated with a high risk of a repeated overdosecall out material?.17 At the end of a 2-year observation, 17% (confidence interval [CI]: 14% to 20%) of patients receiving a high daily dosage of a prescribed opioid had a repeat overdose compared with 15% (CI: 10% to 21%) of those receiving a moderate dosage, 9% (CI: 6% to 14%) of those receiving a low dosage, and 8% (CI: 6% to 11%) of those receiving no opioids.17 Of the patients who overdosed on prescribed opiates, 30% switched to a new prescriber after their overdose, many of whom may not have been aware of the previous overdose. From a public health perspective, it would make sense for prescribers to know of prior opioid and/or benzodiazepine overdoses. This could be reported by emergency department clinicians, law enforcement, and hospitals into a prescription drug monitoring program, which is readily available to prescribers in most states.
Acknowledgment
The authors thank Scott Proescholdbell, MPH, Injury and Violence Prevention Branch, Chronic Disease and Injury Section, Division of Public Health, North Carolina Department of Health and Human Services, for his assistance.
Bottom Line
The collision of the coronavirus disease 2019 pandemic and the drug overdose epidemic has highlighted the urgent need for health care professionals to optimize care for individuals with substance use disorders. Suggested interventions include enhancing access to medication-assisted treatment and virtual treatment, improving education about naloxone and safe opioid prescribing practices, and diverting at-risk patients from the criminal justice system to interventions that focus on treatment.
1. Volkow ND. Collision of the COVID-19 and addiction epidemics. Ann Intern Med. 2020;173(1):61-62.
2.Centers for Disease Control and Prevention. Overdose deaths accelerating during COVID-19. Accessed December 23, 2020. https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html
3.Centers for Disease Control and Prevention. National Center for Health Statistics Vital Statistics Rapid Release. Provisional drug overdose death counts. Accessed December 30, 2020. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
4.Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths -- United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382.
5.Rudd RA, Seth P, David F, et al. Increases in drug and opioid-involved overdose deaths -- United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452.
6.US Drug Enforcement Administration. DEA issues nationwide alert on fentanyl as threat to health and public safety. Published March 19, 2015. Accessed October 28, 2020. http://www.dea.gov/divisions/hq/2015/hq031815.shtml
7.Gladden RM, Martinez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths - 27 states, 2013-2014. MMWR Morb Mortal Wkly Rep. 2016;65(33):837-843.
8.Algren DA, Monteilh CP, Punja M, et al. Fentanyl-associated fatalities among illicit drug users in Wayne County, Michigan (July 2005-May 2006). J Med Toxicol. 2013;9(1):106-115.
9.Centers for Disease Control and Prevention. Increases in fentanyl drug confiscations and fentanyl-related overdose fatalities. HAN Health Advisory. Published October 26, 2015. Accessed October 28, 2020. http://emergency.cdc.gov/han/han00384.asp
10.Wainwright JJ, Mikre M, Whitley P, et al. Analysis of drug test results before and after the us declaration of a national emergency concerning the COVID-19 outbreak. JAMA. 2020;324(16):1674-1677.
11.Niles JK, Gudin J, Radliff J, et al. The opioid epidemic within the COVID-19 pandemic: drug testing in 2020 [published online October 8, 2020]. Population Health Management. doi: 10.1089/pop.2020.0230
12.Ochalek TA, Cumpston KL, Wills BK, et al. Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. JAMA. 2020;324(16):1673-1674.
13.American Medical Association. Issue brief: reports of increases in opioid- and other drug-related overdose and other concerns during COVID pandemic. Published October 31, 2020. Accessed November 9, 2020. https://www.ama-assn.org/system/files/2020-11/issue-brief-increases-in-opioid-related-overdose.pdf
14.American Society of Addiction Medicine. Caring for patients during the COVID-19 pandemic: ASAM COVID-19 Task Force recommendations. Accessed October 30, 2020. https://www.asam.org/docs/default-source/covid-19/medication-formulation-and-dosage-guidance-(1).pdf
15.Pearce LA, Min JE, Piske M, et al. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ. 2020;368:m772. doi: 10.1136/bmj.m772
16.North Carolina Harm Reduction Coalition. NCHRC'S community-based overdose prevention project. Accessed March 29, 2020. http://www.nchrc.org/programs-and-services
17.Larochelle MR, Liebschutz JM, Zhang F, et al. Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study. Ann Intern Med. 2016;164(1):1-9.
Editor's Note: Due to updated statistics from the CDC, the online version of this article has been modified from the version that appears in the printed edition of the January 2021 issue of Current Psychiatry.
Individuals with mental health and substance use disorders (SUDs) are particularly susceptible to negative effects of the coronavirus disease 2019 (COVID-19) pandemic. The collision of the COVID-19 pandemic and the drug overdose epidemic has highlighted the urgent need for physicians, policymakers, and health care professionals to optimize care for individuals with SUDs because they may be particularly vulnerable to the effects of the virus due to compromised respiratory and immune function, and poor social support.1 In this commentary, we highlight the challenges of the drug overdose epidemic, and recommend strategies to mitigate the impact of the COVID-19 pandemic among patients with SUDs.
A crisis exacerbated by COVID-19
The current drug overdose epidemic has become an American public health nightmare. According to preliminary data released by the CDC on December 17, 2020, there were more than 81,000 drug overdose deaths in the United States in the 12 months ending May 2020.2,3 This is the highest number of overdose deaths ever recorded in a 12-month period. The CDC also noted that while overdose deaths were already increasing in the months preceding the COVID-19 pandemic, the latest numbers suggest an acceleration of overdose deaths during the pandemic.
What is causing this significant loss of life? Prescription opioids and illegal opioids such as heroin and illicitly manufactured fentanyl are the main agents associated with overdose deaths. These opioids were responsible for 61% (28,647) of drug overdose deaths in the United States in 2014.4 In 2015, the opioid overdose death rate increased by 15.6%.5
The increase in the number of opioid overdose deaths in part coincides with a sharp increase in the availability and use of heroin. Heroin overdose deaths have more than tripled since 2010, but heroin is not the only opiate involved. Fentanyl, a synthetic, short-acting opioid that is approved for managing pain in patients with advanced cancers, is 50 times more potent than heroin. The abuse of prescribed fentanyl has been accelerating over the past decade, as is the use of illicitly produced fentanyl. Evidence from US Drug Enforcement Administration (DEA) seizure records shows heroin is being adulterated with illicit fentanyl to enhance the potency of the heroin.6,7 Mixing illicit fentanyl with heroin may be contributing to the recent increase in heroin overdose fatalities. According to the CDC, overdose deaths related to synthetic opioids increased 38.4% from the 12-month period leading up to June 2019 compared with the 12-month period leading up to May 2020.2,3 Postmortem studies of individuals who died from a heroin overdose have frequently found the presence of fentanyl along with heroin.8 Overdose deaths involving heroin may be occurring because individuals may be unknowingly using heroin adulterated with fentanyl.9 In addition, carfentanil, a powerful new synthetic fentanyl, has been recently identified in heroin mixtures. Carfentanil is 10,000 times stronger than morphine. Even in miniscule amounts, carfentanil can suppress breathing to the degree that multiple doses of naloxone are needed to restore respirations.
Initial studies indicate that the COVID-19 pandemic has been exacerbating this situation. Wainwright et al10 conducted an analysis of urine drug test results of patients with SUDs from 4 months before and 4 months after COVID-19 was declared a national emergency on March 13, 2020. Compared with before COVID-19, the proportion of specimens testing positive since COVID-19 increased from 3.80% to 7.32% for fentanyl and from 1.29% to 2.09% for heroin.10
A similar drug testing study found that during the pandemic, the proportion of positive results (positivity) increased by 35% for non-prescribed fentanyl and 44% for heroin.11 Positivity for non-prescribed fentanyl increased significantly among patients who tested positive for other drugs, including by 89% for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (P < .1 for all).11
In a review of electronic medical records, Ochalek et al12 found that the number of nonfatal opioid overdoses in an emergency department in Virginia increased from 102 in March-June 2019 to 227 in March-June 2020. In an issue brief published on October 31, 2020, the American Medical Association reported increase in opioid and other drug-related overdoses in more than 40 states during the COVID-19 pandemic.13
Continue to: Strategies for intervention...
Strategies for intervention
A multi-dimensional approach is needed to protect the public from this growing opioid overdose epidemic. To address this challenging task, we recommend several strategies:
Enhance access to virtual treatment
Even when in-person treatment cannot take place due to COVID-19-related restrictions, it is vital that services are accessible to patients with SUDs during this pandemic. Examples of virtual treatment include:
- Telehealth for medication-assisted treatment (MAT) using buprenorphine (recently updated guidance from the US DEA and Substance Abuse and Mental Health Services Administration [SAMHSA] allows this method of prescribing)
- Teletherapy to prevent relapse
- Remote drug screens by sending saliva or urine kits to patients' homes, visiting patients to collect fluid samples, or asking patients to come to a "drive-through" facility to provide samples
- Virtual (online) Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery, and similar meetings to provide support in the absence of in-person meetings.
The American Society of Addiction Medicine (ASAM) offers guidance to treatment programs to focus on infection control and mitigation. The Table14 summarizes the ASAM recommendations for office-based opioid treatment during COVID-19.
Expand access to treatment
This includes access to MAT (such as buprenorphine/naloxone, methadone, naltrexone, and depot naltrexone) and, equally important, to psychosocial treatment, counseling, and/or recovery services. Recent legislative changes have increased the number of patients that a qualified physician can treat with buprenorphine/naloxone from 100 to 275, and allowed physician extenders to prescribe buprenorphine/naloxone in office-based settings. A recent population-based, retrospective Canadian study showed that opioid agonist treatment decreased the risk of mortality among opioid users, and the protective effects of this treatment increased as fentanyl and other synthetic opioids became common in the illicit drug supply.15 However, because of the shortage of psychiatrists and addiction medicine specialists in several regions of the United States, access to treatment is extremely limited and often inadequate. This constitutes a major public health crisis and contributes to our inability to intervene effectively in the opioid epidemic. Telepsychiatry programs can bring needed services to underserved areas, but they need additional support and development. Further, involving other specialties is paramount for treating this epidemic. Integrating MAT in primary care settings can improve access to treatment. Harm-reduction approaches, such as syringe exchange programs, can play an important role in reducing the adverse consequences associated with heroin use and establish health care relationships with at-risk individuals. Syringe exchange programs can also reduce the rate of infections associated with IV drug use, such as human immunodeficiency virus and hepatitis C virus.
Continue to: Increase education on naloxone...
Increase education on naloxone
Naloxone is a safe and effective opioid antagonist used to treat opioid overdoses. Timely access to naloxone is of the essence when treating opioid-related overdoses. Many states have enacted laws allowing health care professionals, law enforcement officers, and patients and relatives to obtain naloxone without a physician's prescription. It appears this approach may be yielding results. For example, the North Carolina Harm Reduction Coalition distributed >101,000 free overdose rescue kits that included naloxone and recorded 13,392 confirmed cases of overdose rescue with naloxone from 2013 to 2019.16
Divert patients with SUDs from the criminal justice system to treatment
We need to develop programs to divert patients with SUDs from the criminal justice system, which is focused on punishment, to interventions that focus on treatment. Data indicates high recidivism rates for incarcerated individuals with SUDs who do not have access to treatment after they are released. Recognizing this, communities are developing programs that divert low-level offenders from the criminal justice system into treatment. For instance, in Seattle, the Law Enforcement Assisted Diversion is a pilot program developed to divert low-level drug and prostitution offenders into community-based treatment and support services. This helps provide housing, health care, job training, treatment, and mental health support. Innovative programs are needed to provide SUD treatment in the rehabilitation programs of correctional facilities and ensure case managers and discharge planners can transition participants to community treatment programs upon their release.
Develop early identification and prevention programs
These programs should focus on individuals at high risk, such as patients with comorbid SUDs and psychiatric disorders, those with chronic pain, and at-risk children whose parents abuse opiates. Traditional addiction treatment programs typically do not address patients with complex conditions or special populations, such as adolescents or pregnant women with substance use issues. Evidence-based approaches such as Screening, Brief Intervention, and Referral to Treatment (SBIRT), Integrated Dual Diagnosis Treatment (IDDT), and prevention approaches that target students in middle schools and high schools need to be more widely available.
Improve education on opioid prescribing
Responsible opioid prescribing for clinicians should include education about the regular use of prescription drug monitoring programs, urine drug screening, avoiding co-prescription of opioids with sedative-hypnotic medications, and better linkage with addiction treatment.
Treat comorbid psychiatric conditions
It is critical to both identify and effectively treat underlying affective, anxiety, and psychotic disorders in patients with SUDs. Anxiety, depression, and emotional dysregulation often contribute to worsening substance abuse, abuse of prescription drugs, diversion of prescribed drugs, and an increased risk of overdoses and suicides. Effective treatment of comorbid psychiatric conditions also may reduce relapses.
Increase research on causes and treatments
Through research, we must expand our knowledge to better understand the factors that contribute to this epidemic and develop better treatments. These efforts may allow for the development of prevention mechanisms. For example, a recent study found that the continued use of opioid medications after an overdose was associated with a high risk of a repeated overdosecall out material?.17 At the end of a 2-year observation, 17% (confidence interval [CI]: 14% to 20%) of patients receiving a high daily dosage of a prescribed opioid had a repeat overdose compared with 15% (CI: 10% to 21%) of those receiving a moderate dosage, 9% (CI: 6% to 14%) of those receiving a low dosage, and 8% (CI: 6% to 11%) of those receiving no opioids.17 Of the patients who overdosed on prescribed opiates, 30% switched to a new prescriber after their overdose, many of whom may not have been aware of the previous overdose. From a public health perspective, it would make sense for prescribers to know of prior opioid and/or benzodiazepine overdoses. This could be reported by emergency department clinicians, law enforcement, and hospitals into a prescription drug monitoring program, which is readily available to prescribers in most states.
Acknowledgment
The authors thank Scott Proescholdbell, MPH, Injury and Violence Prevention Branch, Chronic Disease and Injury Section, Division of Public Health, North Carolina Department of Health and Human Services, for his assistance.
Bottom Line
The collision of the coronavirus disease 2019 pandemic and the drug overdose epidemic has highlighted the urgent need for health care professionals to optimize care for individuals with substance use disorders. Suggested interventions include enhancing access to medication-assisted treatment and virtual treatment, improving education about naloxone and safe opioid prescribing practices, and diverting at-risk patients from the criminal justice system to interventions that focus on treatment.
