Commentary

Every Wednesday evening after supper, I record in a marble notebook some anthropomorphic measurements: my weight taken first thing Monday morning and my waist circumference. I also add how I did with exercise since the previous week’s entry and some comments about sleep, energy, and nutrition.

My personal log now comprises dozens of pages. To my surprise, the first entry was 5 years ago to the month. The earlier entries were far from weekly and contained a lot of narrative on how my food-restriction scheme that month was being violated.

Looking just at the numbers, I did about as well as a control group participant in any medical study of diet modification. Until just a few months ago, there was no trend in either weight or waist circumference over those 5 years, including 2 years of retirement. But it wasn’t for lack of trying. Keeping the journal for as long as I have – and recently, as consistently as I have – suggests serious intent but inadequate execution of the same principles I offered patients, who rarely did much better. But recent studies suggest that perhaps quite a few could.
 

Are we underestimating our patients’ potential?

A recent abstract from the European and International Congress on Obesity suggests that the impressions clinicians get from our office encounters may leave us underestimating the potential for our patients to lose enough weight to move them from one level of risk to another.

Using a national database of primary care visits, the investigators isolated about 550,000 records. Of these, about 60,000 (11%) had records showing weight reductions of 10%-25% (mean, 13%) over at least 4 years. Weight loss was by intent rather than from illness. The remaining individuals maintained their weight within 5% of the first measurement for the duration of the study.

Participants with stable body weight were compared with the successful weight reducers. This analysis showed that the risk for type 2 diabetes, osteoarthritis, sleep apnea, hypertension, and dyslipidemia all measurably declined in weight reducers. This held true whether the patient’s baseline body mass index (BMI) showed modest or severe obesity. Patients with the highest BMI at enrollment actually reduced their risks for hypertension and dyslipidemia below population norms.

This study raises tantalizing, as yet unanswered questions: How did the successful 11% achieve their weight loss goals? Was it via a weight loss program, bariatric surgery, dietitian consult, or with no external assistance?

And of great significance to clinicians: What happened to the people who achieved 5%-10% weight reduction, as that is a more typical outcome of diabetes prevention trials or studies of weight-loss medications? Were they excluded from the study because they did not lose enough weight to achieve the unequivocal health benefit?

Because the data came from an enormous database, the weight management strategies leading to success or failure – what we really need to know to nudge our own patients into the favorable categories – remain hidden.
 

The Advantage of Intensive Interventions

Some answers emerged from a recently reported study in the New England Journal of Medicine comparing supervised diet and lifestyle adjustments (treatment group) with the less intense oversight typically offered by primary care clinicians (usual-care group).

The treatment group not only received the intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, but also participated in mandated training sessions on how to best use the resources provided by the study. Much of the care was delegated by physicians to “coaches” who focused on nutrition, exercise, and behavioral health, including supermarket strategy.

Nearly a quarter of the participants in the intensive intervention group achieved the 10% weight reduction needed to change health risk in a meaningful way. A similar proportion lost less than 10% of their body weight, and about half did not have a notable weight change. Peak weight loss at 6 months averaged 17 lb, and 9.6 lb at 2 years. While this may not seem very impressive considering the extensive resources utilized, there were those who experienced an extraordinary health upgrade not otherwise available, short of bariatric surgery.
 

What does this mean for us?

Both studies indicate that, even under the best-controlled, resource-replete circumstances, the rate of failure to achieve desired progress is very high. But there is a success rate.

The likelihood of success is difficult to interpret from the European data, as it compared only those with major weight loss and those with weight stability, excluding patients with less robust loss or weight gain. The controlled study, however, holds forth an alluring opportunity benefiting a quarter of the targeted participants and even about 5% of the controls who realized that they were being observed.

We also learn that supervision requires a lot more than having a well-meaning but not very well-trained physician ask a patient to log measurements and food intake. Health coaches seem to make the impact.

Failure rates of 50% have a way of dampening enthusiasm, but it may be best to approach the scourge of obesity by offering treatment to everyone with the expectation that not all will experience greatly enhanced quality of life and longevity. Not everyone will benefit, but these two studies confirm that we do have an underutilized capacity to help more people benefit than we currently do.

Richard M. Plotzker, MD, is a retired endocrinologist with 40 years of experience treating patients in both the private practice and hospital settings. He has been a Medscape contributor since 2012.

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

Every Wednesday evening after supper, I record in a marble notebook some anthropomorphic measurements: my weight taken first thing Monday morning and my waist circumference. I also add how I did with exercise since the previous week’s entry and some comments about sleep, energy, and nutrition.

My personal log now comprises dozens of pages. To my surprise, the first entry was 5 years ago to the month. The earlier entries were far from weekly and contained a lot of narrative on how my food-restriction scheme that month was being violated.

Looking just at the numbers, I did about as well as a control group participant in any medical study of diet modification. Until just a few months ago, there was no trend in either weight or waist circumference over those 5 years, including 2 years of retirement. But it wasn’t for lack of trying. Keeping the journal for as long as I have – and recently, as consistently as I have – suggests serious intent but inadequate execution of the same principles I offered patients, who rarely did much better. But recent studies suggest that perhaps quite a few could.
 

Are we underestimating our patients’ potential?

A recent abstract from the European and International Congress on Obesity suggests that the impressions clinicians get from our office encounters may leave us underestimating the potential for our patients to lose enough weight to move them from one level of risk to another.

Using a national database of primary care visits, the investigators isolated about 550,000 records. Of these, about 60,000 (11%) had records showing weight reductions of 10%-25% (mean, 13%) over at least 4 years. Weight loss was by intent rather than from illness. The remaining individuals maintained their weight within 5% of the first measurement for the duration of the study.

Participants with stable body weight were compared with the successful weight reducers. This analysis showed that the risk for type 2 diabetes, osteoarthritis, sleep apnea, hypertension, and dyslipidemia all measurably declined in weight reducers. This held true whether the patient’s baseline body mass index (BMI) showed modest or severe obesity. Patients with the highest BMI at enrollment actually reduced their risks for hypertension and dyslipidemia below population norms.

This study raises tantalizing, as yet unanswered questions: How did the successful 11% achieve their weight loss goals? Was it via a weight loss program, bariatric surgery, dietitian consult, or with no external assistance?

And of great significance to clinicians: What happened to the people who achieved 5%-10% weight reduction, as that is a more typical outcome of diabetes prevention trials or studies of weight-loss medications? Were they excluded from the study because they did not lose enough weight to achieve the unequivocal health benefit?

Because the data came from an enormous database, the weight management strategies leading to success or failure – what we really need to know to nudge our own patients into the favorable categories – remain hidden.
 

The Advantage of Intensive Interventions

Some answers emerged from a recently reported study in the New England Journal of Medicine comparing supervised diet and lifestyle adjustments (treatment group) with the less intense oversight typically offered by primary care clinicians (usual-care group).

The treatment group not only received the intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, but also participated in mandated training sessions on how to best use the resources provided by the study. Much of the care was delegated by physicians to “coaches” who focused on nutrition, exercise, and behavioral health, including supermarket strategy.

Nearly a quarter of the participants in the intensive intervention group achieved the 10% weight reduction needed to change health risk in a meaningful way. A similar proportion lost less than 10% of their body weight, and about half did not have a notable weight change. Peak weight loss at 6 months averaged 17 lb, and 9.6 lb at 2 years. While this may not seem very impressive considering the extensive resources utilized, there were those who experienced an extraordinary health upgrade not otherwise available, short of bariatric surgery.
 

What does this mean for us?

Both studies indicate that, even under the best-controlled, resource-replete circumstances, the rate of failure to achieve desired progress is very high. But there is a success rate.

The likelihood of success is difficult to interpret from the European data, as it compared only those with major weight loss and those with weight stability, excluding patients with less robust loss or weight gain. The controlled study, however, holds forth an alluring opportunity benefiting a quarter of the targeted participants and even about 5% of the controls who realized that they were being observed.

We also learn that supervision requires a lot more than having a well-meaning but not very well-trained physician ask a patient to log measurements and food intake. Health coaches seem to make the impact.

Failure rates of 50% have a way of dampening enthusiasm, but it may be best to approach the scourge of obesity by offering treatment to everyone with the expectation that not all will experience greatly enhanced quality of life and longevity. Not everyone will benefit, but these two studies confirm that we do have an underutilized capacity to help more people benefit than we currently do.

Richard M. Plotzker, MD, is a retired endocrinologist with 40 years of experience treating patients in both the private practice and hospital settings. He has been a Medscape contributor since 2012.

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

Every Wednesday evening after supper, I record in a marble notebook some anthropomorphic measurements: my weight taken first thing Monday morning and my waist circumference. I also add how I did with exercise since the previous week’s entry and some comments about sleep, energy, and nutrition.

My personal log now comprises dozens of pages. To my surprise, the first entry was 5 years ago to the month. The earlier entries were far from weekly and contained a lot of narrative on how my food-restriction scheme that month was being violated.

Looking just at the numbers, I did about as well as a control group participant in any medical study of diet modification. Until just a few months ago, there was no trend in either weight or waist circumference over those 5 years, including 2 years of retirement. But it wasn’t for lack of trying. Keeping the journal for as long as I have – and recently, as consistently as I have – suggests serious intent but inadequate execution of the same principles I offered patients, who rarely did much better. But recent studies suggest that perhaps quite a few could.
 

Are we underestimating our patients’ potential?

A recent abstract from the European and International Congress on Obesity suggests that the impressions clinicians get from our office encounters may leave us underestimating the potential for our patients to lose enough weight to move them from one level of risk to another.

Using a national database of primary care visits, the investigators isolated about 550,000 records. Of these, about 60,000 (11%) had records showing weight reductions of 10%-25% (mean, 13%) over at least 4 years. Weight loss was by intent rather than from illness. The remaining individuals maintained their weight within 5% of the first measurement for the duration of the study.

Participants with stable body weight were compared with the successful weight reducers. This analysis showed that the risk for type 2 diabetes, osteoarthritis, sleep apnea, hypertension, and dyslipidemia all measurably declined in weight reducers. This held true whether the patient’s baseline body mass index (BMI) showed modest or severe obesity. Patients with the highest BMI at enrollment actually reduced their risks for hypertension and dyslipidemia below population norms.

This study raises tantalizing, as yet unanswered questions: How did the successful 11% achieve their weight loss goals? Was it via a weight loss program, bariatric surgery, dietitian consult, or with no external assistance?

And of great significance to clinicians: What happened to the people who achieved 5%-10% weight reduction, as that is a more typical outcome of diabetes prevention trials or studies of weight-loss medications? Were they excluded from the study because they did not lose enough weight to achieve the unequivocal health benefit?

Because the data came from an enormous database, the weight management strategies leading to success or failure – what we really need to know to nudge our own patients into the favorable categories – remain hidden.
 

The Advantage of Intensive Interventions

Some answers emerged from a recently reported study in the New England Journal of Medicine comparing supervised diet and lifestyle adjustments (treatment group) with the less intense oversight typically offered by primary care clinicians (usual-care group).

The treatment group not only received the intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, but also participated in mandated training sessions on how to best use the resources provided by the study. Much of the care was delegated by physicians to “coaches” who focused on nutrition, exercise, and behavioral health, including supermarket strategy.

Nearly a quarter of the participants in the intensive intervention group achieved the 10% weight reduction needed to change health risk in a meaningful way. A similar proportion lost less than 10% of their body weight, and about half did not have a notable weight change. Peak weight loss at 6 months averaged 17 lb, and 9.6 lb at 2 years. While this may not seem very impressive considering the extensive resources utilized, there were those who experienced an extraordinary health upgrade not otherwise available, short of bariatric surgery.
 

What does this mean for us?

Both studies indicate that, even under the best-controlled, resource-replete circumstances, the rate of failure to achieve desired progress is very high. But there is a success rate.

The likelihood of success is difficult to interpret from the European data, as it compared only those with major weight loss and those with weight stability, excluding patients with less robust loss or weight gain. The controlled study, however, holds forth an alluring opportunity benefiting a quarter of the targeted participants and even about 5% of the controls who realized that they were being observed.

We also learn that supervision requires a lot more than having a well-meaning but not very well-trained physician ask a patient to log measurements and food intake. Health coaches seem to make the impact.

Failure rates of 50% have a way of dampening enthusiasm, but it may be best to approach the scourge of obesity by offering treatment to everyone with the expectation that not all will experience greatly enhanced quality of life and longevity. Not everyone will benefit, but these two studies confirm that we do have an underutilized capacity to help more people benefit than we currently do.

Richard M. Plotzker, MD, is a retired endocrinologist with 40 years of experience treating patients in both the private practice and hospital settings. He has been a Medscape contributor since 2012.

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

If you have been faithfully following the COVID-19 stay-at-home restrictive orders, you may have become a victim of “COVID-15,” the additional, unexpected, unwanted 10- to 15-pound weight gain that is making your clothes not fit so well any more.

dulezidar/Thinkstock

A change in routine; being home in comfy, stretchable clothing in front of the TV; and having unhealthy, processed foods ready to grab have set us up to lose the battle with COVID-15. We are set up to gain the weight because of excessive or unhealthful eating, taking an extra daily shot of alcohol, and being inactive, bored, depressed, anxious, and isolated from coworkers and family. Beware – weight gain can be “catching”; we tend to adopt the same poor eating habits and eat the same junk foods as those around us.

Since psychiatry can be a sedentary profession, I’ve (R.W.C.) kept myself very active and physically fit. Prior to the pandemic, I played tennis and ran every day. I was obese only once in my life. I had not realized that I had gained a lot of weight.

Thankfully, a physician called me “obese.” Initially, I was angry at the doctor, however, I realized that he did me the biggest favor of my life. I changed my diet and eating habits, and for the past 20 years, kept my weight between 135-140 pounds and my BMI at 23 consistently – until the pandemic stress caused me to fall into the same bad eating habits that have caused many others to gain the COVID-15.

I was surprised to see that when I weighed myself, and I had gained 12 pounds! I immediately modified my diet and increased my physical activity. I have now lost the extra 12 pounds and will offer suggestions that may help you and your patients exceed your prepandemic physical condition.
 

Possible solutions

1. Keep a food journal. Write down what you eat, the amount of food you eat, the time you are eating, and your mood at that moment. Keeping a small notebook to record what and when you eat is important because upon review, it will make you face reality and be accountable for what you put in your mouth. Until you review your journal, you may have underestimated the amount, as well as the kinds, of food and drinks you actually consume. A food journal can show your areas of struggle and unhealthy eating habits and help you make necessary changes in your habits and diet to eventually lose weight. You will be less likely to eat junk food or have an extra serving of food. If you do not want to use paper and pencil, you can download an app on your phone, such as myplate tracker to keep track of your food and calorie intake. Do your journaling immediately after you eat and include snacks; do not wait until night time to record your food and journal. Include your mood or how you felt during your meal or snack (for example, were you bored, sad, or anxious) since this information will indicate why you may be overeating.

2. Develop healthful eating habits. Eat a maximum of three meals and three snacks per day but eat only when you are hungry (that is, when your stomach growls or you feel light headed). Limiting yourself to eating only when you are hungry will help eliminate emotional eating to fill a loss in your life or to deal with feelings of stress, anxiety, sadness, or isolation, which have been exacerbated by the pandemic. Buy eat only healthful foods and not items with empty calories, such as chips, cake, and items with sugar. When you are eating, devote yourself to that activity only, eat slowly, and savor each bite. Do not watch television during your meal time.

3. Record the amount and type of exercise you engage in each day and determine the number of calories burned. Walk, run, or bicycle outside, or exercise inside with stretching, weights, or an exercycle. You may use a website, such as diet tool on WebMD.com to calculate daily calories burned. To lose weight, calories burned during a day must exceed caloric intake. You may want to invest in a Fitbit or an Apple Watch and use the health section to determine your caloric intake versus output. Analyzing your caloric data will provide a concrete measure of your progress.

4. Do not overconsume calories or underconsume protein. Protein plays a key role in the creation and maintenance of every cell of your body, and because the body does not store protein, it is important to consume it every day. To meet basic protein requirements, the DRI (Dietary Reference Intake) recommends 0.36 grams of protein per pound (0.8 grams per kg) of body weight. This amounts to: 56 grams per day for the average sedentary man, and 46 grams per day for the average sedentary woman. There is also an app entitled the Protein Tracker that can simplify your calculations.

5. Drink water. It is important to be hydrated to regulate body temperature, keep joints lubricated, prevent infections, deliver nutrients to cells, and keep organs functioning properly. Being well hydrated also improves sleep, cognition, and mood. Your daily water intake by ounce should be equal to your weight in pounds multiplied by two-thirds (or 67%) to determine the amount of water to drink daily. For example, if you weigh 175 pounds, you would multiply 175 by two-thirds and learn that you should be drinking about 117 ounces of water every day. You can also meet some of your daily water requirements by consuming fruits and vegetables, such as tomatoes, watermelon, lettuce, etc.

Also, drink 2 cups (16 oz.) of water before every meal: Often when you feel hungry, it is because your body simply needs water. Science has proven that drinking 2 cups of water before every meal helps you to eat less during meal time and lose weight. If you do this three times daily – at breakfast, lunch, and dinner – you have already consumed 48 ounces of water.
 

6. Keep track of your progress. In addition to keeping and analyzing your food journal, weigh yourself once or twice a week. Do not weigh yourself every day; you will not see any results on a day-to-day basis, but once a week gives your body time to regulate and show progress. Always calibrate/zero your scale before each use, and weigh yourself at the same time of the day (preferably after you first wake up in the morning) while wearing the same type of clothing. Keep a record of your weight in your journal to track your progress. Do not panic if the scale indicates you gained 1, 2, or 3 pounds, your weight can fluctuate because of glycogen storage, sodium retention, human bias, reporting or recall errors, and home scales can have a plus or minus 3 pound margin of error. Look at your weight trend over time. You may prefer buying a scale that indicates both weight and body mass index.

7. Celebrate and reward yourself with nonfood items. A healthful fitness and diet regime requires energy and dedication, so if you are able to follow a healthful routine, reward yourself with nonfood rewards for your good choices and new habits as an incentive to maintain your healthful behavior.

8. Don’t buy it if you can’t stop eating it. The biggest decision you make is when you decide what you are going to buy. Don’t lie to yourself in the store that you will only eat one at a time. Only buy what you can afford to binge eat if you can’t stop yourself from eating any particular type of food.

9. Have someone hide the food you can’t resist. You can’t eat what you can’t find. If you can’t avoid having irresistible food around, ask another adult to hide the food from you.

10. Learn what harm foods can cause in your body. Read about the effects of high blood sugar and high blood pressure can cause in your body. Find out which foods boost your immune system. Demonize the bad foods in your mind. Make up your mind before you go into the store that you are going to read food labels and find the best quality food with the lowest amount of sugar or saturated fat. Appreciate the flavor of vegetables and fruit. Gaining weight will suppress your immune system and make you more susceptible to COVID-19.

11. Treat sugar as if it were an addictive drug. You can’t have just one. If you reduce your craving for sugar by slowly reducing your intake of sugar, you will find that you don’t crave sugar any more. This won’t be easy, but once it is done, you will be preventing many of the ravages that sugar takes on your body over time. But you can’t have one piece of pie because the craving will come back. At some point, it may be more likely that you find that piece of pie too sweet.

Here are a few other ideas: Buy a gift for yourself or new clothes, makeup, a plant or flowers, running shoes, exercise clothes, fitness tracker, water bottle, book, movie or network subscription. Improve your home décor. Or treat yourself to online lessons for painting, music, and so on. Or you might adopt a dog, donate food to a shelter or food bank; or organize and declutter your home since staying busy will give you a reason not to eat. In nice weather, enjoy the outdoors by going for a walk, run, bikeride or by gardening.

We are all worried about getting COVID-19. Preventing COVID-15 will go a long way toward boosting our immune systems to help protect us from the coronavirus.
 

Dr. Cohen is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.

If you have been faithfully following the COVID-19 stay-at-home restrictive orders, you may have become a victim of “COVID-15,” the additional, unexpected, unwanted 10- to 15-pound weight gain that is making your clothes not fit so well any more.

dulezidar/Thinkstock

A change in routine; being home in comfy, stretchable clothing in front of the TV; and having unhealthy, processed foods ready to grab have set us up to lose the battle with COVID-15. We are set up to gain the weight because of excessive or unhealthful eating, taking an extra daily shot of alcohol, and being inactive, bored, depressed, anxious, and isolated from coworkers and family. Beware – weight gain can be “catching”; we tend to adopt the same poor eating habits and eat the same junk foods as those around us.

Since psychiatry can be a sedentary profession, I’ve (R.W.C.) kept myself very active and physically fit. Prior to the pandemic, I played tennis and ran every day. I was obese only once in my life. I had not realized that I had gained a lot of weight.

Thankfully, a physician called me “obese.” Initially, I was angry at the doctor, however, I realized that he did me the biggest favor of my life. I changed my diet and eating habits, and for the past 20 years, kept my weight between 135-140 pounds and my BMI at 23 consistently – until the pandemic stress caused me to fall into the same bad eating habits that have caused many others to gain the COVID-15.

I was surprised to see that when I weighed myself, and I had gained 12 pounds! I immediately modified my diet and increased my physical activity. I have now lost the extra 12 pounds and will offer suggestions that may help you and your patients exceed your prepandemic physical condition.
 

Possible solutions

1. Keep a food journal. Write down what you eat, the amount of food you eat, the time you are eating, and your mood at that moment. Keeping a small notebook to record what and when you eat is important because upon review, it will make you face reality and be accountable for what you put in your mouth. Until you review your journal, you may have underestimated the amount, as well as the kinds, of food and drinks you actually consume. A food journal can show your areas of struggle and unhealthy eating habits and help you make necessary changes in your habits and diet to eventually lose weight. You will be less likely to eat junk food or have an extra serving of food. If you do not want to use paper and pencil, you can download an app on your phone, such as myplate tracker to keep track of your food and calorie intake. Do your journaling immediately after you eat and include snacks; do not wait until night time to record your food and journal. Include your mood or how you felt during your meal or snack (for example, were you bored, sad, or anxious) since this information will indicate why you may be overeating.

2. Develop healthful eating habits. Eat a maximum of three meals and three snacks per day but eat only when you are hungry (that is, when your stomach growls or you feel light headed). Limiting yourself to eating only when you are hungry will help eliminate emotional eating to fill a loss in your life or to deal with feelings of stress, anxiety, sadness, or isolation, which have been exacerbated by the pandemic. Buy eat only healthful foods and not items with empty calories, such as chips, cake, and items with sugar. When you are eating, devote yourself to that activity only, eat slowly, and savor each bite. Do not watch television during your meal time.

3. Record the amount and type of exercise you engage in each day and determine the number of calories burned. Walk, run, or bicycle outside, or exercise inside with stretching, weights, or an exercycle. You may use a website, such as diet tool on WebMD.com to calculate daily calories burned. To lose weight, calories burned during a day must exceed caloric intake. You may want to invest in a Fitbit or an Apple Watch and use the health section to determine your caloric intake versus output. Analyzing your caloric data will provide a concrete measure of your progress.

4. Do not overconsume calories or underconsume protein. Protein plays a key role in the creation and maintenance of every cell of your body, and because the body does not store protein, it is important to consume it every day. To meet basic protein requirements, the DRI (Dietary Reference Intake) recommends 0.36 grams of protein per pound (0.8 grams per kg) of body weight. This amounts to: 56 grams per day for the average sedentary man, and 46 grams per day for the average sedentary woman. There is also an app entitled the Protein Tracker that can simplify your calculations.

5. Drink water. It is important to be hydrated to regulate body temperature, keep joints lubricated, prevent infections, deliver nutrients to cells, and keep organs functioning properly. Being well hydrated also improves sleep, cognition, and mood. Your daily water intake by ounce should be equal to your weight in pounds multiplied by two-thirds (or 67%) to determine the amount of water to drink daily. For example, if you weigh 175 pounds, you would multiply 175 by two-thirds and learn that you should be drinking about 117 ounces of water every day. You can also meet some of your daily water requirements by consuming fruits and vegetables, such as tomatoes, watermelon, lettuce, etc.

Also, drink 2 cups (16 oz.) of water before every meal: Often when you feel hungry, it is because your body simply needs water. Science has proven that drinking 2 cups of water before every meal helps you to eat less during meal time and lose weight. If you do this three times daily – at breakfast, lunch, and dinner – you have already consumed 48 ounces of water.
 

6. Keep track of your progress. In addition to keeping and analyzing your food journal, weigh yourself once or twice a week. Do not weigh yourself every day; you will not see any results on a day-to-day basis, but once a week gives your body time to regulate and show progress. Always calibrate/zero your scale before each use, and weigh yourself at the same time of the day (preferably after you first wake up in the morning) while wearing the same type of clothing. Keep a record of your weight in your journal to track your progress. Do not panic if the scale indicates you gained 1, 2, or 3 pounds, your weight can fluctuate because of glycogen storage, sodium retention, human bias, reporting or recall errors, and home scales can have a plus or minus 3 pound margin of error. Look at your weight trend over time. You may prefer buying a scale that indicates both weight and body mass index.

7. Celebrate and reward yourself with nonfood items. A healthful fitness and diet regime requires energy and dedication, so if you are able to follow a healthful routine, reward yourself with nonfood rewards for your good choices and new habits as an incentive to maintain your healthful behavior.

8. Don’t buy it if you can’t stop eating it. The biggest decision you make is when you decide what you are going to buy. Don’t lie to yourself in the store that you will only eat one at a time. Only buy what you can afford to binge eat if you can’t stop yourself from eating any particular type of food.

9. Have someone hide the food you can’t resist. You can’t eat what you can’t find. If you can’t avoid having irresistible food around, ask another adult to hide the food from you.

10. Learn what harm foods can cause in your body. Read about the effects of high blood sugar and high blood pressure can cause in your body. Find out which foods boost your immune system. Demonize the bad foods in your mind. Make up your mind before you go into the store that you are going to read food labels and find the best quality food with the lowest amount of sugar or saturated fat. Appreciate the flavor of vegetables and fruit. Gaining weight will suppress your immune system and make you more susceptible to COVID-19.