Editor's Note: Due to updated statistics from the CDC, the online version of this article has been modified from the version that appears in the printed edition of the January 2021 issue of Current Psychiatry.
Individuals with mental health and substance use disorders (SUDs) are particularly susceptible to negative effects of the coronavirus disease 2019 (COVID-19) pandemic. The collision of the COVID-19 pandemic and the drug overdose epidemic has highlighted the urgent need for physicians, policymakers, and health care professionals to optimize care for individuals with SUDs because they may be particularly vulnerable to the effects of the virus due to compromised respiratory and immune function, and poor social support.1 In this commentary, we highlight the challenges of the drug overdose epidemic, and recommend strategies to mitigate the impact of the COVID-19 pandemic among patients with SUDs.
A crisis exacerbated by COVID-19
The current drug overdose epidemic has become an American public health nightmare. According to preliminary data released by the CDC on December 17, 2020, there were more than 81,000 drug overdose deaths in the United States in the 12 months ending May 2020.2,3 This is the highest number of overdose deaths ever recorded in a 12-month period. The CDC also noted that while overdose deaths were already increasing in the months preceding the COVID-19 pandemic, the latest numbers suggest an acceleration of overdose deaths during the pandemic.
What is causing this significant loss of life? Prescription opioids and illegal opioids such as heroin and illicitly manufactured fentanyl are the main agents associated with overdose deaths. These opioids were responsible for 61% (28,647) of drug overdose deaths in the United States in 2014.4 In 2015, the opioid overdose death rate increased by 15.6%.5
The increase in the number of opioid overdose deaths in part coincides with a sharp increase in the availability and use of heroin. Heroin overdose deaths have more than tripled since 2010, but heroin is not the only opiate involved. Fentanyl, a synthetic, short-acting opioid that is approved for managing pain in patients with advanced cancers, is 50 times more potent than heroin. The abuse of prescribed fentanyl has been accelerating over the past decade, as is the use of illicitly produced fentanyl. Evidence from US Drug Enforcement Administration (DEA) seizure records shows heroin is being adulterated with illicit fentanyl to enhance the potency of the heroin.6,7 Mixing illicit fentanyl with heroin may be contributing to the recent increase in heroin overdose fatalities. According to the CDC, overdose deaths related to synthetic opioids increased 38.4% from the 12-month period leading up to June 2019 compared with the 12-month period leading up to May 2020.2,3 Postmortem studies of individuals who died from a heroin overdose have frequently found the presence of fentanyl along with heroin.8 Overdose deaths involving heroin may be occurring because individuals may be unknowingly using heroin adulterated with fentanyl.9 In addition, carfentanil, a powerful new synthetic fentanyl, has been recently identified in heroin mixtures. Carfentanil is 10,000 times stronger than morphine. Even in miniscule amounts, carfentanil can suppress breathing to the degree that multiple doses of naloxone are needed to restore respirations.
Initial studies indicate that the COVID-19 pandemic has been exacerbating this situation. Wainwright et al10 conducted an analysis of urine drug test results of patients with SUDs from 4 months before and 4 months after COVID-19 was declared a national emergency on March 13, 2020. Compared with before COVID-19, the proportion of specimens testing positive since COVID-19 increased from 3.80% to 7.32% for fentanyl and from 1.29% to 2.09% for heroin.10
A similar drug testing study found that during the pandemic, the proportion of positive results (positivity) increased by 35% for non-prescribed fentanyl and 44% for heroin.11 Positivity for non-prescribed fentanyl increased significantly among patients who tested positive for other drugs, including by 89% for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (P < .1 for all).11
In a review of electronic medical records, Ochalek et al12 found that the number of nonfatal opioid overdoses in an emergency department in Virginia increased from 102 in March-June 2019 to 227 in March-June 2020. In an issue brief published on October 31, 2020, the American Medical Association reported increase in opioid and other drug-related overdoses in more than 40 states during the COVID-19 pandemic.13
Continue to: Strategies for intervention...
Strategies for intervention
A multi-dimensional approach is needed to protect the public from this growing opioid overdose epidemic. To address this challenging task, we recommend several strategies:
Enhance access to virtual treatment
Even when in-person treatment cannot take place due to COVID-19-related restrictions, it is vital that services are accessible to patients with SUDs during this pandemic. Examples of virtual treatment include:
- Telehealth for medication-assisted treatment (MAT) using buprenorphine (recently updated guidance from the US DEA and Substance Abuse and Mental Health Services Administration [SAMHSA] allows this method of prescribing)
- Teletherapy to prevent relapse
- Remote drug screens by sending saliva or urine kits to patients' homes, visiting patients to collect fluid samples, or asking patients to come to a "drive-through" facility to provide samples
- Virtual (online) Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery, and similar meetings to provide support in the absence of in-person meetings.
The American Society of Addiction Medicine (ASAM) offers guidance to treatment programs to focus on infection control and mitigation. The Table14 summarizes the ASAM recommendations for office-based opioid treatment during COVID-19.
Expand access to treatment
This includes access to MAT (such as buprenorphine/naloxone, methadone, naltrexone, and depot naltrexone) and, equally important, to psychosocial treatment, counseling, and/or recovery services. Recent legislative changes have increased the number of patients that a qualified physician can treat with buprenorphine/naloxone from 100 to 275, and allowed physician extenders to prescribe buprenorphine/naloxone in office-based settings. A recent population-based, retrospective Canadian study showed that opioid agonist treatment decreased the risk of mortality among opioid users, and the protective effects of this treatment increased as fentanyl and other synthetic opioids became common in the illicit drug supply.15 However, because of the shortage of psychiatrists and addiction medicine specialists in several regions of the United States, access to treatment is extremely limited and often inadequate. This constitutes a major public health crisis and contributes to our inability to intervene effectively in the opioid epidemic. Telepsychiatry programs can bring needed services to underserved areas, but they need additional support and development. Further, involving other specialties is paramount for treating this epidemic. Integrating MAT in primary care settings can improve access to treatment. Harm-reduction approaches, such as syringe exchange programs, can play an important role in reducing the adverse consequences associated with heroin use and establish health care relationships with at-risk individuals. Syringe exchange programs can also reduce the rate of infections associated with IV drug use, such as human immunodeficiency virus and hepatitis C virus.
Continue to: Increase education on naloxone...
Increase education on naloxone
Naloxone is a safe and effective opioid antagonist used to treat opioid overdoses. Timely access to naloxone is of the essence when treating opioid-related overdoses. Many states have enacted laws allowing health care professionals, law enforcement officers, and patients and relatives to obtain naloxone without a physician's prescription. It appears this approach may be yielding results. For example, the North Carolina Harm Reduction Coalition distributed >101,000 free overdose rescue kits that included naloxone and recorded 13,392 confirmed cases of overdose rescue with naloxone from 2013 to 2019.16
Divert patients with SUDs from the criminal justice system to treatment
We need to develop programs to divert patients with SUDs from the criminal justice system, which is focused on punishment, to interventions that focus on treatment. Data indicates high recidivism rates for incarcerated individuals with SUDs who do not have access to treatment after they are released. Recognizing this, communities are developing programs that divert low-level offenders from the criminal justice system into treatment. For instance, in Seattle, the Law Enforcement Assisted Diversion is a pilot program developed to divert low-level drug and prostitution offenders into community-based treatment and support services. This helps provide housing, health care, job training, treatment, and mental health support. Innovative programs are needed to provide SUD treatment in the rehabilitation programs of correctional facilities and ensure case managers and discharge planners can transition participants to community treatment programs upon their release.
Develop early identification and prevention programs
These programs should focus on individuals at high risk, such as patients with comorbid SUDs and psychiatric disorders, those with chronic pain, and at-risk children whose parents abuse opiates. Traditional addiction treatment programs typically do not address patients with complex conditions or special populations, such as adolescents or pregnant women with substance use issues. Evidence-based approaches such as Screening, Brief Intervention, and Referral to Treatment (SBIRT), Integrated Dual Diagnosis Treatment (IDDT), and prevention approaches that target students in middle schools and high schools need to be more widely available.
Improve education on opioid prescribing
Responsible opioid prescribing for clinicians should include education about the regular use of prescription drug monitoring programs, urine drug screening, avoiding co-prescription of opioids with sedative-hypnotic medications, and better linkage with addiction treatment.
Treat comorbid psychiatric conditions
It is critical to both identify and effectively treat underlying affective, anxiety, and psychotic disorders in patients with SUDs. Anxiety, depression, and emotional dysregulation often contribute to worsening substance abuse, abuse of prescription drugs, diversion of prescribed drugs, and an increased risk of overdoses and suicides. Effective treatment of comorbid psychiatric conditions also may reduce relapses.
Increase research on causes and treatments
Through research, we must expand our knowledge to better understand the factors that contribute to this epidemic and develop better treatments. These efforts may allow for the development of prevention mechanisms. For example, a recent study found that the continued use of opioid medications after an overdose was associated with a high risk of a repeated overdosecall out material?.17 At the end of a 2-year observation, 17% (confidence interval [CI]: 14% to 20%) of patients receiving a high daily dosage of a prescribed opioid had a repeat overdose compared with 15% (CI: 10% to 21%) of those receiving a moderate dosage, 9% (CI: 6% to 14%) of those receiving a low dosage, and 8% (CI: 6% to 11%) of those receiving no opioids.17 Of the patients who overdosed on prescribed opiates, 30% switched to a new prescriber after their overdose, many of whom may not have been aware of the previous overdose. From a public health perspective, it would make sense for prescribers to know of prior opioid and/or benzodiazepine overdoses. This could be reported by emergency department clinicians, law enforcement, and hospitals into a prescription drug monitoring program, which is readily available to prescribers in most states.
Acknowledgment
The authors thank Scott Proescholdbell, MPH, Injury and Violence Prevention Branch, Chronic Disease and Injury Section, Division of Public Health, North Carolina Department of Health and Human Services, for his assistance.
Bottom Line
The collision of the coronavirus disease 2019 pandemic and the drug overdose epidemic has highlighted the urgent need for health care professionals to optimize care for individuals with substance use disorders. Suggested interventions include enhancing access to medication-assisted treatment and virtual treatment, improving education about naloxone and safe opioid prescribing practices, and diverting at-risk patients from the criminal justice system to interventions that focus on treatment.
1. Volkow ND. Collision of the COVID-19 and addiction epidemics. Ann Intern Med. 2020;173(1):61-62.
2.Centers for Disease Control and Prevention. Overdose deaths accelerating during COVID-19. Accessed December 23, 2020. https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html
3.Centers for Disease Control and Prevention. National Center for Health Statistics Vital Statistics Rapid Release. Provisional drug overdose death counts. Accessed December 30, 2020. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
4.Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths -- United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382.
5.Rudd RA, Seth P, David F, et al. Increases in drug and opioid-involved overdose deaths -- United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452.
6.US Drug Enforcement Administration. DEA issues nationwide alert on fentanyl as threat to health and public safety. Published March 19, 2015. Accessed October 28, 2020. http://www.dea.gov/divisions/hq/2015/hq031815.shtml
7.Gladden RM, Martinez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths - 27 states, 2013-2014. MMWR Morb Mortal Wkly Rep. 2016;65(33):837-843.
8.Algren DA, Monteilh CP, Punja M, et al. Fentanyl-associated fatalities among illicit drug users in Wayne County, Michigan (July 2005-May 2006). J Med Toxicol. 2013;9(1):106-115.
9.Centers for Disease Control and Prevention. Increases in fentanyl drug confiscations and fentanyl-related overdose fatalities. HAN Health Advisory. Published October 26, 2015. Accessed October 28, 2020. http://emergency.cdc.gov/han/han00384.asp
10.Wainwright JJ, Mikre M, Whitley P, et al. Analysis of drug test results before and after the us declaration of a national emergency concerning the COVID-19 outbreak. JAMA. 2020;324(16):1674-1677.
11.Niles JK, Gudin J, Radliff J, et al. The opioid epidemic within the COVID-19 pandemic: drug testing in 2020 [published online October 8, 2020]. Population Health Management. doi: 10.1089/pop.2020.0230
12.Ochalek TA, Cumpston KL, Wills BK, et al. Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. JAMA. 2020;324(16):1673-1674.
13.American Medical Association. Issue brief: reports of increases in opioid- and other drug-related overdose and other concerns during COVID pandemic. Published October 31, 2020. Accessed November 9, 2020. https://www.ama-assn.org/system/files/2020-11/issue-brief-increases-in-opioid-related-overdose.pdf
14.American Society of Addiction Medicine. Caring for patients during the COVID-19 pandemic: ASAM COVID-19 Task Force recommendations. Accessed October 30, 2020. https://www.asam.org/docs/default-source/covid-19/medication-formulation-and-dosage-guidance-(1).pdf
15.Pearce LA, Min JE, Piske M, et al. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ. 2020;368:m772. doi: 10.1136/bmj.m772
16.North Carolina Harm Reduction Coalition. NCHRC'S community-based overdose prevention project. Accessed March 29, 2020. http://www.nchrc.org/programs-and-services
17.Larochelle MR, Liebschutz JM, Zhang F, et al. Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study. Ann Intern Med. 2016;164(1):1-9.
1. Volkow ND. Collision of the COVID-19 and addiction epidemics. Ann Intern Med. 2020;173(1):61-62.
2.Centers for Disease Control and Prevention. Overdose deaths accelerating during COVID-19. Accessed December 23, 2020. https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html
3.Centers for Disease Control and Prevention. National Center for Health Statistics Vital Statistics Rapid Release. Provisional drug overdose death counts. Accessed December 30, 2020. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
4.Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths -- United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382.
5.Rudd RA, Seth P, David F, et al. Increases in drug and opioid-involved overdose deaths -- United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452.
6.US Drug Enforcement Administration. DEA issues nationwide alert on fentanyl as threat to health and public safety. Published March 19, 2015. Accessed October 28, 2020. http://www.dea.gov/divisions/hq/2015/hq031815.shtml
7.Gladden RM, Martinez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths - 27 states, 2013-2014. MMWR Morb Mortal Wkly Rep. 2016;65(33):837-843.
8.Algren DA, Monteilh CP, Punja M, et al. Fentanyl-associated fatalities among illicit drug users in Wayne County, Michigan (July 2005-May 2006). J Med Toxicol. 2013;9(1):106-115.