11. Treat sugar as if it were an addictive drug. You can’t have just one. If you reduce your craving for sugar by slowly reducing your intake of sugar, you will find that you don’t crave sugar any more. This won’t be easy, but once it is done, you will be preventing many of the ravages that sugar takes on your body over time. But you can’t have one piece of pie because the craving will come back. At some point, it may be more likely that you find that piece of pie too sweet.

Here are a few other ideas: Buy a gift for yourself or new clothes, makeup, a plant or flowers, running shoes, exercise clothes, fitness tracker, water bottle, book, movie or network subscription. Improve your home décor. Or treat yourself to online lessons for painting, music, and so on. Or you might adopt a dog, donate food to a shelter or food bank; or organize and declutter your home since staying busy will give you a reason not to eat. In nice weather, enjoy the outdoors by going for a walk, run, bikeride or by gardening.

We are all worried about getting COVID-19. Preventing COVID-15 will go a long way toward boosting our immune systems to help protect us from the coronavirus.
 

Dr. Cohen is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.

If you have been faithfully following the COVID-19 stay-at-home restrictive orders, you may have become a victim of “COVID-15,” the additional, unexpected, unwanted 10- to 15-pound weight gain that is making your clothes not fit so well any more.

dulezidar/Thinkstock

A change in routine; being home in comfy, stretchable clothing in front of the TV; and having unhealthy, processed foods ready to grab have set us up to lose the battle with COVID-15. We are set up to gain the weight because of excessive or unhealthful eating, taking an extra daily shot of alcohol, and being inactive, bored, depressed, anxious, and isolated from coworkers and family. Beware – weight gain can be “catching”; we tend to adopt the same poor eating habits and eat the same junk foods as those around us.

Since psychiatry can be a sedentary profession, I’ve (R.W.C.) kept myself very active and physically fit. Prior to the pandemic, I played tennis and ran every day. I was obese only once in my life. I had not realized that I had gained a lot of weight.

Thankfully, a physician called me “obese.” Initially, I was angry at the doctor, however, I realized that he did me the biggest favor of my life. I changed my diet and eating habits, and for the past 20 years, kept my weight between 135-140 pounds and my BMI at 23 consistently – until the pandemic stress caused me to fall into the same bad eating habits that have caused many others to gain the COVID-15.

I was surprised to see that when I weighed myself, and I had gained 12 pounds! I immediately modified my diet and increased my physical activity. I have now lost the extra 12 pounds and will offer suggestions that may help you and your patients exceed your prepandemic physical condition.
 

Possible solutions

1. Keep a food journal. Write down what you eat, the amount of food you eat, the time you are eating, and your mood at that moment. Keeping a small notebook to record what and when you eat is important because upon review, it will make you face reality and be accountable for what you put in your mouth. Until you review your journal, you may have underestimated the amount, as well as the kinds, of food and drinks you actually consume. A food journal can show your areas of struggle and unhealthy eating habits and help you make necessary changes in your habits and diet to eventually lose weight. You will be less likely to eat junk food or have an extra serving of food. If you do not want to use paper and pencil, you can download an app on your phone, such as myplate tracker to keep track of your food and calorie intake. Do your journaling immediately after you eat and include snacks; do not wait until night time to record your food and journal. Include your mood or how you felt during your meal or snack (for example, were you bored, sad, or anxious) since this information will indicate why you may be overeating.

2. Develop healthful eating habits. Eat a maximum of three meals and three snacks per day but eat only when you are hungry (that is, when your stomach growls or you feel light headed). Limiting yourself to eating only when you are hungry will help eliminate emotional eating to fill a loss in your life or to deal with feelings of stress, anxiety, sadness, or isolation, which have been exacerbated by the pandemic. Buy eat only healthful foods and not items with empty calories, such as chips, cake, and items with sugar. When you are eating, devote yourself to that activity only, eat slowly, and savor each bite. Do not watch television during your meal time.

3. Record the amount and type of exercise you engage in each day and determine the number of calories burned. Walk, run, or bicycle outside, or exercise inside with stretching, weights, or an exercycle. You may use a website, such as diet tool on WebMD.com to calculate daily calories burned. To lose weight, calories burned during a day must exceed caloric intake. You may want to invest in a Fitbit or an Apple Watch and use the health section to determine your caloric intake versus output. Analyzing your caloric data will provide a concrete measure of your progress.

4. Do not overconsume calories or underconsume protein. Protein plays a key role in the creation and maintenance of every cell of your body, and because the body does not store protein, it is important to consume it every day. To meet basic protein requirements, the DRI (Dietary Reference Intake) recommends 0.36 grams of protein per pound (0.8 grams per kg) of body weight. This amounts to: 56 grams per day for the average sedentary man, and 46 grams per day for the average sedentary woman. There is also an app entitled the Protein Tracker that can simplify your calculations.

5. Drink water. It is important to be hydrated to regulate body temperature, keep joints lubricated, prevent infections, deliver nutrients to cells, and keep organs functioning properly. Being well hydrated also improves sleep, cognition, and mood. Your daily water intake by ounce should be equal to your weight in pounds multiplied by two-thirds (or 67%) to determine the amount of water to drink daily. For example, if you weigh 175 pounds, you would multiply 175 by two-thirds and learn that you should be drinking about 117 ounces of water every day. You can also meet some of your daily water requirements by consuming fruits and vegetables, such as tomatoes, watermelon, lettuce, etc.

Also, drink 2 cups (16 oz.) of water before every meal: Often when you feel hungry, it is because your body simply needs water. Science has proven that drinking 2 cups of water before every meal helps you to eat less during meal time and lose weight. If you do this three times daily – at breakfast, lunch, and dinner – you have already consumed 48 ounces of water.
 

6. Keep track of your progress. In addition to keeping and analyzing your food journal, weigh yourself once or twice a week. Do not weigh yourself every day; you will not see any results on a day-to-day basis, but once a week gives your body time to regulate and show progress. Always calibrate/zero your scale before each use, and weigh yourself at the same time of the day (preferably after you first wake up in the morning) while wearing the same type of clothing. Keep a record of your weight in your journal to track your progress. Do not panic if the scale indicates you gained 1, 2, or 3 pounds, your weight can fluctuate because of glycogen storage, sodium retention, human bias, reporting or recall errors, and home scales can have a plus or minus 3 pound margin of error. Look at your weight trend over time. You may prefer buying a scale that indicates both weight and body mass index.

7. Celebrate and reward yourself with nonfood items. A healthful fitness and diet regime requires energy and dedication, so if you are able to follow a healthful routine, reward yourself with nonfood rewards for your good choices and new habits as an incentive to maintain your healthful behavior.

8. Don’t buy it if you can’t stop eating it. The biggest decision you make is when you decide what you are going to buy. Don’t lie to yourself in the store that you will only eat one at a time. Only buy what you can afford to binge eat if you can’t stop yourself from eating any particular type of food.

9. Have someone hide the food you can’t resist. You can’t eat what you can’t find. If you can’t avoid having irresistible food around, ask another adult to hide the food from you.

10. Learn what harm foods can cause in your body. Read about the effects of high blood sugar and high blood pressure can cause in your body. Find out which foods boost your immune system. Demonize the bad foods in your mind. Make up your mind before you go into the store that you are going to read food labels and find the best quality food with the lowest amount of sugar or saturated fat. Appreciate the flavor of vegetables and fruit. Gaining weight will suppress your immune system and make you more susceptible to COVID-19.

11. Treat sugar as if it were an addictive drug. You can’t have just one. If you reduce your craving for sugar by slowly reducing your intake of sugar, you will find that you don’t crave sugar any more. This won’t be easy, but once it is done, you will be preventing many of the ravages that sugar takes on your body over time. But you can’t have one piece of pie because the craving will come back. At some point, it may be more likely that you find that piece of pie too sweet.

Here are a few other ideas: Buy a gift for yourself or new clothes, makeup, a plant or flowers, running shoes, exercise clothes, fitness tracker, water bottle, book, movie or network subscription. Improve your home décor. Or treat yourself to online lessons for painting, music, and so on. Or you might adopt a dog, donate food to a shelter or food bank; or organize and declutter your home since staying busy will give you a reason not to eat. In nice weather, enjoy the outdoors by going for a walk, run, bikeride or by gardening.

We are all worried about getting COVID-19. Preventing COVID-15 will go a long way toward boosting our immune systems to help protect us from the coronavirus.
 

Dr. Cohen is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.

When I graduated from residency in 2007, Facebook had just become “a thing,” and my cohort decided to use it to keep in touch. These days, Twitter seems to be the social media platform of choice for health care professionals.

KatarzynaBialasiewicz/Thinkstock

When I started on Twitter a few years ago, it was in reaction to the current political climate. I wanted to keep track of what my favorite thinkers were writing. I was anonymous and tweeted about politics mostly. My husband was my only follower for a while.

I deanonymized when, at last year’s American College of Rheumatology meeting, I presented a poster and wanted to reach a wider audience. I could have created two different personas on Twitter, like many doctors apparently do. Initially, I resisted doing that because I am frankly too lazy to keep track of two different social media profiles, but now I resist because I see my profession as an extension of my political self, and have no problem with using my (very low) profile to amplify both my doctor voice and my human voice.

Professionally, Twitter is rewarding. It is a space for networking and for promoting one’s work. It is a fantastic learning format, as evidenced by the popularity of tweetorials. The international consortium that has worked to collect information on rheumatology patients with COVID started as an idea on Twitter. The fact that ACR Convergence 2020 abstracts are now available? I only know because of the #ACRambassadors that I follow.

But I find that I cannot separate who I am from what I do. As a rheumatologist, I build long-term relationships with patients. I cannot care for their medical conditions in isolation without also concerning myself with their nonmedical circumstances. For that reason, I have opinions that one might call humanist, and I suspect that I am not alone among rheumatologists.

I can think of three areas, broadly construed but with huge overlaps, that concern me a great deal.

First, there are things that affect all physicians: race and gender discrimination in the workplace; advancement of women in science, technology, engineering, or math; Medicare reimbursement; COVID-19 preparedness; immigration issues (an issue near and dear to me, as I am an immigrant and a foreign medical graduate); and federal funding (including funding for training programs and community health centers, funding for the National Institutes of Health, and funding for stem cell research).

Then there are the things that affect rheumatologists in particular. Access to medications and procedures is one thing. (I did say these categories hugely overlap.) If you›ve ever tried to prescribe even a drug as old as oral cyclophosphamide, you’ll have experienced the difficulty of getting it for Medicare patients. Patients who need biologics are limited by insurance contracts with pharmaceutical companies, but also by requirements such as step therapy. I am all varieties of annoyed, incredulous, and apologetic that when a patient asks me how much a treatment will cost him/her, I do not have an answer.

Speaking of pricing, don’t even get me started on pharmaceutical company price gouging. Yes, the H.P. Acthar gel may be the most egregious offender among rheumatology medications, but it’s easy to not prescribe a drug that costs $80,000 a vial and which does not do much more than prednisone does. On the other hand, I remember a time when colchicine cost $0.10 cents a pill and patients did not have to jump through hoops to get it.

And what of reproductive freedom? Our patients rely on us for advice about their childbearing options, including birth control, in vitro fertilization, and pregnancy termination.

Finally, and most important, the things that affect me most are the issues that affect patients. The lowest-hanging fruit here is the abject incompetence of the federal response to the ongoing pandemic. How many of our patients’ lives have been lost or adversely affected? And what of coverage for preexisting conditions for the vast majority of our patients, whose illnesses are chronic?

While we’re at it, the fact of health insurance being tied to employment, something that seemingly no other country in the developed world does, makes living with chronic conditions outright scary, doesn’t it? It isn’t quite so easy to remain employed when one cannot get the right medications for RA.

I could go on. Gun violence and health care disparities, vaccine denialism, coverage for mental health issues, LGBTQ rights, refugee rights, police brutality … there is a seemingly endless list of things to care about. It’s exhausting.

While I do use my Twitter account to learn from colleagues and to promote work that interests me, my primary aim is to participate in civil society as a person. Critics will use “stay in your lane” as shorthand to say x professionals should stick to x (actors to acting, musicians to music, athletes to sports). If only I could. But my humanity won’t let me. Aristotle said man is a political animal; even the venerable New England Journal of Medicine has found it impossible to keep silent.

Karmela Kim Chan, MD, is an assistant professor at Weill Cornell Medicine, New York, and an attending physician at the Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center, both in New York. Before moving to New York City, she spent 7 years in private practice in Rhode Island and was a past columnist for MDedge Rheumatology, writing about the challenges of starting life as a full-fledged rheumatologist in a private practice.
 

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

When I graduated from residency in 2007, Facebook had just become “a thing,” and my cohort decided to use it to keep in touch. These days, Twitter seems to be the social media platform of choice for health care professionals.

KatarzynaBialasiewicz/Thinkstock

When I started on Twitter a few years ago, it was in reaction to the current political climate. I wanted to keep track of what my favorite thinkers were writing. I was anonymous and tweeted about politics mostly. My husband was my only follower for a while.

I deanonymized when, at last year’s American College of Rheumatology meeting, I presented a poster and wanted to reach a wider audience. I could have created two different personas on Twitter, like many doctors apparently do. Initially, I resisted doing that because I am frankly too lazy to keep track of two different social media profiles, but now I resist because I see my profession as an extension of my political self, and have no problem with using my (very low) profile to amplify both my doctor voice and my human voice.

Professionally, Twitter is rewarding. It is a space for networking and for promoting one’s work. It is a fantastic learning format, as evidenced by the popularity of tweetorials. The international consortium that has worked to collect information on rheumatology patients with COVID started as an idea on Twitter. The fact that ACR Convergence 2020 abstracts are now available? I only know because of the #ACRambassadors that I follow.

But I find that I cannot separate who I am from what I do. As a rheumatologist, I build long-term relationships with patients. I cannot care for their medical conditions in isolation without also concerning myself with their nonmedical circumstances. For that reason, I have opinions that one might call humanist, and I suspect that I am not alone among rheumatologists.

I can think of three areas, broadly construed but with huge overlaps, that concern me a great deal.

First, there are things that affect all physicians: race and gender discrimination in the workplace; advancement of women in science, technology, engineering, or math; Medicare reimbursement; COVID-19 preparedness; immigration issues (an issue near and dear to me, as I am an immigrant and a foreign medical graduate); and federal funding (including funding for training programs and community health centers, funding for the National Institutes of Health, and funding for stem cell research).

Then there are the things that affect rheumatologists in particular. Access to medications and procedures is one thing. (I did say these categories hugely overlap.) If you›ve ever tried to prescribe even a drug as old as oral cyclophosphamide, you’ll have experienced the difficulty of getting it for Medicare patients. Patients who need biologics are limited by insurance contracts with pharmaceutical companies, but also by requirements such as step therapy. I am all varieties of annoyed, incredulous, and apologetic that when a patient asks me how much a treatment will cost him/her, I do not have an answer.

Speaking of pricing, don’t even get me started on pharmaceutical company price gouging. Yes, the H.P. Acthar gel may be the most egregious offender among rheumatology medications, but it’s easy to not prescribe a drug that costs $80,000 a vial and which does not do much more than prednisone does. On the other hand, I remember a time when colchicine cost $0.10 cents a pill and patients did not have to jump through hoops to get it.

And what of reproductive freedom? Our patients rely on us for advice about their childbearing options, including birth control, in vitro fertilization, and pregnancy termination.

Finally, and most important, the things that affect me most are the issues that affect patients. The lowest-hanging fruit here is the abject incompetence of the federal response to the ongoing pandemic. How many of our patients’ lives have been lost or adversely affected? And what of coverage for preexisting conditions for the vast majority of our patients, whose illnesses are chronic?

While we’re at it, the fact of health insurance being tied to employment, something that seemingly no other country in the developed world does, makes living with chronic conditions outright scary, doesn’t it? It isn’t quite so easy to remain employed when one cannot get the right medications for RA.

I could go on. Gun violence and health care disparities, vaccine denialism, coverage for mental health issues, LGBTQ rights, refugee rights, police brutality … there is a seemingly endless list of things to care about. It’s exhausting.

While I do use my Twitter account to learn from colleagues and to promote work that interests me, my primary aim is to participate in civil society as a person. Critics will use “stay in your lane” as shorthand to say x professionals should stick to x (actors to acting, musicians to music, athletes to sports). If only I could. But my humanity won’t let me. Aristotle said man is a political animal; even the venerable New England Journal of Medicine has found it impossible to keep silent.

Karmela Kim Chan, MD, is an assistant professor at Weill Cornell Medicine, New York, and an attending physician at the Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center, both in New York. Before moving to New York City, she spent 7 years in private practice in Rhode Island and was a past columnist for MDedge Rheumatology, writing about the challenges of starting life as a full-fledged rheumatologist in a private practice.
 

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

When I graduated from residency in 2007, Facebook had just become “a thing,” and my cohort decided to use it to keep in touch. These days, Twitter seems to be the social media platform of choice for health care professionals.

KatarzynaBialasiewicz/Thinkstock

When I started on Twitter a few years ago, it was in reaction to the current political climate. I wanted to keep track of what my favorite thinkers were writing. I was anonymous and tweeted about politics mostly. My husband was my only follower for a while.

I deanonymized when, at last year’s American College of Rheumatology meeting, I presented a poster and wanted to reach a wider audience. I could have created two different personas on Twitter, like many doctors apparently do. Initially, I resisted doing that because I am frankly too lazy to keep track of two different social media profiles, but now I resist because I see my profession as an extension of my political self, and have no problem with using my (very low) profile to amplify both my doctor voice and my human voice.

Professionally, Twitter is rewarding. It is a space for networking and for promoting one’s work. It is a fantastic learning format, as evidenced by the popularity of tweetorials. The international consortium that has worked to collect information on rheumatology patients with COVID started as an idea on Twitter. The fact that ACR Convergence 2020 abstracts are now available? I only know because of the #ACRambassadors that I follow.

But I find that I cannot separate who I am from what I do. As a rheumatologist, I build long-term relationships with patients. I cannot care for their medical conditions in isolation without also concerning myself with their nonmedical circumstances. For that reason, I have opinions that one might call humanist, and I suspect that I am not alone among rheumatologists.

I can think of three areas, broadly construed but with huge overlaps, that concern me a great deal.

First, there are things that affect all physicians: race and gender discrimination in the workplace; advancement of women in science, technology, engineering, or math; Medicare reimbursement; COVID-19 preparedness; immigration issues (an issue near and dear to me, as I am an immigrant and a foreign medical graduate); and federal funding (including funding for training programs and community health centers, funding for the National Institutes of Health, and funding for stem cell research).

Then there are the things that affect rheumatologists in particular. Access to medications and procedures is one thing. (I did say these categories hugely overlap.) If you›ve ever tried to prescribe even a drug as old as oral cyclophosphamide, you’ll have experienced the difficulty of getting it for Medicare patients. Patients who need biologics are limited by insurance contracts with pharmaceutical companies, but also by requirements such as step therapy. I am all varieties of annoyed, incredulous, and apologetic that when a patient asks me how much a treatment will cost him/her, I do not have an answer.

Speaking of pricing, don’t even get me started on pharmaceutical company price gouging. Yes, the H.P. Acthar gel may be the most egregious offender among rheumatology medications, but it’s easy to not prescribe a drug that costs $80,000 a vial and which does not do much more than prednisone does. On the other hand, I remember a time when colchicine cost $0.10 cents a pill and patients did not have to jump through hoops to get it.

And what of reproductive freedom? Our patients rely on us for advice about their childbearing options, including birth control, in vitro fertilization, and pregnancy termination.

Finally, and most important, the things that affect me most are the issues that affect patients. The lowest-hanging fruit here is the abject incompetence of the federal response to the ongoing pandemic. How many of our patients’ lives have been lost or adversely affected? And what of coverage for preexisting conditions for the vast majority of our patients, whose illnesses are chronic?

While we’re at it, the fact of health insurance being tied to employment, something that seemingly no other country in the developed world does, makes living with chronic conditions outright scary, doesn’t it? It isn’t quite so easy to remain employed when one cannot get the right medications for RA.

I could go on. Gun violence and health care disparities, vaccine denialism, coverage for mental health issues, LGBTQ rights, refugee rights, police brutality … there is a seemingly endless list of things to care about. It’s exhausting.

While I do use my Twitter account to learn from colleagues and to promote work that interests me, my primary aim is to participate in civil society as a person. Critics will use “stay in your lane” as shorthand to say x professionals should stick to x (actors to acting, musicians to music, athletes to sports). If only I could. But my humanity won’t let me. Aristotle said man is a political animal; even the venerable New England Journal of Medicine has found it impossible to keep silent.

Karmela Kim Chan, MD, is an assistant professor at Weill Cornell Medicine, New York, and an attending physician at the Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center, both in New York. Before moving to New York City, she spent 7 years in private practice in Rhode Island and was a past columnist for MDedge Rheumatology, writing about the challenges of starting life as a full-fledged rheumatologist in a private practice.
 

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

An intriguing pattern has emerged for cannabis enthusiasts as a result of lockdowns and statewide safety restrictions for COVID-19.

Consumers, as of late, have been shopping for larger marijuana baskets per trip to the dispensaries in various states, including California, Colorado, Nevada, and Washington, . However, they are also cutting down on the number of trips, perhaps, as a preventive measure to reduce the risk of exposure to coronavirus during this pandemic. Sales dipped considerably by the end of March only to experience a resurgence after the issuing of stimulus checks and unemployment benefits.

For the past few years, cannabis consumption remained steady while the industry continued to thrive with robust sales of the drug. It is a recession-proof phenomenon, therefore presenting a unique opportunity for clinicians with respect to patient education and individualized care.¹

An unfortunate carryover of the governmental restrictions, self-isolation, and social estrangement is that consumers are now turning to the dark web as a source for continuous supply of cannabis. Prepandemic, according to the U.N. 2020 World Drug Report, there was already a 30% increase in sales of cannabis between 2009 and 2018. COVID-19 has fractured the drug’s supply chain and created an inescapable void that is being filled by drug traffickers.² A clinical dilemma is posed when a user procures counterfeit cannabis or a drug batch with impurities.
 

Riding the cytokine storm

Cytokines are a host of proteins with designated regulatory and immune responses that play an instrumental role in cell signaling. The aptly named “cytokine storm” conjures up the image of an imperiled immune system spiraling out of control; it is, in fact, an extreme immune response that culminates into a massive influx of cytokines released into the bloodstream. Without the presence of an immunologic threat, cytokines are responsible for maintaining homeostasis and the functionality of immune cells. However, acute cytokine release (i.e., cytokine storm), as is the case with severe COVID-19, jeopardizes organ function (for example, interstitial lung disease) with clinical symptoms, such as fever, cough, dyspnea, and myalgia.

Benefits and drawbacks of immunosuppressive agents

To inhibit cytokine release (e.g., interleukin-6 cytokine levels), immunosuppressive agents such as tocilizumab have been leveraged to damper the body’s overactive inflammatory response to perceived immunologic stressors, in particular, COVID-19. While the aforementioned agent was remarkably effective with respect to lung consolidation clearance in most of the patients tested, a host of untoward effects prevent its general applicability and use. However, a team of researchers from the University of Nebraska, Omaha, with the Texas Biomedical Research Institute, San Antonio, might have stumbled upon a strategic workaround for mitigating the immune response.

They have proposed that cannabidiol (CBD) be used in lieu of other agents with potentially toxic effects. Animal and human trials have established that CBD confers a relatively high margin of safety coupled with favorable tolerance, providing a viable option for effectively targeting the inflammatory processes of SARS-CoV-2–based pulmonary disease. Furthermore, efficacy increased when CBD was combined with a terpene formulation, especially with respect to the more traditional steroid therapy.³

SARS-CoV-2 exhibits binding affinity for the ACE2 receptor, which is expressed in the lungs as well as other known predilection sites of infection. Ongoing studies attempt to modulate ACE2 expression, thereby eliminating its conspicuous role as “viral gateways,” perhaps even more so in patients with lung pathologies (e.g., people with chronic obstructive pulmonary disease [COPD] and smokers) as they already are prone to increased respiratory morbidity. CBD lacks tetrahydrocannabinol (THC), or the psychoactive component of cannabis sativa, rendering the agent to be particularly attractive from a therapeutic perspective. In addition to being devoid of abuse potential, CBD exhibits remarkable anti-inflammatory properties. It should be noted that considerable overlap exists between tobacco and cannabis users, and it is too early to determine the impact on COVID-19. As opposed to cannabis’s effect on ACE2 levels, smoking exhibits a proinflammatory role by up-regulating ACE2 expression.3 However, there are currently numerous conflicting reports in circulation about the positive effect of nicotine on COVID-19 outcome; confounding variables will need to be explored further in patients with a history of using nicotine and cannabis together.

From an immunologic perspective, the endocannabinoid system (ECS) plays an integral role in cell signaling by interacting with natural chemicals of the body, namely, cannabinoids with designated targets at the cannabinoid receptor 1 (CB1) and the CB2, respectively. The CB2 receptor is of particular interest as it is intimately involved in immune homeostasis; the primary goal of these COVID-19 studies is to modulate the endocannabinoid system via targeted CB2 therapies to produce an immunosuppressant effect.⁴ CB2 activation, be it by means of THC or CBD agonism, may prove to be beneficial by inhibiting the cytokine influx.

Unfortunately, there is a general dearth of data on COVID-19–exposed cannabis users, whether the drug is consumed for medication or recreational purposes. It has been suggested that cannabis intake might contribute toward the development of a cough, complicating the overall clinical outcome for those infected with the virus. The presence of a cough, even in an otherwise asymptomatic individual, facilitates viral spread. As for those cannabis users experiencing COVID-19 symptomatology, they can expect rapid clinical deterioration, including pronounced fatigue and a change in mental status.