9.Centers for Disease Control and Prevention. Increases in fentanyl drug confiscations and fentanyl-related overdose fatalities. HAN Health Advisory. Published October 26, 2015. Accessed October 28, 2020. http://emergency.cdc.gov/han/han00384.asp
10.Wainwright JJ, Mikre M, Whitley P, et al. Analysis of drug test results before and after the us declaration of a national emergency concerning the COVID-19 outbreak. JAMA. 2020;324(16):1674-1677.
11.Niles JK, Gudin J, Radliff J, et al. The opioid epidemic within the COVID-19 pandemic: drug testing in 2020 [published online October 8, 2020]. Population Health Management. doi: 10.1089/pop.2020.0230
12.Ochalek TA, Cumpston KL, Wills BK, et al. Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. JAMA. 2020;324(16):1673-1674.
13.American Medical Association. Issue brief: reports of increases in opioid- and other drug-related overdose and other concerns during COVID pandemic. Published October 31, 2020. Accessed November 9, 2020. https://www.ama-assn.org/system/files/2020-11/issue-brief-increases-in-opioid-related-overdose.pdf
14.American Society of Addiction Medicine. Caring for patients during the COVID-19 pandemic: ASAM COVID-19 Task Force recommendations. Accessed October 30, 2020. https://www.asam.org/docs/default-source/covid-19/medication-formulation-and-dosage-guidance-(1).pdf
15.Pearce LA, Min JE, Piske M, et al. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ. 2020;368:m772. doi: 10.1136/bmj.m772
16.North Carolina Harm Reduction Coalition. NCHRC'S community-based overdose prevention project. Accessed March 29, 2020. http://www.nchrc.org/programs-and-services
17.Larochelle MR, Liebschutz JM, Zhang F, et al. Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study. Ann Intern Med. 2016;164(1):1-9.
DART trial hits the target in angiosarcoma
Rare cancers comprise about 20% of all cancers in the United States and Europe, according to recent estimates, but patients with rare cancers are vastly underrepresented in clinical trials.
Recently, there has been a focus on immune checkpoint blockade (ICB) in common cancer types. Since several rare tumor types share similar biologic features with the more common tumors, there is a need to test ICB in rare tumors, particularly because remissions with ICB can be durable.
Enter the DART trial, a phase 2, single-arm study of combinatorial ICB with ipilimumab plus nivolumab in patients with unresectable or metastatic rare cancers.
Results from DART were recently presented at the Society for Immunotherapy of Cancer’s 35th Anniversary Annual Meeting. Michael J. Wagner, MD, of the University of Washington, Seattle, reported results in patients with advanced or unresectable angiosarcoma, one of the rare tumor types included in DART.
About angiosarcomas
Angiosarcomas account for less than 3% of all adult soft-tissue sarcomas, according to a review published in The Lancet Oncology. Angiosarcomas may arise in any part of the body, especially the head and neck (27%), breast (19.7%), and extremities (15.3%). These cancers can be primary or secondary (i.e., associated with prior radiation therapy or chronic lymphedema).
Angiosarcomas are aggressive, difficult to treat, and confer high mortality. The tumors are responsive to chemotherapy, but responses are brief. The estimated 5-year survival rate for all patients with angiosarcoma, including those who present with localized disease, is 30%-40%.
According to Dr. Wagner, a subset of angiosarcomas are characterized by high tumor mutational burden (TMB) and COSMIC signature 7, a DNA mutational signature that is consistent with other cancers caused by ultraviolet light exposure.
The high TMB subset of angiosarcomas is comparable with other cancer types that are responsive to ICB. Indeed, patients with angiosarcoma treated with ICB have shown responses, according to research published in the Journal for Immunotherapy of Cancer. However, no prospective studies of ICB in angiosarcoma have been published.
About DART
The DART trial includes more than 50 cohorts of rare cancer subtypes. Patients receive IV ipilimumab at 1 mg/kg every 6 weeks and IV nivolumab at 240 mg every 2 weeks.
The primary endpoint is objective response rate, as assessed by RECIST v1.1. Secondary endpoints include progression-free survival, overall survival, stable disease at 6 months, and toxicity.
The trial has a two-stage design. Six patients are enrolled in the first stage, and, if at least one patient responds to treatment, an additional 10 patients are enrolled in the second stage.
If at least two responses are seen among the 16 patients enrolled, further study of ICB is considered warranted.
Results in angiosarcoma
Dr. Wagner reported on the 16 angiosarcoma patients enrolled in DART. Nine patients had cutaneous primary tumors, seven had noncutaneous primary tumors, and three patients had radiation-associated angiosarcoma of the breast or chest wall.
Patients had received a median of two (range, zero to five) prior lines of therapy.
Adverse events (AEs) were consistent with prior safety results of the ipilimumab-nivolumab combination. Three-quarters of patients experienced an AE of any grade. The most common AEs were transaminase elevation, anemia, diarrhea, fatigue, hypothyroidism, pneumonitis, pruritus, and rash.
A quarter of patients had a grade 3-4 AE, and 12.5% of AEs led to premature treatment discontinuation. There were no fatal AEs.
The ORR was 25%. Responses occurred in 4 of the 16 patients, including 3 of 5 patients with primary cutaneous tumors of the scalp or face and 1 of 3 patients with radiation-associated breast angiosarcoma.
Two of the four responses and one case of stable disease have persisted for almost a year, and these patients remain on treatment. To put these results into perspective, Dr. Wagner noted that responses to cytotoxic chemotherapy rarely last 6 months.
The 6-month progression-free survival rate was 38%. The median overall survival has not yet been reached.
Dr. Wagner concluded that the combinatorial ICB regimen employed in DART was well tolerated and had an ORR of 25% in angiosarcoma regardless of primary site. Per the criteria of the DART trial, further investigation of ICB in angiosarcoma is warranted.
Molecular insights
Although correlative analyses of tumor tissue and peripheral blood are embedded in the DART trial, those analyses have not yet been performed. Eight of the 16 angiosarcoma patients had diagnostic molecular studies performed at their parent institutions, utilizing a variety of commercial platforms.
All eight patients for whom molecular data were available had at least two deleterious genomic alterations detected, but each had a distinct molecular profile.
Seven patients had TMB analyzed, including two partial responders to ICB. One of the seven patients had a high TMB, and this patient was one of the two responders. The other responder had an intermediate TMB.
Three patients had programmed death–ligand 1 staining on their tumors. Two of the three had high expression of PD-L1, including the responder with an intermediate TMB.
The real impact of DART
The DART trial is a “basket trial,” employing a similar treatment regimen for multiple tumor types. It provides a uniform framework for studying tumors that have been neglected in clinical trials heretofore.
Although the cohort of angiosarcoma patients is small, central pathology review was not required, and the treatment regimen was not compared directly with other potential therapies, the reported results of the ipilimumab-nivolumab regimen justify further study.
The biospecimens collected in DART will provide a rich source of data to identify common themes among responders and nonresponders, among patients who experience durable remissions and those who do not.
Angiosarcoma is not the only rare cancer for which combinatorial ICB has been valuable under the auspices of the DART trial. In Clinical Cancer Research, investigators reported an ORR of 44% among patients with high-grade neuroendocrine cancers, independent of primary site of origin. Progression-free survival at 6 months was 31%.
The DART trial is available at more than 800 sites, providing access to potentially promising treatment in a rigorous, scientifically valuable study for geographically underserved populations, including patients who live in rural areas.
The key message for practicing oncologists and clinical investigators is that clinical trials in rare tumors are feasible and can yield hope for patients who might lack it otherwise.
DART is funded by the National Cancer Institute and Bristol-Myers Squibb. Dr. Wagner disclosed relationships with Deciphera, Adaptimmune, GlaxoSmithKline, Athenex, and Incyte.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
SOURCE: Wagner M et al. SITC 2020, Abstract 795.
Rare cancers comprise about 20% of all cancers in the United States and Europe, according to recent estimates, but patients with rare cancers are vastly underrepresented in clinical trials.
Recently, there has been a focus on immune checkpoint blockade (ICB) in common cancer types. Since several rare tumor types share similar biologic features with the more common tumors, there is a need to test ICB in rare tumors, particularly because remissions with ICB can be durable.
Enter the DART trial, a phase 2, single-arm study of combinatorial ICB with ipilimumab plus nivolumab in patients with unresectable or metastatic rare cancers.
Results from DART were recently presented at the Society for Immunotherapy of Cancer’s 35th Anniversary Annual Meeting. Michael J. Wagner, MD, of the University of Washington, Seattle, reported results in patients with advanced or unresectable angiosarcoma, one of the rare tumor types included in DART.
About angiosarcomas
Angiosarcomas account for less than 3% of all adult soft-tissue sarcomas, according to a review published in The Lancet Oncology. Angiosarcomas may arise in any part of the body, especially the head and neck (27%), breast (19.7%), and extremities (15.3%). These cancers can be primary or secondary (i.e., associated with prior radiation therapy or chronic lymphedema).
Angiosarcomas are aggressive, difficult to treat, and confer high mortality. The tumors are responsive to chemotherapy, but responses are brief. The estimated 5-year survival rate for all patients with angiosarcoma, including those who present with localized disease, is 30%-40%.
According to Dr. Wagner, a subset of angiosarcomas are characterized by high tumor mutational burden (TMB) and COSMIC signature 7, a DNA mutational signature that is consistent with other cancers caused by ultraviolet light exposure.
The high TMB subset of angiosarcomas is comparable with other cancer types that are responsive to ICB. Indeed, patients with angiosarcoma treated with ICB have shown responses, according to research published in the Journal for Immunotherapy of Cancer. However, no prospective studies of ICB in angiosarcoma have been published.
About DART
The DART trial includes more than 50 cohorts of rare cancer subtypes. Patients receive IV ipilimumab at 1 mg/kg every 6 weeks and IV nivolumab at 240 mg every 2 weeks.
The primary endpoint is objective response rate, as assessed by RECIST v1.1. Secondary endpoints include progression-free survival, overall survival, stable disease at 6 months, and toxicity.
The trial has a two-stage design. Six patients are enrolled in the first stage, and, if at least one patient responds to treatment, an additional 10 patients are enrolled in the second stage.
If at least two responses are seen among the 16 patients enrolled, further study of ICB is considered warranted.
Results in angiosarcoma
Dr. Wagner reported on the 16 angiosarcoma patients enrolled in DART. Nine patients had cutaneous primary tumors, seven had noncutaneous primary tumors, and three patients had radiation-associated angiosarcoma of the breast or chest wall.
Patients had received a median of two (range, zero to five) prior lines of therapy.
Adverse events (AEs) were consistent with prior safety results of the ipilimumab-nivolumab combination. Three-quarters of patients experienced an AE of any grade. The most common AEs were transaminase elevation, anemia, diarrhea, fatigue, hypothyroidism, pneumonitis, pruritus, and rash.
A quarter of patients had a grade 3-4 AE, and 12.5% of AEs led to premature treatment discontinuation. There were no fatal AEs.
The ORR was 25%. Responses occurred in 4 of the 16 patients, including 3 of 5 patients with primary cutaneous tumors of the scalp or face and 1 of 3 patients with radiation-associated breast angiosarcoma.
Two of the four responses and one case of stable disease have persisted for almost a year, and these patients remain on treatment. To put these results into perspective, Dr. Wagner noted that responses to cytotoxic chemotherapy rarely last 6 months.
The 6-month progression-free survival rate was 38%. The median overall survival has not yet been reached.
Dr. Wagner concluded that the combinatorial ICB regimen employed in DART was well tolerated and had an ORR of 25% in angiosarcoma regardless of primary site. Per the criteria of the DART trial, further investigation of ICB in angiosarcoma is warranted.
Molecular insights
Although correlative analyses of tumor tissue and peripheral blood are embedded in the DART trial, those analyses have not yet been performed. Eight of the 16 angiosarcoma patients had diagnostic molecular studies performed at their parent institutions, utilizing a variety of commercial platforms.
All eight patients for whom molecular data were available had at least two deleterious genomic alterations detected, but each had a distinct molecular profile.
Seven patients had TMB analyzed, including two partial responders to ICB. One of the seven patients had a high TMB, and this patient was one of the two responders. The other responder had an intermediate TMB.
Three patients had programmed death–ligand 1 staining on their tumors. Two of the three had high expression of PD-L1, including the responder with an intermediate TMB.
The real impact of DART
The DART trial is a “basket trial,” employing a similar treatment regimen for multiple tumor types. It provides a uniform framework for studying tumors that have been neglected in clinical trials heretofore.
Although the cohort of angiosarcoma patients is small, central pathology review was not required, and the treatment regimen was not compared directly with other potential therapies, the reported results of the ipilimumab-nivolumab regimen justify further study.
The biospecimens collected in DART will provide a rich source of data to identify common themes among responders and nonresponders, among patients who experience durable remissions and those who do not.
Angiosarcoma is not the only rare cancer for which combinatorial ICB has been valuable under the auspices of the DART trial. In Clinical Cancer Research, investigators reported an ORR of 44% among patients with high-grade neuroendocrine cancers, independent of primary site of origin. Progression-free survival at 6 months was 31%.
The DART trial is available at more than 800 sites, providing access to potentially promising treatment in a rigorous, scientifically valuable study for geographically underserved populations, including patients who live in rural areas.
The key message for practicing oncologists and clinical investigators is that clinical trials in rare tumors are feasible and can yield hope for patients who might lack it otherwise.
DART is funded by the National Cancer Institute and Bristol-Myers Squibb. Dr. Wagner disclosed relationships with Deciphera, Adaptimmune, GlaxoSmithKline, Athenex, and Incyte.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
SOURCE: Wagner M et al. SITC 2020, Abstract 795.
Rare cancers comprise about 20% of all cancers in the United States and Europe, according to recent estimates, but patients with rare cancers are vastly underrepresented in clinical trials.
Recently, there has been a focus on immune checkpoint blockade (ICB) in common cancer types. Since several rare tumor types share similar biologic features with the more common tumors, there is a need to test ICB in rare tumors, particularly because remissions with ICB can be durable.
Enter the DART trial, a phase 2, single-arm study of combinatorial ICB with ipilimumab plus nivolumab in patients with unresectable or metastatic rare cancers.
Results from DART were recently presented at the Society for Immunotherapy of Cancer’s 35th Anniversary Annual Meeting. Michael J. Wagner, MD, of the University of Washington, Seattle, reported results in patients with advanced or unresectable angiosarcoma, one of the rare tumor types included in DART.