According to pulmonary specialists and representatives of the American Lung Association, recreational cannabis use may be associated with a bronchitis-like inflammation (comparable with chronic bronchitis/COPD for chronic users) of the airways, along the lines of cigarette smoking.⁵ As far as cannabis smokers are concerned, the rationale for lung irritation is believed to stem from the relatively large portion of unburnt plant content that is inhaled in a given joint. If there is a superimposed infection, as is the case with COVID-19, the patient may experience further risk of adverse respiratory effects. This serves as a diagnostic dilemma for physicians, especially when they encounter patients who recently started dabbling with cannabis as a means of placating themselves or because they’ve heard rumors that it will somehow protect them from COVID-19. The entire assessment plan is slowed down as a result of the confounding variable (onset of a cough), which may arise independently of COVID-19 in cannabis users. Vulnerable populations include smokers and those with COPD or asthma, as they are more likely to require ventilator assistance during the course of COVID-19 therapy.⁵ Asthmatics and COPD patients are prone to bronchospasms because of sensitive airways.


 

COVID-19 safety protocols for cannabis users

Because of increased risk of respiratory morbidity, clinicians advise that consumption of recreational cannabinoids be scaled back during the course of the pandemic. In light of conflicting news from several media outlets regarding the efficacy of cannabis intake with respect to COVID-19, preexisting users might unwittingly increase their consumption as a preemptive measure against being exposed to the infection. To prevent transmission among users, clinicians should discourage patients from sharing joints. This recommendation is thematically consistent with general precautionary measures about the dangers of sharing utensils, drinking cups/glasses, and so on, amid the pandemic.

Despite promising preliminary research results, CBD cannot be wholeheartedly recommended at this time; patients already on medically administered cannabinoids are urged to discuss the risk-benefit ratio with their respective health care clinicians. Cannabinoid therapies present a massive opportunity from the perspective of immunomodulation, especially when considering the prevalence of drug use. However, to improve clinical guidelines with respect to COVID-19 outcomes, it would be prudent to increase the overall volume of preclinical knowledge by gathering retrospective data (from case-control designs) and randomized prospective trials.

A more comprehensive list of advice from physicians concerning casual or chronic cannabis users may also include: adopting a dedicated delivery or dispensing system for cannabis products, making considerations for decontamination (i.e., disinfecting mouthpieces), ensuring cleansing precautions are maintained (washing thoroughly before and after use or procurement), switching to inhalation alternates (e.g., tinctures, edibles, and/or oils) to decrease further irritation to the lungs. For bong users, it is recommended that they apply rubbing alcohol to clean their device followed with a minute of air-drying.⁶

Conclusion

The literature from preclinical studies appears to largely favor the use of CBD, but there remains an element of uncertainty with respect to implementing cannabinoids for the treatment of coronavirus.

COVID-19 cannabinoid intervention is a hot topic with renewed interest from the industry and the public at large, but viral-focused therapies remain a relatively underused area worth exploring with case-control designs and randomized prospective trials. As cannabis legalization is picking up momentum across five additional states, the time is ripe to systematically investigate the therapeutic applications of the drug beyond merely preclinical data. Aside from educational reform initiatives, clinicians might proactively launch a platform that integrates telemedicine as well as digital apps, directly linking the patient to the clinician and monitoring the efficacy of program initiatives in real time.
 

References

1. Long A. Consumers’ cannabis buying patterns change markedly in wake of COVID-19 pandemic. Marijuana Business Daily. 2020 Sep 22. https://mjbizdaily.com/consumers-cannabis-buying-patterns-change-markedly-in-wake-of-covid-pandemic/.

2. Bures B. How the coronavirus pandemic is increasing global demand for marijuana. Chicago Tribune. 2020 Jul 1. https://www.chicagotribune.com/marijuana/sns-tft-coronavirus-increases-global-marijuana-demand-20200701-oygaxryb7vhcjfeu44cgacicaa-story.html.

3. Walters J. Marijuana and COVID-19: Top studies. CannaMD. 2020 Aug 19. https://www.cannamd.com/marijuana-covid-19-top-studies/.

4. El Biali M et al. Med Cannabis Cannabinoids. 2020 Aug 19. doi: 10.1159/000510799.

5. LaMotte S. “Smoking weed and coronavirus: Even occasional use raises risk of COVID-19 complications.” CNN Health. 2020 Apr 10. https://www.cnn.com/2020/04/10/health/smoking-weed-coronavirus-wellness/index.html

6. Yafai S and Etengoff S. The case for cannabis: Advising cannabis users about COVID-19. Emergency Medicine News. 2020 May 20;42(5B).

Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Mr. Choudhry is a research assistant at the IMCHF. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF and is Mr. Choudhry’s father. Dr. Islam, Mr. Choudhry, and Dr. Choudhry reported no relevant disclosures.

An intriguing pattern has emerged for cannabis enthusiasts as a result of lockdowns and statewide safety restrictions for COVID-19.

Consumers, as of late, have been shopping for larger marijuana baskets per trip to the dispensaries in various states, including California, Colorado, Nevada, and Washington, . However, they are also cutting down on the number of trips, perhaps, as a preventive measure to reduce the risk of exposure to coronavirus during this pandemic. Sales dipped considerably by the end of March only to experience a resurgence after the issuing of stimulus checks and unemployment benefits.

For the past few years, cannabis consumption remained steady while the industry continued to thrive with robust sales of the drug. It is a recession-proof phenomenon, therefore presenting a unique opportunity for clinicians with respect to patient education and individualized care.¹

An unfortunate carryover of the governmental restrictions, self-isolation, and social estrangement is that consumers are now turning to the dark web as a source for continuous supply of cannabis. Prepandemic, according to the U.N. 2020 World Drug Report, there was already a 30% increase in sales of cannabis between 2009 and 2018. COVID-19 has fractured the drug’s supply chain and created an inescapable void that is being filled by drug traffickers.² A clinical dilemma is posed when a user procures counterfeit cannabis or a drug batch with impurities.
 

Riding the cytokine storm

Cytokines are a host of proteins with designated regulatory and immune responses that play an instrumental role in cell signaling. The aptly named “cytokine storm” conjures up the image of an imperiled immune system spiraling out of control; it is, in fact, an extreme immune response that culminates into a massive influx of cytokines released into the bloodstream. Without the presence of an immunologic threat, cytokines are responsible for maintaining homeostasis and the functionality of immune cells. However, acute cytokine release (i.e., cytokine storm), as is the case with severe COVID-19, jeopardizes organ function (for example, interstitial lung disease) with clinical symptoms, such as fever, cough, dyspnea, and myalgia.

Benefits and drawbacks of immunosuppressive agents

To inhibit cytokine release (e.g., interleukin-6 cytokine levels), immunosuppressive agents such as tocilizumab have been leveraged to damper the body’s overactive inflammatory response to perceived immunologic stressors, in particular, COVID-19. While the aforementioned agent was remarkably effective with respect to lung consolidation clearance in most of the patients tested, a host of untoward effects prevent its general applicability and use. However, a team of researchers from the University of Nebraska, Omaha, with the Texas Biomedical Research Institute, San Antonio, might have stumbled upon a strategic workaround for mitigating the immune response.

They have proposed that cannabidiol (CBD) be used in lieu of other agents with potentially toxic effects. Animal and human trials have established that CBD confers a relatively high margin of safety coupled with favorable tolerance, providing a viable option for effectively targeting the inflammatory processes of SARS-CoV-2–based pulmonary disease. Furthermore, efficacy increased when CBD was combined with a terpene formulation, especially with respect to the more traditional steroid therapy.³

SARS-CoV-2 exhibits binding affinity for the ACE2 receptor, which is expressed in the lungs as well as other known predilection sites of infection. Ongoing studies attempt to modulate ACE2 expression, thereby eliminating its conspicuous role as “viral gateways,” perhaps even more so in patients with lung pathologies (e.g., people with chronic obstructive pulmonary disease [COPD] and smokers) as they already are prone to increased respiratory morbidity. CBD lacks tetrahydrocannabinol (THC), or the psychoactive component of cannabis sativa, rendering the agent to be particularly attractive from a therapeutic perspective. In addition to being devoid of abuse potential, CBD exhibits remarkable anti-inflammatory properties. It should be noted that considerable overlap exists between tobacco and cannabis users, and it is too early to determine the impact on COVID-19. As opposed to cannabis’s effect on ACE2 levels, smoking exhibits a proinflammatory role by up-regulating ACE2 expression.3 However, there are currently numerous conflicting reports in circulation about the positive effect of nicotine on COVID-19 outcome; confounding variables will need to be explored further in patients with a history of using nicotine and cannabis together.

From an immunologic perspective, the endocannabinoid system (ECS) plays an integral role in cell signaling by interacting with natural chemicals of the body, namely, cannabinoids with designated targets at the cannabinoid receptor 1 (CB1) and the CB2, respectively. The CB2 receptor is of particular interest as it is intimately involved in immune homeostasis; the primary goal of these COVID-19 studies is to modulate the endocannabinoid system via targeted CB2 therapies to produce an immunosuppressant effect.⁴ CB2 activation, be it by means of THC or CBD agonism, may prove to be beneficial by inhibiting the cytokine influx.

Unfortunately, there is a general dearth of data on COVID-19–exposed cannabis users, whether the drug is consumed for medication or recreational purposes. It has been suggested that cannabis intake might contribute toward the development of a cough, complicating the overall clinical outcome for those infected with the virus. The presence of a cough, even in an otherwise asymptomatic individual, facilitates viral spread. As for those cannabis users experiencing COVID-19 symptomatology, they can expect rapid clinical deterioration, including pronounced fatigue and a change in mental status.

According to pulmonary specialists and representatives of the American Lung Association, recreational cannabis use may be associated with a bronchitis-like inflammation (comparable with chronic bronchitis/COPD for chronic users) of the airways, along the lines of cigarette smoking.⁵ As far as cannabis smokers are concerned, the rationale for lung irritation is believed to stem from the relatively large portion of unburnt plant content that is inhaled in a given joint. If there is a superimposed infection, as is the case with COVID-19, the patient may experience further risk of adverse respiratory effects. This serves as a diagnostic dilemma for physicians, especially when they encounter patients who recently started dabbling with cannabis as a means of placating themselves or because they’ve heard rumors that it will somehow protect them from COVID-19. The entire assessment plan is slowed down as a result of the confounding variable (onset of a cough), which may arise independently of COVID-19 in cannabis users. Vulnerable populations include smokers and those with COPD or asthma, as they are more likely to require ventilator assistance during the course of COVID-19 therapy.⁵ Asthmatics and COPD patients are prone to bronchospasms because of sensitive airways.


 

COVID-19 safety protocols for cannabis users

Because of increased risk of respiratory morbidity, clinicians advise that consumption of recreational cannabinoids be scaled back during the course of the pandemic. In light of conflicting news from several media outlets regarding the efficacy of cannabis intake with respect to COVID-19, preexisting users might unwittingly increase their consumption as a preemptive measure against being exposed to the infection. To prevent transmission among users, clinicians should discourage patients from sharing joints. This recommendation is thematically consistent with general precautionary measures about the dangers of sharing utensils, drinking cups/glasses, and so on, amid the pandemic.

Despite promising preliminary research results, CBD cannot be wholeheartedly recommended at this time; patients already on medically administered cannabinoids are urged to discuss the risk-benefit ratio with their respective health care clinicians. Cannabinoid therapies present a massive opportunity from the perspective of immunomodulation, especially when considering the prevalence of drug use. However, to improve clinical guidelines with respect to COVID-19 outcomes, it would be prudent to increase the overall volume of preclinical knowledge by gathering retrospective data (from case-control designs) and randomized prospective trials.

A more comprehensive list of advice from physicians concerning casual or chronic cannabis users may also include: adopting a dedicated delivery or dispensing system for cannabis products, making considerations for decontamination (i.e., disinfecting mouthpieces), ensuring cleansing precautions are maintained (washing thoroughly before and after use or procurement), switching to inhalation alternates (e.g., tinctures, edibles, and/or oils) to decrease further irritation to the lungs. For bong users, it is recommended that they apply rubbing alcohol to clean their device followed with a minute of air-drying.⁶

Conclusion

The literature from preclinical studies appears to largely favor the use of CBD, but there remains an element of uncertainty with respect to implementing cannabinoids for the treatment of coronavirus.

COVID-19 cannabinoid intervention is a hot topic with renewed interest from the industry and the public at large, but viral-focused therapies remain a relatively underused area worth exploring with case-control designs and randomized prospective trials. As cannabis legalization is picking up momentum across five additional states, the time is ripe to systematically investigate the therapeutic applications of the drug beyond merely preclinical data. Aside from educational reform initiatives, clinicians might proactively launch a platform that integrates telemedicine as well as digital apps, directly linking the patient to the clinician and monitoring the efficacy of program initiatives in real time.
 

References

1. Long A. Consumers’ cannabis buying patterns change markedly in wake of COVID-19 pandemic. Marijuana Business Daily. 2020 Sep 22. https://mjbizdaily.com/consumers-cannabis-buying-patterns-change-markedly-in-wake-of-covid-pandemic/.

2. Bures B. How the coronavirus pandemic is increasing global demand for marijuana. Chicago Tribune. 2020 Jul 1. https://www.chicagotribune.com/marijuana/sns-tft-coronavirus-increases-global-marijuana-demand-20200701-oygaxryb7vhcjfeu44cgacicaa-story.html.