About angiosarcomas
Angiosarcomas account for less than 3% of all adult soft-tissue sarcomas, according to a review published in The Lancet Oncology. Angiosarcomas may arise in any part of the body, especially the head and neck (27%), breast (19.7%), and extremities (15.3%). These cancers can be primary or secondary (i.e., associated with prior radiation therapy or chronic lymphedema).
Angiosarcomas are aggressive, difficult to treat, and confer high mortality. The tumors are responsive to chemotherapy, but responses are brief. The estimated 5-year survival rate for all patients with angiosarcoma, including those who present with localized disease, is 30%-40%.
According to Dr. Wagner, a subset of angiosarcomas are characterized by high tumor mutational burden (TMB) and COSMIC signature 7, a DNA mutational signature that is consistent with other cancers caused by ultraviolet light exposure.
The high TMB subset of angiosarcomas is comparable with other cancer types that are responsive to ICB. Indeed, patients with angiosarcoma treated with ICB have shown responses, according to research published in the Journal for Immunotherapy of Cancer. However, no prospective studies of ICB in angiosarcoma have been published.
About DART
The DART trial includes more than 50 cohorts of rare cancer subtypes. Patients receive IV ipilimumab at 1 mg/kg every 6 weeks and IV nivolumab at 240 mg every 2 weeks.
The primary endpoint is objective response rate, as assessed by RECIST v1.1. Secondary endpoints include progression-free survival, overall survival, stable disease at 6 months, and toxicity.
The trial has a two-stage design. Six patients are enrolled in the first stage, and, if at least one patient responds to treatment, an additional 10 patients are enrolled in the second stage.
If at least two responses are seen among the 16 patients enrolled, further study of ICB is considered warranted.
Results in angiosarcoma
Dr. Wagner reported on the 16 angiosarcoma patients enrolled in DART. Nine patients had cutaneous primary tumors, seven had noncutaneous primary tumors, and three patients had radiation-associated angiosarcoma of the breast or chest wall.
Patients had received a median of two (range, zero to five) prior lines of therapy.
Adverse events (AEs) were consistent with prior safety results of the ipilimumab-nivolumab combination. Three-quarters of patients experienced an AE of any grade. The most common AEs were transaminase elevation, anemia, diarrhea, fatigue, hypothyroidism, pneumonitis, pruritus, and rash.
A quarter of patients had a grade 3-4 AE, and 12.5% of AEs led to premature treatment discontinuation. There were no fatal AEs.
The ORR was 25%. Responses occurred in 4 of the 16 patients, including 3 of 5 patients with primary cutaneous tumors of the scalp or face and 1 of 3 patients with radiation-associated breast angiosarcoma.
Two of the four responses and one case of stable disease have persisted for almost a year, and these patients remain on treatment. To put these results into perspective, Dr. Wagner noted that responses to cytotoxic chemotherapy rarely last 6 months.
The 6-month progression-free survival rate was 38%. The median overall survival has not yet been reached.
Dr. Wagner concluded that the combinatorial ICB regimen employed in DART was well tolerated and had an ORR of 25% in angiosarcoma regardless of primary site. Per the criteria of the DART trial, further investigation of ICB in angiosarcoma is warranted.
Molecular insights
Although correlative analyses of tumor tissue and peripheral blood are embedded in the DART trial, those analyses have not yet been performed. Eight of the 16 angiosarcoma patients had diagnostic molecular studies performed at their parent institutions, utilizing a variety of commercial platforms.
All eight patients for whom molecular data were available had at least two deleterious genomic alterations detected, but each had a distinct molecular profile.
Seven patients had TMB analyzed, including two partial responders to ICB. One of the seven patients had a high TMB, and this patient was one of the two responders. The other responder had an intermediate TMB.
Three patients had programmed death–ligand 1 staining on their tumors. Two of the three had high expression of PD-L1, including the responder with an intermediate TMB.
The real impact of DART
The DART trial is a “basket trial,” employing a similar treatment regimen for multiple tumor types. It provides a uniform framework for studying tumors that have been neglected in clinical trials heretofore.
Although the cohort of angiosarcoma patients is small, central pathology review was not required, and the treatment regimen was not compared directly with other potential therapies, the reported results of the ipilimumab-nivolumab regimen justify further study.
The biospecimens collected in DART will provide a rich source of data to identify common themes among responders and nonresponders, among patients who experience durable remissions and those who do not.
Angiosarcoma is not the only rare cancer for which combinatorial ICB has been valuable under the auspices of the DART trial. In Clinical Cancer Research, investigators reported an ORR of 44% among patients with high-grade neuroendocrine cancers, independent of primary site of origin. Progression-free survival at 6 months was 31%.
The DART trial is available at more than 800 sites, providing access to potentially promising treatment in a rigorous, scientifically valuable study for geographically underserved populations, including patients who live in rural areas.
The key message for practicing oncologists and clinical investigators is that clinical trials in rare tumors are feasible and can yield hope for patients who might lack it otherwise.
DART is funded by the National Cancer Institute and Bristol-Myers Squibb. Dr. Wagner disclosed relationships with Deciphera, Adaptimmune, GlaxoSmithKline, Athenex, and Incyte.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
SOURCE: Wagner M et al. SITC 2020, Abstract 795.
FROM SITC 2020
Reproductive Rounds: Fertility preservation options for cancer patients
What is more stressful in the mind of a patient – a diagnosis of cancer or infertility? An infertile woman’s anxiety and depression scores are equivalent to one with cancer (J Psychosom Obstet Gynecol. 1993;14 Suppl:45-52). These two diseases intersect in the burgeoning field of oncofertility, the collaboration of oncology with reproductive endocrinology to offer patients the option of fertility preservation. The term oncofertility was first coined by Teresa Woodruff, PhD, in 2005 during her invited lecture at the University of Calgary symposium called “Pushing the Boundaries – Advances that Will Change the World in 20 Years.” Her prediction has reached its fruition. This article will review fertility preservation options for female oncology patients.
The ability for oncofertility to exist is the result of improved cancer survival rates and advances in reproductive medicine. Improvements in the treatment of cancer enable many young women to survive and focus on the potential of having a family. Malignancies striking young people, particularly breast, lymphoma, and melanoma, have encouraging 5-year survival rates. If invasive cancer is located only in the breast (affecting 62% of women diagnosed), the 5-year survival rate is 99%. For all with Hodgkin lymphoma, the 5-year survival is 87%, increasing to 92% if the cancer is found in its earliest stages. Among all people with melanoma of the skin, from the time of initial diagnosis, the 5-year survival is 92%.
Long-term survival is expected for 80% of children and adolescents diagnosed with cancer (Obstet Gynecol. 2010;116: 1171-83).
Iatrogenic effects
The reproductive risk of cancer treatment is gonadotoxicity and the subsequent iatrogenic primary ovarian insufficiency (POI, prior termed premature ovarian failure) or infertility.
Chemotherapy with alkylating agents, such as cyclophosphamide, is associated with the greatest chance of amenorrhea (Breast Cancer Res Treat. 2014;145:113-28). Chemotherapy with cyclophosphamide, methotrexate, and 5 fluorouracil (CMF – commonly used for the treatment of breast cancer) will usually result in loss of ovarian function in 33% of women under age 30, 50% of women aged 30-35, 75% of women aged 35-40, and 95% of women over age 40 (J Clin Oncol. 2006;24:5769-79).
The dose at which 50% of oocytes are lost due to radiation is under 2 Gy (Hum Reprod. 2003;18:117-21). Unfortunately, the minimum dose decreases with advancing age of the woman, contributed by natural diminishing reserve and an increase in radiosensitivity of oocytes. Age, proximity of the radiation field to the ovaries, and total dose are important factors determining risk of POI. For brain tumors, cranial irradiation may result in hypothalamic amenorrhea.
Protection
The use of GnRH agonist for 6 months during chemotherapy has been controversial with mixed results in avoiding ovarian failure. A recent study suggests a GnRH agonist does reduce the prevalence of POI (J Clin Oncol. 2018;36:1981-90) in women treated for breast cancer but the subsequent ovarian reserve is low (Ann Oncol. 2017;28:1811-6). There are not enough data now to consider this the sole viable option for all patients to preserve fertility.
Patients requiring local pelvic radiation treatment may benefit from transposition of the ovaries to sites away from maximal radiation exposure.
Oocyte cryopreservation (OC) and ovarian tissue cryopreservation (OTC)
Since 2012, the American Society for Reproductive Medicine lifted the experimental designation on OC and, last year, the society removed the same label for OTC, providing an additional fertility preservation option.
Ovarian stimulation and egg retrieval for OC can now occur literally within 2 weeks because of a random start protocol whereby women are stimulated any day in their cycle, pre- and post ovulation. Studies have shown equivalent yield of oocytes.
OC followed by thawing for subsequent fertilization and embryo transfer is employed as a routine matter with egg donation cycles. While there remains debate over whether live birth rates using frozen eggs are inferior to fresh eggs, a learning curve with the new technology may be the important factor (Obstet Gynecol. 2020;135:709-16).
When urgent cancer treatment precludes ovarian stimulation for OC, then OTC is a viable option. Another population that could benefit from OTC are prepubertal girls facing gonadotoxic therapy. More research is required to determine the quality of eggs obtained through ovarian stimulation in adolescent and young adult patients. While leukemic patients are eligible for OTC, there is concern about reseeding malignant cells with future autologous transplantation of tissue.
OTC involves obtaining ovarian cortical tissue, dissecting the tissue into small fragments, and cryopreserving it using either a slow-cool technique or vitrification. Orthotopic transplantation has been the most successful method for using ovarian tissue in humans. To date, live birth rates are modest (Fertil Steril. 2015;104:1097-8).
Recent research has combined the freezing of both mature and immature eggs, the latter undergoing IVM (in-vitro maturation) to maximize the potential for fertilizable eggs. Women with polycystic ovary syndrome and certain cancers or medical conditions that warrant avoiding supraphysiologic levels of estradiol from ovarian stimulation, may benefit from the retrieval of immature eggs from unstimulated ovaries.
Pregnancy outcomes using embryos created from ovaries recently exposed to chemotherapy in humans are not known but animal studies suggest there may be higher rates of miscarriage and birth defects.
Breast cancer – a special scenario
With every breast cancer patient, I review the theoretical concern over increasing estradiol levels during an IVF stimulation cycle with the potential impact on her cancer prognosis. Fortunately, the literature has not demonstrated an increased risk of breast cancer or recurrence after undergoing an IVF cycle. Currently, the use of aromatase inhibitors with gonadotropins along with a GnRH-antagonist is the protocol to maintain a lower estradiol level during stimulation, which may be of benefit for breast cancer prognosis. The use of aromatase inhibitors is an off-label indication for fertility with no definitive evidence of teratogenicity. Preimplantation genetic testing of embryos is available and approved by the American Society for Reproductive Medicine for BRCA gene mutation patients.
Oncofertility is an exciting field to allow cancer survivors the option for a biological child. We recommend all our cancer patients meet with our reproductive psychologist to assist in coping with the overwhelming information presented in a short time frame.
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.
What is more stressful in the mind of a patient – a diagnosis of cancer or infertility? An infertile woman’s anxiety and depression scores are equivalent to one with cancer (J Psychosom Obstet Gynecol. 1993;14 Suppl:45-52). These two diseases intersect in the burgeoning field of oncofertility, the collaboration of oncology with reproductive endocrinology to offer patients the option of fertility preservation. The term oncofertility was first coined by Teresa Woodruff, PhD, in 2005 during her invited lecture at the University of Calgary symposium called “Pushing the Boundaries – Advances that Will Change the World in 20 Years.” Her prediction has reached its fruition. This article will review fertility preservation options for female oncology patients.
The ability for oncofertility to exist is the result of improved cancer survival rates and advances in reproductive medicine. Improvements in the treatment of cancer enable many young women to survive and focus on the potential of having a family. Malignancies striking young people, particularly breast, lymphoma, and melanoma, have encouraging 5-year survival rates. If invasive cancer is located only in the breast (affecting 62% of women diagnosed), the 5-year survival rate is 99%. For all with Hodgkin lymphoma, the 5-year survival is 87%, increasing to 92% if the cancer is found in its earliest stages. Among all people with melanoma of the skin, from the time of initial diagnosis, the 5-year survival is 92%.
Long-term survival is expected for 80% of children and adolescents diagnosed with cancer (Obstet Gynecol. 2010;116: 1171-83).
Iatrogenic effects
The reproductive risk of cancer treatment is gonadotoxicity and the subsequent iatrogenic primary ovarian insufficiency (POI, prior termed premature ovarian failure) or infertility.
Chemotherapy with alkylating agents, such as cyclophosphamide, is associated with the greatest chance of amenorrhea (Breast Cancer Res Treat. 2014;145:113-28). Chemotherapy with cyclophosphamide, methotrexate, and 5 fluorouracil (CMF – commonly used for the treatment of breast cancer) will usually result in loss of ovarian function in 33% of women under age 30, 50% of women aged 30-35, 75% of women aged 35-40, and 95% of women over age 40 (J Clin Oncol. 2006;24:5769-79).
The dose at which 50% of oocytes are lost due to radiation is under 2 Gy (Hum Reprod. 2003;18:117-21). Unfortunately, the minimum dose decreases with advancing age of the woman, contributed by natural diminishing reserve and an increase in radiosensitivity of oocytes. Age, proximity of the radiation field to the ovaries, and total dose are important factors determining risk of POI. For brain tumors, cranial irradiation may result in hypothalamic amenorrhea.
Protection
The use of GnRH agonist for 6 months during chemotherapy has been controversial with mixed results in avoiding ovarian failure. A recent study suggests a GnRH agonist does reduce the prevalence of POI (J Clin Oncol. 2018;36:1981-90) in women treated for breast cancer but the subsequent ovarian reserve is low (Ann Oncol. 2017;28:1811-6). There are not enough data now to consider this the sole viable option for all patients to preserve fertility.
Patients requiring local pelvic radiation treatment may benefit from transposition of the ovaries to sites away from maximal radiation exposure.
Oocyte cryopreservation (OC) and ovarian tissue cryopreservation (OTC)
Since 2012, the American Society for Reproductive Medicine lifted the experimental designation on OC and, last year, the society removed the same label for OTC, providing an additional fertility preservation option.
Ovarian stimulation and egg retrieval for OC can now occur literally within 2 weeks because of a random start protocol whereby women are stimulated any day in their cycle, pre- and post ovulation. Studies have shown equivalent yield of oocytes.
OC followed by thawing for subsequent fertilization and embryo transfer is employed as a routine matter with egg donation cycles. While there remains debate over whether live birth rates using frozen eggs are inferior to fresh eggs, a learning curve with the new technology may be the important factor (Obstet Gynecol. 2020;135:709-16).
When urgent cancer treatment precludes ovarian stimulation for OC, then OTC is a viable option. Another population that could benefit from OTC are prepubertal girls facing gonadotoxic therapy. More research is required to determine the quality of eggs obtained through ovarian stimulation in adolescent and young adult patients. While leukemic patients are eligible for OTC, there is concern about reseeding malignant cells with future autologous transplantation of tissue.
OTC involves obtaining ovarian cortical tissue, dissecting the tissue into small fragments, and cryopreserving it using either a slow-cool technique or vitrification. Orthotopic transplantation has been the most successful method for using ovarian tissue in humans. To date, live birth rates are modest (Fertil Steril. 2015;104:1097-8).
Recent research has combined the freezing of both mature and immature eggs, the latter undergoing IVM (in-vitro maturation) to maximize the potential for fertilizable eggs. Women with polycystic ovary syndrome and certain cancers or medical conditions that warrant avoiding supraphysiologic levels of estradiol from ovarian stimulation, may benefit from the retrieval of immature eggs from unstimulated ovaries.
Pregnancy outcomes using embryos created from ovaries recently exposed to chemotherapy in humans are not known but animal studies suggest there may be higher rates of miscarriage and birth defects.
Breast cancer – a special scenario
With every breast cancer patient, I review the theoretical concern over increasing estradiol levels during an IVF stimulation cycle with the potential impact on her cancer prognosis. Fortunately, the literature has not demonstrated an increased risk of breast cancer or recurrence after undergoing an IVF cycle. Currently, the use of aromatase inhibitors with gonadotropins along with a GnRH-antagonist is the protocol to maintain a lower estradiol level during stimulation, which may be of benefit for breast cancer prognosis. The use of aromatase inhibitors is an off-label indication for fertility with no definitive evidence of teratogenicity. Preimplantation genetic testing of embryos is available and approved by the American Society for Reproductive Medicine for BRCA gene mutation patients.
Oncofertility is an exciting field to allow cancer survivors the option for a biological child. We recommend all our cancer patients meet with our reproductive psychologist to assist in coping with the overwhelming information presented in a short time frame.
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.
What is more stressful in the mind of a patient – a diagnosis of cancer or infertility? An infertile woman’s anxiety and depression scores are equivalent to one with cancer (J Psychosom Obstet Gynecol. 1993;14 Suppl:45-52). These two diseases intersect in the burgeoning field of oncofertility, the collaboration of oncology with reproductive endocrinology to offer patients the option of fertility preservation. The term oncofertility was first coined by Teresa Woodruff, PhD, in 2005 during her invited lecture at the University of Calgary symposium called “Pushing the Boundaries – Advances that Will Change the World in 20 Years.” Her prediction has reached its fruition. This article will review fertility preservation options for female oncology patients.
The ability for oncofertility to exist is the result of improved cancer survival rates and advances in reproductive medicine. Improvements in the treatment of cancer enable many young women to survive and focus on the potential of having a family. Malignancies striking young people, particularly breast, lymphoma, and melanoma, have encouraging 5-year survival rates. If invasive cancer is located only in the breast (affecting 62% of women diagnosed), the 5-year survival rate is 99%. For all with Hodgkin lymphoma, the 5-year survival is 87%, increasing to 92% if the cancer is found in its earliest stages. Among all people with melanoma of the skin, from the time of initial diagnosis, the 5-year survival is 92%.
Long-term survival is expected for 80% of children and adolescents diagnosed with cancer (Obstet Gynecol. 2010;116: 1171-83).
Iatrogenic effects
The reproductive risk of cancer treatment is gonadotoxicity and the subsequent iatrogenic primary ovarian insufficiency (POI, prior termed premature ovarian failure) or infertility.
Chemotherapy with alkylating agents, such as cyclophosphamide, is associated with the greatest chance of amenorrhea (Breast Cancer Res Treat. 2014;145:113-28). Chemotherapy with cyclophosphamide, methotrexate, and 5 fluorouracil (CMF – commonly used for the treatment of breast cancer) will usually result in loss of ovarian function in 33% of women under age 30, 50% of women aged 30-35, 75% of women aged 35-40, and 95% of women over age 40 (J Clin Oncol. 2006;24:5769-79).
The dose at which 50% of oocytes are lost due to radiation is under 2 Gy (Hum Reprod. 2003;18:117-21). Unfortunately, the minimum dose decreases with advancing age of the woman, contributed by natural diminishing reserve and an increase in radiosensitivity of oocytes. Age, proximity of the radiation field to the ovaries, and total dose are important factors determining risk of POI. For brain tumors, cranial irradiation may result in hypothalamic amenorrhea.
Protection
The use of GnRH agonist for 6 months during chemotherapy has been controversial with mixed results in avoiding ovarian failure. A recent study suggests a GnRH agonist does reduce the prevalence of POI (J Clin Oncol. 2018;36:1981-90) in women treated for breast cancer but the subsequent ovarian reserve is low (Ann Oncol. 2017;28:1811-6). There are not enough data now to consider this the sole viable option for all patients to preserve fertility.
Patients requiring local pelvic radiation treatment may benefit from transposition of the ovaries to sites away from maximal radiation exposure.
Oocyte cryopreservation (OC) and ovarian tissue cryopreservation (OTC)
Since 2012, the American Society for Reproductive Medicine lifted the experimental designation on OC and, last year, the society removed the same label for OTC, providing an additional fertility preservation option.
Ovarian stimulation and egg retrieval for OC can now occur literally within 2 weeks because of a random start protocol whereby women are stimulated any day in their cycle, pre- and post ovulation. Studies have shown equivalent yield of oocytes.
OC followed by thawing for subsequent fertilization and embryo transfer is employed as a routine matter with egg donation cycles. While there remains debate over whether live birth rates using frozen eggs are inferior to fresh eggs, a learning curve with the new technology may be the important factor (Obstet Gynecol. 2020;135:709-16).
When urgent cancer treatment precludes ovarian stimulation for OC, then OTC is a viable option. Another population that could benefit from OTC are prepubertal girls facing gonadotoxic therapy. More research is required to determine the quality of eggs obtained through ovarian stimulation in adolescent and young adult patients. While leukemic patients are eligible for OTC, there is concern about reseeding malignant cells with future autologous transplantation of tissue.
OTC involves obtaining ovarian cortical tissue, dissecting the tissue into small fragments, and cryopreserving it using either a slow-cool technique or vitrification. Orthotopic transplantation has been the most successful method for using ovarian tissue in humans. To date, live birth rates are modest (Fertil Steril. 2015;104:1097-8).
Recent research has combined the freezing of both mature and immature eggs, the latter undergoing IVM (in-vitro maturation) to maximize the potential for fertilizable eggs. Women with polycystic ovary syndrome and certain cancers or medical conditions that warrant avoiding supraphysiologic levels of estradiol from ovarian stimulation, may benefit from the retrieval of immature eggs from unstimulated ovaries.
Pregnancy outcomes using embryos created from ovaries recently exposed to chemotherapy in humans are not known but animal studies suggest there may be higher rates of miscarriage and birth defects.
Breast cancer – a special scenario
With every breast cancer patient, I review the theoretical concern over increasing estradiol levels during an IVF stimulation cycle with the potential impact on her cancer prognosis. Fortunately, the literature has not demonstrated an increased risk of breast cancer or recurrence after undergoing an IVF cycle. Currently, the use of aromatase inhibitors with gonadotropins along with a GnRH-antagonist is the protocol to maintain a lower estradiol level during stimulation, which may be of benefit for breast cancer prognosis. The use of aromatase inhibitors is an off-label indication for fertility with no definitive evidence of teratogenicity. Preimplantation genetic testing of embryos is available and approved by the American Society for Reproductive Medicine for BRCA gene mutation patients.
Oncofertility is an exciting field to allow cancer survivors the option for a biological child. We recommend all our cancer patients meet with our reproductive psychologist to assist in coping with the overwhelming information presented in a short time frame.
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.
Let’s ‘cancel’ these obsolete terms in DSM
Psychiatry has made significant scientific advances over the past century. However, it is still saddled with archaic terms, with pejorative connotations, disguised as official medical diagnoses. It is time to “cancel” those terms and replace them with ones that are neutral and have not accumulated baggage.
This process of “creative destruction” of psychiatric terminology is long overdue. It is frankly disturbing that the psychiatric jargon used around the time that the American Psychiatric Association was established 175 years ago (1844) is now considered insults and epithets. We no longer work in “lunatic asylums for the insane,” and our patients with intellectual disabilities are no longer classified as “morons,” “idiots,” or “imbeciles.” Such “diagnoses” have certainly contributed to the stigma of psychiatric brain disorders. Even the noble word “asylum” has acquired a negative valence because in the past it referred to hospitals that housed persons with serious mental illness.
Thankfully, some of the outrageous terms fabricated during the condemnable and dark era of slavery 2 centuries ago were never adopted by organized psychiatry. The absurd diagnosis of “negritude,” whose tenet was that black skin is a disease curable by whitening the skin, was “invented” by none other than Benjamin Rush, the Father of Psychiatry, whose conflicted soul was depicted by concomitantly owning a slave and positioning himself as an ardent abolitionist!
Terms that need to be replaced
Fast-forward to the modern era and consider the following:
Borderline personality disorder. It is truly tragic how this confusing and non-scientific term is used as an official diagnosis for a set of seriously ill persons. It is loaded with obloquy, indignity, and derision that completely ignore the tumult, self-harm, and disability with which patients who carry this label are burdened throughout their lives, despite being intelligent. This is a serious brain disorder that has been shown to be highly genetic and is characterized by many well-established structural brain abnormalities that have been documented in neuroimaging studies.1,2 Borderline personality should not be classified as a personality disorder but as an illness with multiple signs and symptoms, including mood lability, anger, impulsivity, self-cutting, suicidal urges, feelings of abandonment, and micro-psychotic episodes. A more clinically accurate term should be coined very soon to replace borderline personality, which should be discarded to the trash heap of obsolete psychiatric terms, and no longer inflicted on patients.
Neurosis. What is the justification for continuing to use the term “neurotic” for a person who has an anxiety disorder? Is it used because Jung and Freud propagated the term “neurosis” (after it was coined by William Cullen in 1769)? Neurosis has degenerated from a psychiatric diagnosis to a scornful snub that must never be used for any patient.
Schizophrenia. This diagnosis, coined by Eugen Bleuler to replace the narrow and pessimistic “dementia praecox” proposed by Emil Kraepelin in the 1920s, initially seemed to be a neutral description of a thought disorder (split associations, not split personality). Bleuler was perceptive enough to call his book Dementia Praecox or the Group of Schizophrenias, which is consistent with the modern scientific research that confirms schizophrenia is a very heterogeneous syndrome with hundreds of genetic and environmental biotypes with a similar phenotype but a wide range of severity, treatment response, and functional outcomes. However, in subsequent decades, schizophrenia became one of the most demeaning labels in psychiatry, casting a shadow of hopelessness and disability on the people who have this serious neurologic condition with many psychiatric symptoms. The term that should replace schizophrenia should be no more degrading than stroke, multiple sclerosis, or myocardial infarction.
Continue to: Over the past 15 years...
Over the past 15 years, an expanding group of schizophrenia experts have agreed that this term must be changed to one that reflects the core features of this syndrome, and have proposed terms such as “salience syndrome,” “psychosis-spectrum,” and “reality distortion and cognitive impairment disorder.”3 In fact, several countries have already adopted a new official diagnosis for schizophrenia.4 Japan now uses the term “integration disorder,” which has significantly reduced the stigma of this brain disorder.5 South Korea changed the name to “attunement disorder.” Hong Kong and Taiwan now use “dysfunction of thought and perception.” Some researchers recommend calling schizophrenia “Bleuler’s syndrome,” a neutral eponymous designation.
One of the most irritating things about the term schizophrenia is the widespread misconception that it means “split personality.” This prompts some sports announcers to call a football team “schizophrenic” if they play well in the first half and badly in the second. The stock market is labeled “schizophrenic” if it goes up one day and way down on the next. No other medical term is misused by the media as often as the term schizophrenia.
Narcissistic personality disorder. The origin of this diagnostic category is the concept of “malignant narcissism” coined by Erich Fromm in 1964, which he designated as “the quintessence of evil.” I strongly object to implying that evil is part of any psychiatric diagnosis. Numerous studies have found structural brain abnormalities (in both gray and white matter) in patients diagnosed with psychopathic traits.6 Later, malignant narcissism was reframed as narcissistic personality disorder in 1971 by Herbert Rosenfeld. Although malignant narcissism was never accepted by either the DSM or the International Classification of Diseases, narcissistic personality disorder has been included in the DSM for the past few decades. This diagnosis reeks of disparagement and negativity. Persons with narcissistic personality disorder have been shown to have pathological brain changes in resting-state functional connectivity,7 weakened frontostriatal white matter connectivity,8,9 and a reduced frontal thickness and cortical volume.10 A distorted sense of self and others is a socially disabling disorder that should generate empathy, not disdain. Narcissistic personality disorder should be replaced by a term that accurately describes its behavioral pathology, and should not incorporate Greek mythology.
Mania. This is another unfortunate diagnosis that immediately evokes a negative image of patients who suffer from a potentially lethal brain disorder. It was fortunate that Robert Kendall coined the term “bipolar disorder” to replace “manic-depressive illness,” but mania is still being used within bipolar disorder as a prominent clinical phase. While depression accurately describes the mood in the other phase of this disorder, the term mania evokes wild, irrational behavior. Because the actual mood symptom cluster in mania is either elation/grandiosity or irritability/anger, why not replace mania with “elation/irritability phase of bipolar disorder”? It is more descriptive of the patient’s mood and is less pejorative.
Nomenclature is vital, and words do matter, especially when used as a diagnostic medical term. Psychiatry must “cancel” its archaic names, which are infused with negative connotations. Reinventing the psychiatric lexicon is a necessary act of renewal in a specialty where a poorly worded diagnostic label can morph into the equivalent of a “scarlet letter.” Think of other contemptuous terms, such as refrigerator mother, male hysteria, moral insanity, toxic parents, inadequate personality disorder, neurasthenia, or catastrophic schizophrenia.
General medicine regularly discards many of its obsolete terms.11 These include terms such as ablepsy, ague, camp fever, bloody flux, chlorosis, catarrh, consumption, dropsy, French pox, phthisis, milk sickness, and scrumpox.