3. Walters J. Marijuana and COVID-19: Top studies. CannaMD. 2020 Aug 19. https://www.cannamd.com/marijuana-covid-19-top-studies/.

4. El Biali M et al. Med Cannabis Cannabinoids. 2020 Aug 19. doi: 10.1159/000510799.

5. LaMotte S. “Smoking weed and coronavirus: Even occasional use raises risk of COVID-19 complications.” CNN Health. 2020 Apr 10. https://www.cnn.com/2020/04/10/health/smoking-weed-coronavirus-wellness/index.html

6. Yafai S and Etengoff S. The case for cannabis: Advising cannabis users about COVID-19. Emergency Medicine News. 2020 May 20;42(5B).

Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Mr. Choudhry is a research assistant at the IMCHF. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF and is Mr. Choudhry’s father. Dr. Islam, Mr. Choudhry, and Dr. Choudhry reported no relevant disclosures.

An intriguing pattern has emerged for cannabis enthusiasts as a result of lockdowns and statewide safety restrictions for COVID-19.

Consumers, as of late, have been shopping for larger marijuana baskets per trip to the dispensaries in various states, including California, Colorado, Nevada, and Washington, . However, they are also cutting down on the number of trips, perhaps, as a preventive measure to reduce the risk of exposure to coronavirus during this pandemic. Sales dipped considerably by the end of March only to experience a resurgence after the issuing of stimulus checks and unemployment benefits.

For the past few years, cannabis consumption remained steady while the industry continued to thrive with robust sales of the drug. It is a recession-proof phenomenon, therefore presenting a unique opportunity for clinicians with respect to patient education and individualized care.¹

An unfortunate carryover of the governmental restrictions, self-isolation, and social estrangement is that consumers are now turning to the dark web as a source for continuous supply of cannabis. Prepandemic, according to the U.N. 2020 World Drug Report, there was already a 30% increase in sales of cannabis between 2009 and 2018. COVID-19 has fractured the drug’s supply chain and created an inescapable void that is being filled by drug traffickers.² A clinical dilemma is posed when a user procures counterfeit cannabis or a drug batch with impurities.
 

Riding the cytokine storm

Cytokines are a host of proteins with designated regulatory and immune responses that play an instrumental role in cell signaling. The aptly named “cytokine storm” conjures up the image of an imperiled immune system spiraling out of control; it is, in fact, an extreme immune response that culminates into a massive influx of cytokines released into the bloodstream. Without the presence of an immunologic threat, cytokines are responsible for maintaining homeostasis and the functionality of immune cells. However, acute cytokine release (i.e., cytokine storm), as is the case with severe COVID-19, jeopardizes organ function (for example, interstitial lung disease) with clinical symptoms, such as fever, cough, dyspnea, and myalgia.

Benefits and drawbacks of immunosuppressive agents

To inhibit cytokine release (e.g., interleukin-6 cytokine levels), immunosuppressive agents such as tocilizumab have been leveraged to damper the body’s overactive inflammatory response to perceived immunologic stressors, in particular, COVID-19. While the aforementioned agent was remarkably effective with respect to lung consolidation clearance in most of the patients tested, a host of untoward effects prevent its general applicability and use. However, a team of researchers from the University of Nebraska, Omaha, with the Texas Biomedical Research Institute, San Antonio, might have stumbled upon a strategic workaround for mitigating the immune response.

They have proposed that cannabidiol (CBD) be used in lieu of other agents with potentially toxic effects. Animal and human trials have established that CBD confers a relatively high margin of safety coupled with favorable tolerance, providing a viable option for effectively targeting the inflammatory processes of SARS-CoV-2–based pulmonary disease. Furthermore, efficacy increased when CBD was combined with a terpene formulation, especially with respect to the more traditional steroid therapy.³

SARS-CoV-2 exhibits binding affinity for the ACE2 receptor, which is expressed in the lungs as well as other known predilection sites of infection. Ongoing studies attempt to modulate ACE2 expression, thereby eliminating its conspicuous role as “viral gateways,” perhaps even more so in patients with lung pathologies (e.g., people with chronic obstructive pulmonary disease [COPD] and smokers) as they already are prone to increased respiratory morbidity. CBD lacks tetrahydrocannabinol (THC), or the psychoactive component of cannabis sativa, rendering the agent to be particularly attractive from a therapeutic perspective. In addition to being devoid of abuse potential, CBD exhibits remarkable anti-inflammatory properties. It should be noted that considerable overlap exists between tobacco and cannabis users, and it is too early to determine the impact on COVID-19. As opposed to cannabis’s effect on ACE2 levels, smoking exhibits a proinflammatory role by up-regulating ACE2 expression.3 However, there are currently numerous conflicting reports in circulation about the positive effect of nicotine on COVID-19 outcome; confounding variables will need to be explored further in patients with a history of using nicotine and cannabis together.

From an immunologic perspective, the endocannabinoid system (ECS) plays an integral role in cell signaling by interacting with natural chemicals of the body, namely, cannabinoids with designated targets at the cannabinoid receptor 1 (CB1) and the CB2, respectively. The CB2 receptor is of particular interest as it is intimately involved in immune homeostasis; the primary goal of these COVID-19 studies is to modulate the endocannabinoid system via targeted CB2 therapies to produce an immunosuppressant effect.⁴ CB2 activation, be it by means of THC or CBD agonism, may prove to be beneficial by inhibiting the cytokine influx.

Unfortunately, there is a general dearth of data on COVID-19–exposed cannabis users, whether the drug is consumed for medication or recreational purposes. It has been suggested that cannabis intake might contribute toward the development of a cough, complicating the overall clinical outcome for those infected with the virus. The presence of a cough, even in an otherwise asymptomatic individual, facilitates viral spread. As for those cannabis users experiencing COVID-19 symptomatology, they can expect rapid clinical deterioration, including pronounced fatigue and a change in mental status.

According to pulmonary specialists and representatives of the American Lung Association, recreational cannabis use may be associated with a bronchitis-like inflammation (comparable with chronic bronchitis/COPD for chronic users) of the airways, along the lines of cigarette smoking.⁵ As far as cannabis smokers are concerned, the rationale for lung irritation is believed to stem from the relatively large portion of unburnt plant content that is inhaled in a given joint. If there is a superimposed infection, as is the case with COVID-19, the patient may experience further risk of adverse respiratory effects. This serves as a diagnostic dilemma for physicians, especially when they encounter patients who recently started dabbling with cannabis as a means of placating themselves or because they’ve heard rumors that it will somehow protect them from COVID-19. The entire assessment plan is slowed down as a result of the confounding variable (onset of a cough), which may arise independently of COVID-19 in cannabis users. Vulnerable populations include smokers and those with COPD or asthma, as they are more likely to require ventilator assistance during the course of COVID-19 therapy.⁵ Asthmatics and COPD patients are prone to bronchospasms because of sensitive airways.


 

COVID-19 safety protocols for cannabis users

Because of increased risk of respiratory morbidity, clinicians advise that consumption of recreational cannabinoids be scaled back during the course of the pandemic. In light of conflicting news from several media outlets regarding the efficacy of cannabis intake with respect to COVID-19, preexisting users might unwittingly increase their consumption as a preemptive measure against being exposed to the infection. To prevent transmission among users, clinicians should discourage patients from sharing joints. This recommendation is thematically consistent with general precautionary measures about the dangers of sharing utensils, drinking cups/glasses, and so on, amid the pandemic.

Despite promising preliminary research results, CBD cannot be wholeheartedly recommended at this time; patients already on medically administered cannabinoids are urged to discuss the risk-benefit ratio with their respective health care clinicians. Cannabinoid therapies present a massive opportunity from the perspective of immunomodulation, especially when considering the prevalence of drug use. However, to improve clinical guidelines with respect to COVID-19 outcomes, it would be prudent to increase the overall volume of preclinical knowledge by gathering retrospective data (from case-control designs) and randomized prospective trials.

A more comprehensive list of advice from physicians concerning casual or chronic cannabis users may also include: adopting a dedicated delivery or dispensing system for cannabis products, making considerations for decontamination (i.e., disinfecting mouthpieces), ensuring cleansing precautions are maintained (washing thoroughly before and after use or procurement), switching to inhalation alternates (e.g., tinctures, edibles, and/or oils) to decrease further irritation to the lungs. For bong users, it is recommended that they apply rubbing alcohol to clean their device followed with a minute of air-drying.⁶

Conclusion

The literature from preclinical studies appears to largely favor the use of CBD, but there remains an element of uncertainty with respect to implementing cannabinoids for the treatment of coronavirus.

COVID-19 cannabinoid intervention is a hot topic with renewed interest from the industry and the public at large, but viral-focused therapies remain a relatively underused area worth exploring with case-control designs and randomized prospective trials. As cannabis legalization is picking up momentum across five additional states, the time is ripe to systematically investigate the therapeutic applications of the drug beyond merely preclinical data. Aside from educational reform initiatives, clinicians might proactively launch a platform that integrates telemedicine as well as digital apps, directly linking the patient to the clinician and monitoring the efficacy of program initiatives in real time.
 

References

1. Long A. Consumers’ cannabis buying patterns change markedly in wake of COVID-19 pandemic. Marijuana Business Daily. 2020 Sep 22. https://mjbizdaily.com/consumers-cannabis-buying-patterns-change-markedly-in-wake-of-covid-pandemic/.

2. Bures B. How the coronavirus pandemic is increasing global demand for marijuana. Chicago Tribune. 2020 Jul 1. https://www.chicagotribune.com/marijuana/sns-tft-coronavirus-increases-global-marijuana-demand-20200701-oygaxryb7vhcjfeu44cgacicaa-story.html.

3. Walters J. Marijuana and COVID-19: Top studies. CannaMD. 2020 Aug 19. https://www.cannamd.com/marijuana-covid-19-top-studies/.

4. El Biali M et al. Med Cannabis Cannabinoids. 2020 Aug 19. doi: 10.1159/000510799.

5. LaMotte S. “Smoking weed and coronavirus: Even occasional use raises risk of COVID-19 complications.” CNN Health. 2020 Apr 10. https://www.cnn.com/2020/04/10/health/smoking-weed-coronavirus-wellness/index.html

6. Yafai S and Etengoff S. The case for cannabis: Advising cannabis users about COVID-19. Emergency Medicine News. 2020 May 20;42(5B).

Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Mr. Choudhry is a research assistant at the IMCHF. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF and is Mr. Choudhry’s father. Dr. Islam, Mr. Choudhry, and Dr. Choudhry reported no relevant disclosures.

While the concept of home-based care and remote monitoring of patients may not be a new concept, the importance of this option for managing patients has taken on great importance during this COVID-19 pandemic.

Courtesy Dr. Noel Deep

We are currently living and working in unprecedented times and the impact of the pandemic is quite evident, and it plays an important part in every health care worker’s daily life. The high volumes of patients presenting to emergency rooms and urgent care/walk-in clinics and seeking posthospitalization visits with their physicians is stressing the health care environment. In such difficult times, the hospital-at-home model of care provides a valuable and viable option to provide appropriate care to those patients who may require close monitoring of their health without being hospitalized and using valuable inpatient resources that could then be used for the higher-acuity patients. As a physician who lives this every day and as a practicing internist and a part-time administrator, I welcome the hospital-at-home approach that complements the care provided in the emergency room, inpatient and ambulatory practice settings. I believe this type of approach to patient care would benefit those patients who, while being acutely ill, may not require the 24/7 intensive care that more critically ill individuals may need. As long as the patients are provided with appropriate telemonitoring devices such as a blood pressure cuff, pulse oximeter, and thermometer, and have access to video telemonitoring, the appropriately selected patients would benefit from this method of care provision for their acute illness.
 

Mental health benefits

I see several benefits for patients who can be triaged/assigned to this telemonitoring model of care. A patient would probably be happier being at home because they could sleep in their own bed and eat their own food and be able to walk around their house or even venture outdoors to enjoy the fresh air and nature. Being able to do these things will contribute positively to their emotional and psychological well-being.

For some elderly individuals, having access to the familiarity of their surroundings would mean these patients would have fewer incidences of hospital-associated delirium or falls. Additionally, they would be able to enjoy the company of their family members, which, during this COVID pandemic, is not possible in many hospitals. This would reduce emotional tensions for the patients and their families and the risk of transmission of infections to the patients and their visitors in the hospitals.
 

Freeing up resources

More importantly, this model would help physicians and hospitals provide the much needed care to the appropriate patients in the appropriate settings, thereby leading to decreased use of emergency rooms, health care workers, and personal protective equipment – all of which are currently in high demand.

Having a dedicated team of physicians, nurses, respiratory therapists, and other health care workers available to monitor these home-based patients on a daily or more frequent basis, depending on their health status, would result in these patients receiving equivalent care to what they would have received in a hospital.

Another positive outcome of using this home-based care model in the pandemic is that it would free up hospital beds for non–COVID-19 patients who might need hospitalization for management of their acute illnesses or exacerbation of chronic health conditions.
 