Think also of how society abandoned the antediluvian names of boys and girls. Few parents these days would name their son Ackley, Allard, Arundel, Awarnach, Beldon, Durward, Grower, Kenlm, or Legolan, or name their daughter Afton, Agrona, Arantxa, Corliss, Demelza, Eartha, Maida, Obsession, Radella, or Sacrifice.In summary, a necessary part of psychiatry’s progress is shedding obsolete terminology, even if it means slaughtering some widely used “traditional” vocabulary. It is a necessary act of renewal, and the image of psychiatry will be burnished by it.
1. Nasrallah HA. Borderline personality disorder is a heritable brain disease. Current Psychiatry. 2014;13(4):19-20,32.
2. Sagarwala R, Nasrallah HA. White matter pathology in patients with borderline personality disorder: a review of controlled DTI studies. Ann Clin Psychiatry. 2020;32(4):281-286.
3. Keshavan MS, Tandon R, Nasrallah HA. Renaming schizophrenia: keeping up with the facts. Schizophr Res. 2013;148(1-3):1-2.
4. Lasalvia A, Penta E, Sartorius N, et al. Should the label “schizophrenia” be abandoned? Schizophr Res. 2015;162(1-3):276-284.
5. Takahashi H, Ideno T, Okubo S, et al. Impact of changing the Japanese term for “schizophrenia” for reasons of stereotypical beliefs of schizophrenia in Japanese youth. Schizophr Res. 2009;112(1-3):149-152.
6. Johanson M, Vaurio D, Tiihunen J, et al. A systematic literature review of neuroimaging of psychopathic traits. Front Psychiatry. 2020;10:1027.
7. Yang, W, Cun L, Du X, et al. Gender differences in brain structure and resting-state functional connectivity related to narcissistic personality. Sci Rep. 2015;5:10924.
8. Chester DS, Cynam DR, Powell DK, et al. Narcissismis associated with weakened frontostriatal connectivity: a DTI study. Soc Cogn Affect Neurosci. 2016;11(7):1036-1040.
9. Nenadic I, Gullmar D, Dietzek M, et al. Brain structure in narcissistic personality disorder: a VBM and DTI pilot study. Psychiatry Res. 2015;231(2):184-186.
10. Mao Y, Sang N, Wang Y, et al. Reduced frontal cortex thickness and cortical volume associated with pathological narcissism. Neuroscience. 2016;378:51-57.
11. Nasrallah HA. The transient truths of medical ‘progress.’ Current Psychiatry. 2014;13(6):23-24.
Psychiatry has made significant scientific advances over the past century. However, it is still saddled with archaic terms, with pejorative connotations, disguised as official medical diagnoses. It is time to “cancel” those terms and replace them with ones that are neutral and have not accumulated baggage.
This process of “creative destruction” of psychiatric terminology is long overdue. It is frankly disturbing that the psychiatric jargon used around the time that the American Psychiatric Association was established 175 years ago (1844) is now considered insults and epithets. We no longer work in “lunatic asylums for the insane,” and our patients with intellectual disabilities are no longer classified as “morons,” “idiots,” or “imbeciles.” Such “diagnoses” have certainly contributed to the stigma of psychiatric brain disorders. Even the noble word “asylum” has acquired a negative valence because in the past it referred to hospitals that housed persons with serious mental illness.
Thankfully, some of the outrageous terms fabricated during the condemnable and dark era of slavery 2 centuries ago were never adopted by organized psychiatry. The absurd diagnosis of “negritude,” whose tenet was that black skin is a disease curable by whitening the skin, was “invented” by none other than Benjamin Rush, the Father of Psychiatry, whose conflicted soul was depicted by concomitantly owning a slave and positioning himself as an ardent abolitionist!
Terms that need to be replaced
Fast-forward to the modern era and consider the following:
Borderline personality disorder. It is truly tragic how this confusing and non-scientific term is used as an official diagnosis for a set of seriously ill persons. It is loaded with obloquy, indignity, and derision that completely ignore the tumult, self-harm, and disability with which patients who carry this label are burdened throughout their lives, despite being intelligent. This is a serious brain disorder that has been shown to be highly genetic and is characterized by many well-established structural brain abnormalities that have been documented in neuroimaging studies.1,2 Borderline personality should not be classified as a personality disorder but as an illness with multiple signs and symptoms, including mood lability, anger, impulsivity, self-cutting, suicidal urges, feelings of abandonment, and micro-psychotic episodes. A more clinically accurate term should be coined very soon to replace borderline personality, which should be discarded to the trash heap of obsolete psychiatric terms, and no longer inflicted on patients.
Neurosis. What is the justification for continuing to use the term “neurotic” for a person who has an anxiety disorder? Is it used because Jung and Freud propagated the term “neurosis” (after it was coined by William Cullen in 1769)? Neurosis has degenerated from a psychiatric diagnosis to a scornful snub that must never be used for any patient.
Schizophrenia. This diagnosis, coined by Eugen Bleuler to replace the narrow and pessimistic “dementia praecox” proposed by Emil Kraepelin in the 1920s, initially seemed to be a neutral description of a thought disorder (split associations, not split personality). Bleuler was perceptive enough to call his book Dementia Praecox or the Group of Schizophrenias, which is consistent with the modern scientific research that confirms schizophrenia is a very heterogeneous syndrome with hundreds of genetic and environmental biotypes with a similar phenotype but a wide range of severity, treatment response, and functional outcomes. However, in subsequent decades, schizophrenia became one of the most demeaning labels in psychiatry, casting a shadow of hopelessness and disability on the people who have this serious neurologic condition with many psychiatric symptoms. The term that should replace schizophrenia should be no more degrading than stroke, multiple sclerosis, or myocardial infarction.
Continue to: Over the past 15 years...
Over the past 15 years, an expanding group of schizophrenia experts have agreed that this term must be changed to one that reflects the core features of this syndrome, and have proposed terms such as “salience syndrome,” “psychosis-spectrum,” and “reality distortion and cognitive impairment disorder.”3 In fact, several countries have already adopted a new official diagnosis for schizophrenia.4 Japan now uses the term “integration disorder,” which has significantly reduced the stigma of this brain disorder.5 South Korea changed the name to “attunement disorder.” Hong Kong and Taiwan now use “dysfunction of thought and perception.” Some researchers recommend calling schizophrenia “Bleuler’s syndrome,” a neutral eponymous designation.
One of the most irritating things about the term schizophrenia is the widespread misconception that it means “split personality.” This prompts some sports announcers to call a football team “schizophrenic” if they play well in the first half and badly in the second. The stock market is labeled “schizophrenic” if it goes up one day and way down on the next. No other medical term is misused by the media as often as the term schizophrenia.
Narcissistic personality disorder. The origin of this diagnostic category is the concept of “malignant narcissism” coined by Erich Fromm in 1964, which he designated as “the quintessence of evil.” I strongly object to implying that evil is part of any psychiatric diagnosis. Numerous studies have found structural brain abnormalities (in both gray and white matter) in patients diagnosed with psychopathic traits.6 Later, malignant narcissism was reframed as narcissistic personality disorder in 1971 by Herbert Rosenfeld. Although malignant narcissism was never accepted by either the DSM or the International Classification of Diseases, narcissistic personality disorder has been included in the DSM for the past few decades. This diagnosis reeks of disparagement and negativity. Persons with narcissistic personality disorder have been shown to have pathological brain changes in resting-state functional connectivity,7 weakened frontostriatal white matter connectivity,8,9 and a reduced frontal thickness and cortical volume.10 A distorted sense of self and others is a socially disabling disorder that should generate empathy, not disdain. Narcissistic personality disorder should be replaced by a term that accurately describes its behavioral pathology, and should not incorporate Greek mythology.
Mania. This is another unfortunate diagnosis that immediately evokes a negative image of patients who suffer from a potentially lethal brain disorder. It was fortunate that Robert Kendall coined the term “bipolar disorder” to replace “manic-depressive illness,” but mania is still being used within bipolar disorder as a prominent clinical phase. While depression accurately describes the mood in the other phase of this disorder, the term mania evokes wild, irrational behavior. Because the actual mood symptom cluster in mania is either elation/grandiosity or irritability/anger, why not replace mania with “elation/irritability phase of bipolar disorder”? It is more descriptive of the patient’s mood and is less pejorative.
Nomenclature is vital, and words do matter, especially when used as a diagnostic medical term. Psychiatry must “cancel” its archaic names, which are infused with negative connotations. Reinventing the psychiatric lexicon is a necessary act of renewal in a specialty where a poorly worded diagnostic label can morph into the equivalent of a “scarlet letter.” Think of other contemptuous terms, such as refrigerator mother, male hysteria, moral insanity, toxic parents, inadequate personality disorder, neurasthenia, or catastrophic schizophrenia.
General medicine regularly discards many of its obsolete terms.11 These include terms such as ablepsy, ague, camp fever, bloody flux, chlorosis, catarrh, consumption, dropsy, French pox, phthisis, milk sickness, and scrumpox.
Think also of how society abandoned the antediluvian names of boys and girls. Few parents these days would name their son Ackley, Allard, Arundel, Awarnach, Beldon, Durward, Grower, Kenlm, or Legolan, or name their daughter Afton, Agrona, Arantxa, Corliss, Demelza, Eartha, Maida, Obsession, Radella, or Sacrifice.In summary, a necessary part of psychiatry’s progress is shedding obsolete terminology, even if it means slaughtering some widely used “traditional” vocabulary. It is a necessary act of renewal, and the image of psychiatry will be burnished by it.
Psychiatry has made significant scientific advances over the past century. However, it is still saddled with archaic terms, with pejorative connotations, disguised as official medical diagnoses. It is time to “cancel” those terms and replace them with ones that are neutral and have not accumulated baggage.
This process of “creative destruction” of psychiatric terminology is long overdue. It is frankly disturbing that the psychiatric jargon used around the time that the American Psychiatric Association was established 175 years ago (1844) is now considered insults and epithets. We no longer work in “lunatic asylums for the insane,” and our patients with intellectual disabilities are no longer classified as “morons,” “idiots,” or “imbeciles.” Such “diagnoses” have certainly contributed to the stigma of psychiatric brain disorders. Even the noble word “asylum” has acquired a negative valence because in the past it referred to hospitals that housed persons with serious mental illness.
Thankfully, some of the outrageous terms fabricated during the condemnable and dark era of slavery 2 centuries ago were never adopted by organized psychiatry. The absurd diagnosis of “negritude,” whose tenet was that black skin is a disease curable by whitening the skin, was “invented” by none other than Benjamin Rush, the Father of Psychiatry, whose conflicted soul was depicted by concomitantly owning a slave and positioning himself as an ardent abolitionist!
Terms that need to be replaced
Fast-forward to the modern era and consider the following:
Borderline personality disorder. It is truly tragic how this confusing and non-scientific term is used as an official diagnosis for a set of seriously ill persons. It is loaded with obloquy, indignity, and derision that completely ignore the tumult, self-harm, and disability with which patients who carry this label are burdened throughout their lives, despite being intelligent. This is a serious brain disorder that has been shown to be highly genetic and is characterized by many well-established structural brain abnormalities that have been documented in neuroimaging studies.1,2 Borderline personality should not be classified as a personality disorder but as an illness with multiple signs and symptoms, including mood lability, anger, impulsivity, self-cutting, suicidal urges, feelings of abandonment, and micro-psychotic episodes. A more clinically accurate term should be coined very soon to replace borderline personality, which should be discarded to the trash heap of obsolete psychiatric terms, and no longer inflicted on patients.
Neurosis. What is the justification for continuing to use the term “neurotic” for a person who has an anxiety disorder? Is it used because Jung and Freud propagated the term “neurosis” (after it was coined by William Cullen in 1769)? Neurosis has degenerated from a psychiatric diagnosis to a scornful snub that must never be used for any patient.
Schizophrenia. This diagnosis, coined by Eugen Bleuler to replace the narrow and pessimistic “dementia praecox” proposed by Emil Kraepelin in the 1920s, initially seemed to be a neutral description of a thought disorder (split associations, not split personality). Bleuler was perceptive enough to call his book Dementia Praecox or the Group of Schizophrenias, which is consistent with the modern scientific research that confirms schizophrenia is a very heterogeneous syndrome with hundreds of genetic and environmental biotypes with a similar phenotype but a wide range of severity, treatment response, and functional outcomes. However, in subsequent decades, schizophrenia became one of the most demeaning labels in psychiatry, casting a shadow of hopelessness and disability on the people who have this serious neurologic condition with many psychiatric symptoms. The term that should replace schizophrenia should be no more degrading than stroke, multiple sclerosis, or myocardial infarction.
Continue to: Over the past 15 years...
Over the past 15 years, an expanding group of schizophrenia experts have agreed that this term must be changed to one that reflects the core features of this syndrome, and have proposed terms such as “salience syndrome,” “psychosis-spectrum,” and “reality distortion and cognitive impairment disorder.”3 In fact, several countries have already adopted a new official diagnosis for schizophrenia.4 Japan now uses the term “integration disorder,” which has significantly reduced the stigma of this brain disorder.5 South Korea changed the name to “attunement disorder.” Hong Kong and Taiwan now use “dysfunction of thought and perception.” Some researchers recommend calling schizophrenia “Bleuler’s syndrome,” a neutral eponymous designation.
One of the most irritating things about the term schizophrenia is the widespread misconception that it means “split personality.” This prompts some sports announcers to call a football team “schizophrenic” if they play well in the first half and badly in the second. The stock market is labeled “schizophrenic” if it goes up one day and way down on the next. No other medical term is misused by the media as often as the term schizophrenia.
Narcissistic personality disorder. The origin of this diagnostic category is the concept of “malignant narcissism” coined by Erich Fromm in 1964, which he designated as “the quintessence of evil.” I strongly object to implying that evil is part of any psychiatric diagnosis. Numerous studies have found structural brain abnormalities (in both gray and white matter) in patients diagnosed with psychopathic traits.6 Later, malignant narcissism was reframed as narcissistic personality disorder in 1971 by Herbert Rosenfeld. Although malignant narcissism was never accepted by either the DSM or the International Classification of Diseases, narcissistic personality disorder has been included in the DSM for the past few decades. This diagnosis reeks of disparagement and negativity. Persons with narcissistic personality disorder have been shown to have pathological brain changes in resting-state functional connectivity,7 weakened frontostriatal white matter connectivity,8,9 and a reduced frontal thickness and cortical volume.10 A distorted sense of self and others is a socially disabling disorder that should generate empathy, not disdain. Narcissistic personality disorder should be replaced by a term that accurately describes its behavioral pathology, and should not incorporate Greek mythology.
Mania. This is another unfortunate diagnosis that immediately evokes a negative image of patients who suffer from a potentially lethal brain disorder. It was fortunate that Robert Kendall coined the term “bipolar disorder” to replace “manic-depressive illness,” but mania is still being used within bipolar disorder as a prominent clinical phase. While depression accurately describes the mood in the other phase of this disorder, the term mania evokes wild, irrational behavior. Because the actual mood symptom cluster in mania is either elation/grandiosity or irritability/anger, why not replace mania with “elation/irritability phase of bipolar disorder”? It is more descriptive of the patient’s mood and is less pejorative.
Nomenclature is vital, and words do matter, especially when used as a diagnostic medical term. Psychiatry must “cancel” its archaic names, which are infused with negative connotations. Reinventing the psychiatric lexicon is a necessary act of renewal in a specialty where a poorly worded diagnostic label can morph into the equivalent of a “scarlet letter.” Think of other contemptuous terms, such as refrigerator mother, male hysteria, moral insanity, toxic parents, inadequate personality disorder, neurasthenia, or catastrophic schizophrenia.
General medicine regularly discards many of its obsolete terms.11 These include terms such as ablepsy, ague, camp fever, bloody flux, chlorosis, catarrh, consumption, dropsy, French pox, phthisis, milk sickness, and scrumpox.
Think also of how society abandoned the antediluvian names of boys and girls. Few parents these days would name their son Ackley, Allard, Arundel, Awarnach, Beldon, Durward, Grower, Kenlm, or Legolan, or name their daughter Afton, Agrona, Arantxa, Corliss, Demelza, Eartha, Maida, Obsession, Radella, or Sacrifice.In summary, a necessary part of psychiatry’s progress is shedding obsolete terminology, even if it means slaughtering some widely used “traditional” vocabulary. It is a necessary act of renewal, and the image of psychiatry will be burnished by it.
1. Nasrallah HA. Borderline personality disorder is a heritable brain disease. Current Psychiatry. 2014;13(4):19-20,32.
2. Sagarwala R, Nasrallah HA. White matter pathology in patients with borderline personality disorder: a review of controlled DTI studies. Ann Clin Psychiatry. 2020;32(4):281-286.
3. Keshavan MS, Tandon R, Nasrallah HA. Renaming schizophrenia: keeping up with the facts. Schizophr Res. 2013;148(1-3):1-2.
4. Lasalvia A, Penta E, Sartorius N, et al. Should the label “schizophrenia” be abandoned? Schizophr Res. 2015;162(1-3):276-284.
5. Takahashi H, Ideno T, Okubo S, et al. Impact of changing the Japanese term for “schizophrenia” for reasons of stereotypical beliefs of schizophrenia in Japanese youth. Schizophr Res. 2009;112(1-3):149-152.
6. Johanson M, Vaurio D, Tiihunen J, et al. A systematic literature review of neuroimaging of psychopathic traits. Front Psychiatry. 2020;10:1027.
7. Yang, W, Cun L, Du X, et al. Gender differences in brain structure and resting-state functional connectivity related to narcissistic personality. Sci Rep. 2015;5:10924.
8. Chester DS, Cynam DR, Powell DK, et al. Narcissismis associated with weakened frontostriatal connectivity: a DTI study. Soc Cogn Affect Neurosci. 2016;11(7):1036-1040.
9. Nenadic I, Gullmar D, Dietzek M, et al. Brain structure in narcissistic personality disorder: a VBM and DTI pilot study. Psychiatry Res. 2015;231(2):184-186.
10. Mao Y, Sang N, Wang Y, et al. Reduced frontal cortex thickness and cortical volume associated with pathological narcissism. Neuroscience. 2016;378:51-57.
11. Nasrallah HA. The transient truths of medical ‘progress.’ Current Psychiatry. 2014;13(6):23-24.
1. Nasrallah HA. Borderline personality disorder is a heritable brain disease. Current Psychiatry. 2014;13(4):19-20,32.
2. Sagarwala R, Nasrallah HA. White matter pathology in patients with borderline personality disorder: a review of controlled DTI studies. Ann Clin Psychiatry. 2020;32(4):281-286.
3. Keshavan MS, Tandon R, Nasrallah HA. Renaming schizophrenia: keeping up with the facts. Schizophr Res. 2013;148(1-3):1-2.
4. Lasalvia A, Penta E, Sartorius N, et al. Should the label “schizophrenia” be abandoned? Schizophr Res. 2015;162(1-3):276-284.
5. Takahashi H, Ideno T, Okubo S, et al. Impact of changing the Japanese term for “schizophrenia” for reasons of stereotypical beliefs of schizophrenia in Japanese youth. Schizophr Res. 2009;112(1-3):149-152.
6. Johanson M, Vaurio D, Tiihunen J, et al. A systematic literature review of neuroimaging of psychopathic traits. Front Psychiatry. 2020;10:1027.
7. Yang, W, Cun L, Du X, et al. Gender differences in brain structure and resting-state functional connectivity related to narcissistic personality. Sci Rep. 2015;5:10924.
8. Chester DS, Cynam DR, Powell DK, et al. Narcissismis associated with weakened frontostriatal connectivity: a DTI study. Soc Cogn Affect Neurosci. 2016;11(7):1036-1040.
9. Nenadic I, Gullmar D, Dietzek M, et al. Brain structure in narcissistic personality disorder: a VBM and DTI pilot study. Psychiatry Res. 2015;231(2):184-186.
10. Mao Y, Sang N, Wang Y, et al. Reduced frontal cortex thickness and cortical volume associated with pathological narcissism. Neuroscience. 2016;378:51-57.
11. Nasrallah HA. The transient truths of medical ‘progress.’ Current Psychiatry. 2014;13(6):23-24.
Paul Summergrad, MD, on the state of psychiatry
For this Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Paul Summergrad, MD. Dr. Summergrad is the Dr. Frances S. Arkin Professor and Chair of the Department of Psychiatry and Professor of Psychiatry and Medicine at Tufts University School of Medicine and Psychiatrist-in-Chief at Tufts Medical Center, Boston, Massachusetts. From 2014 to 2015, Dr. Summergrad served as the 141st president of the American Psychiatric Association, and is a past president of the American Association of Chairs of Departments of Psychiatry. Dr. Summergrad’s research focuses on mood disorders, medical/psychiatric comorbidity, and health system design. He received the Distinguished Faculty Award from Tufts University School of Medicine in 2015 and the Leadership Award of the American Association of Chairs of Departments of Psychiatry in 2018. In 2020, he was elected to the Honorary Fellowship of the Royal College of Psychiatrists, their highest honor. He is the lead editor of Textbook of Medical Psychiatry, which was published by American Psychiatric Association Publishing in 2020.
Dr. Aftab: Much of your career has been devoted to the practice of “medical psychiatry” in which you have fruitfully integrated your medical training as well as psychoanalytic training. How has this influenced your understanding of the medical model in psychiatry and psychiatry’s relationship with medicine?
Dr. Summergrad: It is a really complex and ongoing influence. I think there is a misunderstanding of what is meant by the medical model in psychiatry. It has nothing to do with the etiology of mental disorders or their treatment. At its core, the medical model is based on a syndromic view of disorders: that we attend to those symptoms of illness that occur together more frequently than they might by chance and then, based on that provisional diagnostic cluster, look for causes, risk factors, and interventions that affect the putative disorder’s course. As a consequence of that process, disorders are refined, often separated into a group of disorders, or in some cases discarded. An excellent example that we have all been living through has been our evolving understanding of COVID-19, which is now understood to be as much a clotting and inflammatory disorder as a respiratory condition.
Medical psychiatry is a different and discrete area of clinical psychiatric interest. It covers a variety of areas: the complexity of the management of patients with comorbid medical and psychiatric illness, the impact of medical illness on the course of psychiatric illness and life expectancy, and conversely the effects of psychiatric illness on the course of medical disorders—for example, the increased mortality in patients with myocardial infarction (MI) and post-MI major depression. At its core is the study of medical disorders, including neurologic conditions, that directly cause syndromes in the realm that we define as mental disorders. This was the focus of our recent Textbook of Medical Psychiatry. This has been a long-standing interest of mine since I did my medical residency at Boston City Hospital before I trained in psychiatry, and it has informed my career in many other ways.
Dr. Aftab: What do you see as some of the strengths of our profession?
Dr. Summergrad: Psychiatry has so many riches: a long clinical tradition based on close and long-term observation and interaction with patients, effective psychotherapies such as cognitive-behavioral therapy and psychodynamic therapies, and evidence-based pharmacologic and other somatic therapies.
Second, there has been substantial growth in our fundamental understanding of the neurobiology of psychiatric illness with regards to circuitry, imaging, and genetics. While many of these advances have arisen from more basic research, it is also the case that the evolution of a consistent diagnostic nomenclature in the 1970s, even with all its limitations, allowed for advances in research, diagnosis, and treatment.
Finally, our other great strengths are our roots in medicine and the importance of those skills in assessing patients and caring for active comorbidities. We are one of the last fields in clinical medicine where doctors can take the time to establish a detailed and close working relationship with our patients. We are fortunate to have this great mix of science, medicine, and interpersonal skills, which is highly rewarding.
Continue to: Dr. Aftab: Are there ways...
Dr. Aftab: Are there ways in which the status quo in psychiatry falls short of the ideal? What are our areas of relative weakness?
Dr. Summergrad: There are many, as there are in many other fields of medicine. For too many, there is a reification of a diagnostic nomenclature as being identical to detailed and thoughtful clinical evaluation. For many, the pressures of health care economics mean that they may be taking care of more inpatients than is optimal, or are under pressure to see a larger number of patients as a so-called “prescriber,” a term I think should be banished.
We have struggled significantly to have a coherent link between our clinical work, including our interventions, our emerging understanding of neuroscience and genetics, and the experiences of our patients, including the onset and timing of many of the disorders we treat. Part of this is that we lack a unified model of mental functioning that unites the onset of illness, its clinical phenomena, and any underlying pathophysiology. We operate at multiple levels of abstraction (brain-mind) compared with other medical fields. While other medical fields incorporate experience, they are more fully operating, from a pathophysiologic perspective, at a physical level alone. Even in common parlance, we can easily talk about the heart as a pump, or the kidney as a filter, but there is no corresponding way to describe what the brain-mind is and does. This could be construed as a weakness; I see it more as an intrinsic complexity of our field.
What we refer to as psychiatric disorders deal with the most intimate aspects of people’s beings: their sense of self and capacity. Many people experience our diagnostic work and nomenclature as wounding, demeaning, distancing, or defining their very essence or being as ill. There is a wonderful story that I heard from the great Elyn Saks, the constitutional law professor, regarding her own illness, about which she has been admirably open. She described a long course of significant psychotic illness, eventually diagnosed as schizophrenia, for which she received years of psychotherapy, psychopharmacology, and hospital care, both when she studied at Oxford and while she was a law student at Yale. She described that after 10 years of care, she was eventually prescribed clozapine, which made a major difference in her illness. It was about the same time that she finally accepted that she had a psychiatric illness, and it was at that very moment of acceptance that she realized that it wasn’t about her, that it didn’t define who she was in her essence. Very moving and important. In defining pathophysiology or what we call psychopathology, we need to make sure it is clear that we are not labeling or diagnosing anyone’s essential being.
I think we need to tread very carefully in these areas, including being very sensitive with our language. Much of this is in the nature of the illnesses we deal with and their profound intimacy, but again we need to be mindful of this. These areas are ones which I think contribute to a resentment of psychiatry, and are possibly related to some of the anti-psychiatry sentiments and criticisms of the so-called medical model in psychiatry, which as I noted above is, I think, not well understood.
Continue to: Dr. Aftab: What is your perception...
Dr. Aftab: What is your perception of the threats that psychiatry faces or is likely to face in the future?
Dr. Summergrad: I actually am very bullish on psychiatry’s future. While we are far from perfect, the illnesses we care for are so ubiquitous that many if not most people will experience them personally or in close family members over their lifetime. As such, there is a real and broad understanding about the need for psychiatric care; we do, however, have to always strive to do it better and with greater sensitivity to the human experiences of those who seek our care.
Dr. Aftab: What do you envision for the future of psychiatry? What opportunities lie ahead for us?
Dr. Summergrad: I think we will see an expansion of awareness of mental disorders globally. While it may seem counterintuitive to say this in the midst of a global pandemic, over the course of the last 80 years, the global burden of disease related to communicable diseases has fallen across much of the developed world and the burden of disease attributable to noncommunicable disease has increased. Psychiatric disorders are among the most frequent noncommunicable disorders and are increasing as a proportion of total illness burden. As such, the need for mental health–related care will increase dramatically over the next half century, if not longer.
Second, I think our understanding of neurobiology, the impact of medical disorders, and pathophysiology related to mechanisms such as inflammation in psychiatric disorders will increase. Likewise, our appreciation will grow for non-allelic influences on the genetics or heritability of psychiatric disorders. I don’t think we have come near to tapping the effects of epigenetics on psychiatric illnesses, and that will become increasingly important.
I also think that over time, our understanding of particular neurobiological pathways and our ability to modulate these pathways will increase. How that will eventually yield the ability to treat patients with greater precision I don’t know, but I expect that will occur. Over time, we may even learn enough to have a workable theory of mind and brain, but I am not sure that all of these mysteries will yield anytime soon, and for some of them, answers may have to come from other domains of human experience.
For this Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Paul Summergrad, MD. Dr. Summergrad is the Dr. Frances S. Arkin Professor and Chair of the Department of Psychiatry and Professor of Psychiatry and Medicine at Tufts University School of Medicine and Psychiatrist-in-Chief at Tufts Medical Center, Boston, Massachusetts. From 2014 to 2015, Dr. Summergrad served as the 141st president of the American Psychiatric Association, and is a past president of the American Association of Chairs of Departments of Psychiatry. Dr. Summergrad’s research focuses on mood disorders, medical/psychiatric comorbidity, and health system design. He received the Distinguished Faculty Award from Tufts University School of Medicine in 2015 and the Leadership Award of the American Association of Chairs of Departments of Psychiatry in 2018. In 2020, he was elected to the Honorary Fellowship of the Royal College of Psychiatrists, their highest honor. He is the lead editor of Textbook of Medical Psychiatry, which was published by American Psychiatric Association Publishing in 2020.