Possible limitations

This model of care has some limitations, including that it is not geared toward high volumes in my opinion and will not work in every home. Patients need to have Internet capabilities, phone services, and other features in their homes that make it possible for them to access this type of care. Additionally, patients may not be able to get their insurance companies to pay for these services. While the Centers for Medicare & Medicaid Services recently authorized patients to be transferred from EDs or inpatient wards to hospital-level care at home, for how long will reimbursements for this kind of care continue? If insurance will not pay for this monitoring at home, then will physician practices and hospital based practices provide this non reimbursed service?

Also, patients and their families may not be accepting of this model of care because they may feel it is inferior to inpatient hospitalization.

Despite these limitations, as long as Medicare and other health insurance programs provide reimbursement for such hospital-at-home services, I foresee this concept being highly used and benefiting health care entities in the United States.
 

Dr. Deep is a general internist in a multispecialty group practice with Aspirus Antigo (Wis.) Clinic and the chief medical officer and a staff physician at Aspirus Langlade Hospital in Antigo. He is also assistant clinical professor at the Medical College of Wisconsin, Central Wisconsin Campus, and the governor of the Wisconsin chapter of the American College of Physicians. Dr. Deep serves on the editorial advisory board of Internal Medicine News. Contact him at imnews@mdedge.com.

While the concept of home-based care and remote monitoring of patients may not be a new concept, the importance of this option for managing patients has taken on great importance during this COVID-19 pandemic.

Courtesy Dr. Noel Deep

We are currently living and working in unprecedented times and the impact of the pandemic is quite evident, and it plays an important part in every health care worker’s daily life. The high volumes of patients presenting to emergency rooms and urgent care/walk-in clinics and seeking posthospitalization visits with their physicians is stressing the health care environment. In such difficult times, the hospital-at-home model of care provides a valuable and viable option to provide appropriate care to those patients who may require close monitoring of their health without being hospitalized and using valuable inpatient resources that could then be used for the higher-acuity patients. As a physician who lives this every day and as a practicing internist and a part-time administrator, I welcome the hospital-at-home approach that complements the care provided in the emergency room, inpatient and ambulatory practice settings. I believe this type of approach to patient care would benefit those patients who, while being acutely ill, may not require the 24/7 intensive care that more critically ill individuals may need. As long as the patients are provided with appropriate telemonitoring devices such as a blood pressure cuff, pulse oximeter, and thermometer, and have access to video telemonitoring, the appropriately selected patients would benefit from this method of care provision for their acute illness.
 

Mental health benefits

I see several benefits for patients who can be triaged/assigned to this telemonitoring model of care. A patient would probably be happier being at home because they could sleep in their own bed and eat their own food and be able to walk around their house or even venture outdoors to enjoy the fresh air and nature. Being able to do these things will contribute positively to their emotional and psychological well-being.

For some elderly individuals, having access to the familiarity of their surroundings would mean these patients would have fewer incidences of hospital-associated delirium or falls. Additionally, they would be able to enjoy the company of their family members, which, during this COVID pandemic, is not possible in many hospitals. This would reduce emotional tensions for the patients and their families and the risk of transmission of infections to the patients and their visitors in the hospitals.
 

Freeing up resources

More importantly, this model would help physicians and hospitals provide the much needed care to the appropriate patients in the appropriate settings, thereby leading to decreased use of emergency rooms, health care workers, and personal protective equipment – all of which are currently in high demand.

Having a dedicated team of physicians, nurses, respiratory therapists, and other health care workers available to monitor these home-based patients on a daily or more frequent basis, depending on their health status, would result in these patients receiving equivalent care to what they would have received in a hospital.

Another positive outcome of using this home-based care model in the pandemic is that it would free up hospital beds for non–COVID-19 patients who might need hospitalization for management of their acute illnesses or exacerbation of chronic health conditions.
 

Possible limitations

This model of care has some limitations, including that it is not geared toward high volumes in my opinion and will not work in every home. Patients need to have Internet capabilities, phone services, and other features in their homes that make it possible for them to access this type of care. Additionally, patients may not be able to get their insurance companies to pay for these services. While the Centers for Medicare & Medicaid Services recently authorized patients to be transferred from EDs or inpatient wards to hospital-level care at home, for how long will reimbursements for this kind of care continue? If insurance will not pay for this monitoring at home, then will physician practices and hospital based practices provide this non reimbursed service?

Also, patients and their families may not be accepting of this model of care because they may feel it is inferior to inpatient hospitalization.

Despite these limitations, as long as Medicare and other health insurance programs provide reimbursement for such hospital-at-home services, I foresee this concept being highly used and benefiting health care entities in the United States.
 

Dr. Deep is a general internist in a multispecialty group practice with Aspirus Antigo (Wis.) Clinic and the chief medical officer and a staff physician at Aspirus Langlade Hospital in Antigo. He is also assistant clinical professor at the Medical College of Wisconsin, Central Wisconsin Campus, and the governor of the Wisconsin chapter of the American College of Physicians. Dr. Deep serves on the editorial advisory board of Internal Medicine News. Contact him at imnews@mdedge.com.

While the concept of home-based care and remote monitoring of patients may not be a new concept, the importance of this option for managing patients has taken on great importance during this COVID-19 pandemic.

Courtesy Dr. Noel Deep

We are currently living and working in unprecedented times and the impact of the pandemic is quite evident, and it plays an important part in every health care worker’s daily life. The high volumes of patients presenting to emergency rooms and urgent care/walk-in clinics and seeking posthospitalization visits with their physicians is stressing the health care environment. In such difficult times, the hospital-at-home model of care provides a valuable and viable option to provide appropriate care to those patients who may require close monitoring of their health without being hospitalized and using valuable inpatient resources that could then be used for the higher-acuity patients. As a physician who lives this every day and as a practicing internist and a part-time administrator, I welcome the hospital-at-home approach that complements the care provided in the emergency room, inpatient and ambulatory practice settings. I believe this type of approach to patient care would benefit those patients who, while being acutely ill, may not require the 24/7 intensive care that more critically ill individuals may need. As long as the patients are provided with appropriate telemonitoring devices such as a blood pressure cuff, pulse oximeter, and thermometer, and have access to video telemonitoring, the appropriately selected patients would benefit from this method of care provision for their acute illness.
 

Mental health benefits

I see several benefits for patients who can be triaged/assigned to this telemonitoring model of care. A patient would probably be happier being at home because they could sleep in their own bed and eat their own food and be able to walk around their house or even venture outdoors to enjoy the fresh air and nature. Being able to do these things will contribute positively to their emotional and psychological well-being.

For some elderly individuals, having access to the familiarity of their surroundings would mean these patients would have fewer incidences of hospital-associated delirium or falls. Additionally, they would be able to enjoy the company of their family members, which, during this COVID pandemic, is not possible in many hospitals. This would reduce emotional tensions for the patients and their families and the risk of transmission of infections to the patients and their visitors in the hospitals.
 

Freeing up resources

More importantly, this model would help physicians and hospitals provide the much needed care to the appropriate patients in the appropriate settings, thereby leading to decreased use of emergency rooms, health care workers, and personal protective equipment – all of which are currently in high demand.

Having a dedicated team of physicians, nurses, respiratory therapists, and other health care workers available to monitor these home-based patients on a daily or more frequent basis, depending on their health status, would result in these patients receiving equivalent care to what they would have received in a hospital.

Another positive outcome of using this home-based care model in the pandemic is that it would free up hospital beds for non–COVID-19 patients who might need hospitalization for management of their acute illnesses or exacerbation of chronic health conditions.
 

Possible limitations

This model of care has some limitations, including that it is not geared toward high volumes in my opinion and will not work in every home. Patients need to have Internet capabilities, phone services, and other features in their homes that make it possible for them to access this type of care. Additionally, patients may not be able to get their insurance companies to pay for these services. While the Centers for Medicare & Medicaid Services recently authorized patients to be transferred from EDs or inpatient wards to hospital-level care at home, for how long will reimbursements for this kind of care continue? If insurance will not pay for this monitoring at home, then will physician practices and hospital based practices provide this non reimbursed service?

Also, patients and their families may not be accepting of this model of care because they may feel it is inferior to inpatient hospitalization.

Despite these limitations, as long as Medicare and other health insurance programs provide reimbursement for such hospital-at-home services, I foresee this concept being highly used and benefiting health care entities in the United States.
 

Dr. Deep is a general internist in a multispecialty group practice with Aspirus Antigo (Wis.) Clinic and the chief medical officer and a staff physician at Aspirus Langlade Hospital in Antigo. He is also assistant clinical professor at the Medical College of Wisconsin, Central Wisconsin Campus, and the governor of the Wisconsin chapter of the American College of Physicians. Dr. Deep serves on the editorial advisory board of Internal Medicine News. Contact him at imnews@mdedge.com.

Editor’s note: Psychiatry Leaders’ Perspectives is a new department in Current Psychiatry in which we interview a prominent psychiatrist about the strengths, weaknesses, opportunities, and threats facing the field of psychiatry.

In this first Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Dilip V. Jeste, MD. Dr. Jeste is Senior Associate Dean for Healthy Aging and Senior Care, Estelle and Edgar Levi Memorial Chair in Aging, Director of the Sam and Rose Stein Institute for Research on Aging, Distinguished Professor of Psychiatry and Neurosciences, University of California San Diego; and Co-Director of the UC San Diego-IBM Center on Artificial Intelligence for Healthy Living. His main areas of research include schizophrenia, neuro­psychiatric interventions, and successful aging. He served as the 139th President of the American Psychiatric Association (APA) and also is a past president of the American Association for Geriatric Psychiatry, the West Coast College of Biological Psychiatry, and founding president of International College of Geriatric Psychoneuropharmacology.

Dr. Aftab: The focus of your term as president of the APA was on “positive psychiatry.” You are also one of the world’s foremost experts in this area. How successful have you been in your mission to promote positive psychiatry, and how has your message been received?

Dr. Jeste: Let me start with a little bit of background about why I got into positive psychiatry. As a geriatric psychiatrist, my research work has brought me face to face with the paradox of aging: although physical health declines with age, mental health and well-being improve on average. This is the case not just for individuals in the community but also for individuals with serious mental illnesses. That got me into thinking more and more about the ways in which we can bring positive change in the lives of patients. When I became the president of the APA, one of my main tasks was to finalize and publish the DSM-5, which rightly focuses on the disorders we treat, but it also provided me with an opportunity to highlight the side of psychiatry that focuses on the positive aspects of our own and our patients’ lives, such as wisdom, resilience, meaning, and social connectedness.

As is the case with any new idea, there is a lot of resistance in the beginning and this will always be the case. However, I would say that positive psychiatry has been received very well. We now have an APA Caucus and a World Psychiatric Association Section on positive psychiatry. Our book, Positive Psychiatry, turned out to be one of the best sellers for American Psychiatric Publishing! Every year, there are symposia on positive psychiatry and papers and books from other countries. Overall, the reception has been very promising.

Dr. Aftab: Thank you for this interesting background, Dr. Jeste. Now let me ask you about the current state of psychiatry. What do you see as some of the strengths of our profession?

Dr. Jeste: Psychiatry’s unique strength is our skill in promoting adaptive behavior change, with a focus on positive factors such as resilience, wisdom, optimism, social engagement, improved health, and longevity. If you look at the research literature, the effect sizes of factors such as optimism, resilience, and social engagement are equal to or greater than interventions such as statins, smoking cessation, and exercise. Cardiothoracic surgeons and radiologists can’t help people increase their resilience, optimism, and social engagement, but psychiatrists can. Behavior change is our expertise. When people are suicidal, we give them hope; we help depressed individuals become active, productive, and happy. We treat people with schizophrenia and bipolar disorder, reduce their psychopathological behaviors, and improve their everyday functioning.

Continue to: Dr. Aftab

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. Jeste: Unfortunately, there are a lot of restrictions posed by the current reimbursement system. As a result, psychiatrists spend most of their time prescribing medications in clinical practice. I have nothing against psychopharmacology, but we also need to focus on important aspects of our lives, such as lifestyle, cognitive attitudes, self-care, and social engagement. We need to go beyond symptom reduction. A prominent example is loneliness, which is a major risk factor for morbidity and mortality; the treatment for loneliness is not increasing social network, it’s actually changing one’s perception of and ability to enhance appropriate socialization. Who can do that? Psychiatrists! But we don’t do that right now because the health insurance system doesn’t reimburse psychiatrists to do that.

Dr. Aftab: What is your perception of the threats that psychiatry faces? You had to fend off a variety of challenges during your year as APA president, such as issues surrounding revision of DSM-5. How has that experience shaped your assessment?

Dr. Jeste: I was honored to oversee the finalization and publication of DSM-5 as the president of the APA, even though I lost a lot of sleep working on it! What I found was that there was a lot of antagonism in the media, as well as among several advocacy groups, about the DSM. The misperception was that psychiatry and the APA were trying to expand diagnoses so that the drug companies could sell medications to more people, and psychiatry would benefit from this because of its relationship with the industry. That was actually not the case at all. What I tried to do was to understand where these groups were coming from, and to treat them as collaborators and partners, not as enemies. One thing I am particularly proud of is that we established the Summit Group for DSM-5, which brought together perspectives of the various stakeholders, and our communication both within and outside of the APA improved significantly. It’s gratifying to note that much of the controversy in the media died down after DSM-5 was published. The often-critical New York Times wrote that while DSM-5 is far from perfect, it is the best we have today clinically, and I’m very proud of the work we did on it.