Dr. Aftab: Much of your career has been devoted to the practice of “medical psychiatry” in which you have fruitfully integrated your medical training as well as psychoanalytic training. How has this influenced your understanding of the medical model in psychiatry and psychiatry’s relationship with medicine?
Dr. Summergrad: It is a really complex and ongoing influence. I think there is a misunderstanding of what is meant by the medical model in psychiatry. It has nothing to do with the etiology of mental disorders or their treatment. At its core, the medical model is based on a syndromic view of disorders: that we attend to those symptoms of illness that occur together more frequently than they might by chance and then, based on that provisional diagnostic cluster, look for causes, risk factors, and interventions that affect the putative disorder’s course. As a consequence of that process, disorders are refined, often separated into a group of disorders, or in some cases discarded. An excellent example that we have all been living through has been our evolving understanding of COVID-19, which is now understood to be as much a clotting and inflammatory disorder as a respiratory condition.
Medical psychiatry is a different and discrete area of clinical psychiatric interest. It covers a variety of areas: the complexity of the management of patients with comorbid medical and psychiatric illness, the impact of medical illness on the course of psychiatric illness and life expectancy, and conversely the effects of psychiatric illness on the course of medical disorders—for example, the increased mortality in patients with myocardial infarction (MI) and post-MI major depression. At its core is the study of medical disorders, including neurologic conditions, that directly cause syndromes in the realm that we define as mental disorders. This was the focus of our recent Textbook of Medical Psychiatry. This has been a long-standing interest of mine since I did my medical residency at Boston City Hospital before I trained in psychiatry, and it has informed my career in many other ways.
Dr. Aftab: What do you see as some of the strengths of our profession?
Dr. Summergrad: Psychiatry has so many riches: a long clinical tradition based on close and long-term observation and interaction with patients, effective psychotherapies such as cognitive-behavioral therapy and psychodynamic therapies, and evidence-based pharmacologic and other somatic therapies.
Second, there has been substantial growth in our fundamental understanding of the neurobiology of psychiatric illness with regards to circuitry, imaging, and genetics. While many of these advances have arisen from more basic research, it is also the case that the evolution of a consistent diagnostic nomenclature in the 1970s, even with all its limitations, allowed for advances in research, diagnosis, and treatment.
Finally, our other great strengths are our roots in medicine and the importance of those skills in assessing patients and caring for active comorbidities. We are one of the last fields in clinical medicine where doctors can take the time to establish a detailed and close working relationship with our patients. We are fortunate to have this great mix of science, medicine, and interpersonal skills, which is highly rewarding.
Continue to: Dr. Aftab: Are there ways...
Dr. Aftab: Are there ways in which the status quo in psychiatry falls short of the ideal? What are our areas of relative weakness?
Dr. Summergrad: There are many, as there are in many other fields of medicine. For too many, there is a reification of a diagnostic nomenclature as being identical to detailed and thoughtful clinical evaluation. For many, the pressures of health care economics mean that they may be taking care of more inpatients than is optimal, or are under pressure to see a larger number of patients as a so-called “prescriber,” a term I think should be banished.
We have struggled significantly to have a coherent link between our clinical work, including our interventions, our emerging understanding of neuroscience and genetics, and the experiences of our patients, including the onset and timing of many of the disorders we treat. Part of this is that we lack a unified model of mental functioning that unites the onset of illness, its clinical phenomena, and any underlying pathophysiology. We operate at multiple levels of abstraction (brain-mind) compared with other medical fields. While other medical fields incorporate experience, they are more fully operating, from a pathophysiologic perspective, at a physical level alone. Even in common parlance, we can easily talk about the heart as a pump, or the kidney as a filter, but there is no corresponding way to describe what the brain-mind is and does. This could be construed as a weakness; I see it more as an intrinsic complexity of our field.
What we refer to as psychiatric disorders deal with the most intimate aspects of people’s beings: their sense of self and capacity. Many people experience our diagnostic work and nomenclature as wounding, demeaning, distancing, or defining their very essence or being as ill. There is a wonderful story that I heard from the great Elyn Saks, the constitutional law professor, regarding her own illness, about which she has been admirably open. She described a long course of significant psychotic illness, eventually diagnosed as schizophrenia, for which she received years of psychotherapy, psychopharmacology, and hospital care, both when she studied at Oxford and while she was a law student at Yale. She described that after 10 years of care, she was eventually prescribed clozapine, which made a major difference in her illness. It was about the same time that she finally accepted that she had a psychiatric illness, and it was at that very moment of acceptance that she realized that it wasn’t about her, that it didn’t define who she was in her essence. Very moving and important. In defining pathophysiology or what we call psychopathology, we need to make sure it is clear that we are not labeling or diagnosing anyone’s essential being.
I think we need to tread very carefully in these areas, including being very sensitive with our language. Much of this is in the nature of the illnesses we deal with and their profound intimacy, but again we need to be mindful of this. These areas are ones which I think contribute to a resentment of psychiatry, and are possibly related to some of the anti-psychiatry sentiments and criticisms of the so-called medical model in psychiatry, which as I noted above is, I think, not well understood.
Continue to: Dr. Aftab: What is your perception...
Dr. Aftab: What is your perception of the threats that psychiatry faces or is likely to face in the future?
Dr. Summergrad: I actually am very bullish on psychiatry’s future. While we are far from perfect, the illnesses we care for are so ubiquitous that many if not most people will experience them personally or in close family members over their lifetime. As such, there is a real and broad understanding about the need for psychiatric care; we do, however, have to always strive to do it better and with greater sensitivity to the human experiences of those who seek our care.
Dr. Aftab: What do you envision for the future of psychiatry? What opportunities lie ahead for us?
Dr. Summergrad: I think we will see an expansion of awareness of mental disorders globally. While it may seem counterintuitive to say this in the midst of a global pandemic, over the course of the last 80 years, the global burden of disease related to communicable diseases has fallen across much of the developed world and the burden of disease attributable to noncommunicable disease has increased. Psychiatric disorders are among the most frequent noncommunicable disorders and are increasing as a proportion of total illness burden. As such, the need for mental health–related care will increase dramatically over the next half century, if not longer.
Second, I think our understanding of neurobiology, the impact of medical disorders, and pathophysiology related to mechanisms such as inflammation in psychiatric disorders will increase. Likewise, our appreciation will grow for non-allelic influences on the genetics or heritability of psychiatric disorders. I don’t think we have come near to tapping the effects of epigenetics on psychiatric illnesses, and that will become increasingly important.
I also think that over time, our understanding of particular neurobiological pathways and our ability to modulate these pathways will increase. How that will eventually yield the ability to treat patients with greater precision I don’t know, but I expect that will occur. Over time, we may even learn enough to have a workable theory of mind and brain, but I am not sure that all of these mysteries will yield anytime soon, and for some of them, answers may have to come from other domains of human experience.
For this Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Paul Summergrad, MD. Dr. Summergrad is the Dr. Frances S. Arkin Professor and Chair of the Department of Psychiatry and Professor of Psychiatry and Medicine at Tufts University School of Medicine and Psychiatrist-in-Chief at Tufts Medical Center, Boston, Massachusetts. From 2014 to 2015, Dr. Summergrad served as the 141st president of the American Psychiatric Association, and is a past president of the American Association of Chairs of Departments of Psychiatry. Dr. Summergrad’s research focuses on mood disorders, medical/psychiatric comorbidity, and health system design. He received the Distinguished Faculty Award from Tufts University School of Medicine in 2015 and the Leadership Award of the American Association of Chairs of Departments of Psychiatry in 2018. In 2020, he was elected to the Honorary Fellowship of the Royal College of Psychiatrists, their highest honor. He is the lead editor of Textbook of Medical Psychiatry, which was published by American Psychiatric Association Publishing in 2020.
Dr. Aftab: Much of your career has been devoted to the practice of “medical psychiatry” in which you have fruitfully integrated your medical training as well as psychoanalytic training. How has this influenced your understanding of the medical model in psychiatry and psychiatry’s relationship with medicine?
Dr. Summergrad: It is a really complex and ongoing influence. I think there is a misunderstanding of what is meant by the medical model in psychiatry. It has nothing to do with the etiology of mental disorders or their treatment. At its core, the medical model is based on a syndromic view of disorders: that we attend to those symptoms of illness that occur together more frequently than they might by chance and then, based on that provisional diagnostic cluster, look for causes, risk factors, and interventions that affect the putative disorder’s course. As a consequence of that process, disorders are refined, often separated into a group of disorders, or in some cases discarded. An excellent example that we have all been living through has been our evolving understanding of COVID-19, which is now understood to be as much a clotting and inflammatory disorder as a respiratory condition.
Medical psychiatry is a different and discrete area of clinical psychiatric interest. It covers a variety of areas: the complexity of the management of patients with comorbid medical and psychiatric illness, the impact of medical illness on the course of psychiatric illness and life expectancy, and conversely the effects of psychiatric illness on the course of medical disorders—for example, the increased mortality in patients with myocardial infarction (MI) and post-MI major depression. At its core is the study of medical disorders, including neurologic conditions, that directly cause syndromes in the realm that we define as mental disorders. This was the focus of our recent Textbook of Medical Psychiatry. This has been a long-standing interest of mine since I did my medical residency at Boston City Hospital before I trained in psychiatry, and it has informed my career in many other ways.
Dr. Aftab: What do you see as some of the strengths of our profession?
Dr. Summergrad: Psychiatry has so many riches: a long clinical tradition based on close and long-term observation and interaction with patients, effective psychotherapies such as cognitive-behavioral therapy and psychodynamic therapies, and evidence-based pharmacologic and other somatic therapies.
Second, there has been substantial growth in our fundamental understanding of the neurobiology of psychiatric illness with regards to circuitry, imaging, and genetics. While many of these advances have arisen from more basic research, it is also the case that the evolution of a consistent diagnostic nomenclature in the 1970s, even with all its limitations, allowed for advances in research, diagnosis, and treatment.
Finally, our other great strengths are our roots in medicine and the importance of those skills in assessing patients and caring for active comorbidities. We are one of the last fields in clinical medicine where doctors can take the time to establish a detailed and close working relationship with our patients. We are fortunate to have this great mix of science, medicine, and interpersonal skills, which is highly rewarding.
Continue to: Dr. Aftab: Are there ways...
Dr. Aftab: Are there ways in which the status quo in psychiatry falls short of the ideal? What are our areas of relative weakness?
Dr. Summergrad: There are many, as there are in many other fields of medicine. For too many, there is a reification of a diagnostic nomenclature as being identical to detailed and thoughtful clinical evaluation. For many, the pressures of health care economics mean that they may be taking care of more inpatients than is optimal, or are under pressure to see a larger number of patients as a so-called “prescriber,” a term I think should be banished.
We have struggled significantly to have a coherent link between our clinical work, including our interventions, our emerging understanding of neuroscience and genetics, and the experiences of our patients, including the onset and timing of many of the disorders we treat. Part of this is that we lack a unified model of mental functioning that unites the onset of illness, its clinical phenomena, and any underlying pathophysiology. We operate at multiple levels of abstraction (brain-mind) compared with other medical fields. While other medical fields incorporate experience, they are more fully operating, from a pathophysiologic perspective, at a physical level alone. Even in common parlance, we can easily talk about the heart as a pump, or the kidney as a filter, but there is no corresponding way to describe what the brain-mind is and does. This could be construed as a weakness; I see it more as an intrinsic complexity of our field.
What we refer to as psychiatric disorders deal with the most intimate aspects of people’s beings: their sense of self and capacity. Many people experience our diagnostic work and nomenclature as wounding, demeaning, distancing, or defining their very essence or being as ill. There is a wonderful story that I heard from the great Elyn Saks, the constitutional law professor, regarding her own illness, about which she has been admirably open. She described a long course of significant psychotic illness, eventually diagnosed as schizophrenia, for which she received years of psychotherapy, psychopharmacology, and hospital care, both when she studied at Oxford and while she was a law student at Yale. She described that after 10 years of care, she was eventually prescribed clozapine, which made a major difference in her illness. It was about the same time that she finally accepted that she had a psychiatric illness, and it was at that very moment of acceptance that she realized that it wasn’t about her, that it didn’t define who she was in her essence. Very moving and important. In defining pathophysiology or what we call psychopathology, we need to make sure it is clear that we are not labeling or diagnosing anyone’s essential being.
I think we need to tread very carefully in these areas, including being very sensitive with our language. Much of this is in the nature of the illnesses we deal with and their profound intimacy, but again we need to be mindful of this. These areas are ones which I think contribute to a resentment of psychiatry, and are possibly related to some of the anti-psychiatry sentiments and criticisms of the so-called medical model in psychiatry, which as I noted above is, I think, not well understood.
Continue to: Dr. Aftab: What is your perception...
Dr. Aftab: What is your perception of the threats that psychiatry faces or is likely to face in the future?
Dr. Summergrad: I actually am very bullish on psychiatry’s future. While we are far from perfect, the illnesses we care for are so ubiquitous that many if not most people will experience them personally or in close family members over their lifetime. As such, there is a real and broad understanding about the need for psychiatric care; we do, however, have to always strive to do it better and with greater sensitivity to the human experiences of those who seek our care.
Dr. Aftab: What do you envision for the future of psychiatry? What opportunities lie ahead for us?
Dr. Summergrad: I think we will see an expansion of awareness of mental disorders globally. While it may seem counterintuitive to say this in the midst of a global pandemic, over the course of the last 80 years, the global burden of disease related to communicable diseases has fallen across much of the developed world and the burden of disease attributable to noncommunicable disease has increased. Psychiatric disorders are among the most frequent noncommunicable disorders and are increasing as a proportion of total illness burden. As such, the need for mental health–related care will increase dramatically over the next half century, if not longer.
Second, I think our understanding of neurobiology, the impact of medical disorders, and pathophysiology related to mechanisms such as inflammation in psychiatric disorders will increase. Likewise, our appreciation will grow for non-allelic influences on the genetics or heritability of psychiatric disorders. I don’t think we have come near to tapping the effects of epigenetics on psychiatric illnesses, and that will become increasingly important.
I also think that over time, our understanding of particular neurobiological pathways and our ability to modulate these pathways will increase. How that will eventually yield the ability to treat patients with greater precision I don’t know, but I expect that will occur. Over time, we may even learn enough to have a workable theory of mind and brain, but I am not sure that all of these mysteries will yield anytime soon, and for some of them, answers may have to come from other domains of human experience.