Dr. Aftab: What sort of opportunities lie ahead for psychiatry? What do you envision for the future of the field?

Continue to: Dr. Jeste

Dr. Jeste: As a neuroscientist, I’m excited about the new developments in brain science. Our understanding of the neurobiologic basis of mental illnesses is slowly but surely increasing. I’m also very heartened by all the research going on with regard to the prevention of mental illnesses. I think we will be able to reduce the risk of many psychiatric disorders in the future. This is an exciting time for the field, and psychiatry is going to look very different 20 years from now!

Dr. Aftab: Some people think there’s a conflict between a neuroscientific and psychosocial understanding of psychiatry. How do you think the 2 relate to each other?

Dr. Jeste: The reality, I think, is that there is no conflict. Ultimately, the mind is a function of the brain, and the mind operates within a society. Neuroscientists are also realizing the importance of psychosocial aspects, and there is a growing social neuroscience, looking at the neurobiology of things such as loneliness, social isolation, and wisdom. The effects of psychosocial interventions such as meditation and long-term cognitive-behavioral therapy on the brain are now indisputable. I like to say that psychosocial interventions are often more biological in their effects than the drugs!

Dr. Aftab: Any words of wisdom for psychiatry trainees and early career psychiatrists?

Dr. Jeste: First of all, I congratulate them for going into psychiatry, which is rapidly advancing and is the field of the future. Looking at new developments, such as in artificial intelligence, I wish I could be a young person again just getting into psychiatry! The role of psychiatrists is also evolving, and psychiatrists will become leaders of multidisciplinary teams. I would advise trainees and early career psychiatrists not to get frustrated by issues such as insurance reimbursements; these obstacles will pass. Society is becoming far more conscious of the importance of mental health to our well-being. So I see a reason to be optimistic. I would also mention that the younger generation has a lot to teach the older generation while at the same time benefitting from the wisdom they have to offer. One of the best things we can promote is intergenerational activity, both within and outside of our profession.

Editor’s note: Psychiatry Leaders’ Perspectives is a new department in Current Psychiatry in which we interview a prominent psychiatrist about the strengths, weaknesses, opportunities, and threats facing the field of psychiatry.

In this first Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Dilip V. Jeste, MD. Dr. Jeste is Senior Associate Dean for Healthy Aging and Senior Care, Estelle and Edgar Levi Memorial Chair in Aging, Director of the Sam and Rose Stein Institute for Research on Aging, Distinguished Professor of Psychiatry and Neurosciences, University of California San Diego; and Co-Director of the UC San Diego-IBM Center on Artificial Intelligence for Healthy Living. His main areas of research include schizophrenia, neuro­psychiatric interventions, and successful aging. He served as the 139th President of the American Psychiatric Association (APA) and also is a past president of the American Association for Geriatric Psychiatry, the West Coast College of Biological Psychiatry, and founding president of International College of Geriatric Psychoneuropharmacology.

Dr. Aftab: The focus of your term as president of the APA was on “positive psychiatry.” You are also one of the world’s foremost experts in this area. How successful have you been in your mission to promote positive psychiatry, and how has your message been received?

Dr. Jeste: Let me start with a little bit of background about why I got into positive psychiatry. As a geriatric psychiatrist, my research work has brought me face to face with the paradox of aging: although physical health declines with age, mental health and well-being improve on average. This is the case not just for individuals in the community but also for individuals with serious mental illnesses. That got me into thinking more and more about the ways in which we can bring positive change in the lives of patients. When I became the president of the APA, one of my main tasks was to finalize and publish the DSM-5, which rightly focuses on the disorders we treat, but it also provided me with an opportunity to highlight the side of psychiatry that focuses on the positive aspects of our own and our patients’ lives, such as wisdom, resilience, meaning, and social connectedness.

As is the case with any new idea, there is a lot of resistance in the beginning and this will always be the case. However, I would say that positive psychiatry has been received very well. We now have an APA Caucus and a World Psychiatric Association Section on positive psychiatry. Our book, Positive Psychiatry, turned out to be one of the best sellers for American Psychiatric Publishing! Every year, there are symposia on positive psychiatry and papers and books from other countries. Overall, the reception has been very promising.

Dr. Aftab: Thank you for this interesting background, Dr. Jeste. Now let me ask you about the current state of psychiatry. What do you see as some of the strengths of our profession?

Dr. Jeste: Psychiatry’s unique strength is our skill in promoting adaptive behavior change, with a focus on positive factors such as resilience, wisdom, optimism, social engagement, improved health, and longevity. If you look at the research literature, the effect sizes of factors such as optimism, resilience, and social engagement are equal to or greater than interventions such as statins, smoking cessation, and exercise. Cardiothoracic surgeons and radiologists can’t help people increase their resilience, optimism, and social engagement, but psychiatrists can. Behavior change is our expertise. When people are suicidal, we give them hope; we help depressed individuals become active, productive, and happy. We treat people with schizophrenia and bipolar disorder, reduce their psychopathological behaviors, and improve their everyday functioning.

Continue to: Dr. Aftab

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. Jeste: Unfortunately, there are a lot of restrictions posed by the current reimbursement system. As a result, psychiatrists spend most of their time prescribing medications in clinical practice. I have nothing against psychopharmacology, but we also need to focus on important aspects of our lives, such as lifestyle, cognitive attitudes, self-care, and social engagement. We need to go beyond symptom reduction. A prominent example is loneliness, which is a major risk factor for morbidity and mortality; the treatment for loneliness is not increasing social network, it’s actually changing one’s perception of and ability to enhance appropriate socialization. Who can do that? Psychiatrists! But we don’t do that right now because the health insurance system doesn’t reimburse psychiatrists to do that.

Dr. Aftab: What is your perception of the threats that psychiatry faces? You had to fend off a variety of challenges during your year as APA president, such as issues surrounding revision of DSM-5. How has that experience shaped your assessment?

Dr. Jeste: I was honored to oversee the finalization and publication of DSM-5 as the president of the APA, even though I lost a lot of sleep working on it! What I found was that there was a lot of antagonism in the media, as well as among several advocacy groups, about the DSM. The misperception was that psychiatry and the APA were trying to expand diagnoses so that the drug companies could sell medications to more people, and psychiatry would benefit from this because of its relationship with the industry. That was actually not the case at all. What I tried to do was to understand where these groups were coming from, and to treat them as collaborators and partners, not as enemies. One thing I am particularly proud of is that we established the Summit Group for DSM-5, which brought together perspectives of the various stakeholders, and our communication both within and outside of the APA improved significantly. It’s gratifying to note that much of the controversy in the media died down after DSM-5 was published. The often-critical New York Times wrote that while DSM-5 is far from perfect, it is the best we have today clinically, and I’m very proud of the work we did on it.

Dr. Aftab: What sort of opportunities lie ahead for psychiatry? What do you envision for the future of the field?

Continue to: Dr. Jeste

Dr. Jeste: As a neuroscientist, I’m excited about the new developments in brain science. Our understanding of the neurobiologic basis of mental illnesses is slowly but surely increasing. I’m also very heartened by all the research going on with regard to the prevention of mental illnesses. I think we will be able to reduce the risk of many psychiatric disorders in the future. This is an exciting time for the field, and psychiatry is going to look very different 20 years from now!

Dr. Aftab: Some people think there’s a conflict between a neuroscientific and psychosocial understanding of psychiatry. How do you think the 2 relate to each other?

Dr. Jeste: The reality, I think, is that there is no conflict. Ultimately, the mind is a function of the brain, and the mind operates within a society. Neuroscientists are also realizing the importance of psychosocial aspects, and there is a growing social neuroscience, looking at the neurobiology of things such as loneliness, social isolation, and wisdom. The effects of psychosocial interventions such as meditation and long-term cognitive-behavioral therapy on the brain are now indisputable. I like to say that psychosocial interventions are often more biological in their effects than the drugs!

Dr. Aftab: Any words of wisdom for psychiatry trainees and early career psychiatrists?

Dr. Jeste: First of all, I congratulate them for going into psychiatry, which is rapidly advancing and is the field of the future. Looking at new developments, such as in artificial intelligence, I wish I could be a young person again just getting into psychiatry! The role of psychiatrists is also evolving, and psychiatrists will become leaders of multidisciplinary teams. I would advise trainees and early career psychiatrists not to get frustrated by issues such as insurance reimbursements; these obstacles will pass. Society is becoming far more conscious of the importance of mental health to our well-being. So I see a reason to be optimistic. I would also mention that the younger generation has a lot to teach the older generation while at the same time benefitting from the wisdom they have to offer. One of the best things we can promote is intergenerational activity, both within and outside of our profession.

Editor’s note: Psychiatry Leaders’ Perspectives is a new department in Current Psychiatry in which we interview a prominent psychiatrist about the strengths, weaknesses, opportunities, and threats facing the field of psychiatry.

In this first Psychiatry Leaders’ Perspectives, Awais Aftab, MD, interviewed Dilip V. Jeste, MD. Dr. Jeste is Senior Associate Dean for Healthy Aging and Senior Care, Estelle and Edgar Levi Memorial Chair in Aging, Director of the Sam and Rose Stein Institute for Research on Aging, Distinguished Professor of Psychiatry and Neurosciences, University of California San Diego; and Co-Director of the UC San Diego-IBM Center on Artificial Intelligence for Healthy Living. His main areas of research include schizophrenia, neuro­psychiatric interventions, and successful aging. He served as the 139th President of the American Psychiatric Association (APA) and also is a past president of the American Association for Geriatric Psychiatry, the West Coast College of Biological Psychiatry, and founding president of International College of Geriatric Psychoneuropharmacology.

Dr. Aftab: The focus of your term as president of the APA was on “positive psychiatry.” You are also one of the world’s foremost experts in this area. How successful have you been in your mission to promote positive psychiatry, and how has your message been received?

Dr. Jeste: Let me start with a little bit of background about why I got into positive psychiatry. As a geriatric psychiatrist, my research work has brought me face to face with the paradox of aging: although physical health declines with age, mental health and well-being improve on average. This is the case not just for individuals in the community but also for individuals with serious mental illnesses. That got me into thinking more and more about the ways in which we can bring positive change in the lives of patients. When I became the president of the APA, one of my main tasks was to finalize and publish the DSM-5, which rightly focuses on the disorders we treat, but it also provided me with an opportunity to highlight the side of psychiatry that focuses on the positive aspects of our own and our patients’ lives, such as wisdom, resilience, meaning, and social connectedness.

As is the case with any new idea, there is a lot of resistance in the beginning and this will always be the case. However, I would say that positive psychiatry has been received very well. We now have an APA Caucus and a World Psychiatric Association Section on positive psychiatry. Our book, Positive Psychiatry, turned out to be one of the best sellers for American Psychiatric Publishing! Every year, there are symposia on positive psychiatry and papers and books from other countries. Overall, the reception has been very promising.

Dr. Aftab: Thank you for this interesting background, Dr. Jeste. Now let me ask you about the current state of psychiatry. What do you see as some of the strengths of our profession?

Dr. Jeste: Psychiatry’s unique strength is our skill in promoting adaptive behavior change, with a focus on positive factors such as resilience, wisdom, optimism, social engagement, improved health, and longevity. If you look at the research literature, the effect sizes of factors such as optimism, resilience, and social engagement are equal to or greater than interventions such as statins, smoking cessation, and exercise. Cardiothoracic surgeons and radiologists can’t help people increase their resilience, optimism, and social engagement, but psychiatrists can. Behavior change is our expertise. When people are suicidal, we give them hope; we help depressed individuals become active, productive, and happy. We treat people with schizophrenia and bipolar disorder, reduce their psychopathological behaviors, and improve their everyday functioning.

Continue to: Dr. Aftab

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. Jeste: Unfortunately, there are a lot of restrictions posed by the current reimbursement system. As a result, psychiatrists spend most of their time prescribing medications in clinical practice. I have nothing against psychopharmacology, but we also need to focus on important aspects of our lives, such as lifestyle, cognitive attitudes, self-care, and social engagement. We need to go beyond symptom reduction. A prominent example is loneliness, which is a major risk factor for morbidity and mortality; the treatment for loneliness is not increasing social network, it’s actually changing one’s perception of and ability to enhance appropriate socialization. Who can do that? Psychiatrists! But we don’t do that right now because the health insurance system doesn’t reimburse psychiatrists to do that.

Dr. Aftab: What is your perception of the threats that psychiatry faces? You had to fend off a variety of challenges during your year as APA president, such as issues surrounding revision of DSM-5. How has that experience shaped your assessment?

Dr. Jeste: I was honored to oversee the finalization and publication of DSM-5 as the president of the APA, even though I lost a lot of sleep working on it! What I found was that there was a lot of antagonism in the media, as well as among several advocacy groups, about the DSM. The misperception was that psychiatry and the APA were trying to expand diagnoses so that the drug companies could sell medications to more people, and psychiatry would benefit from this because of its relationship with the industry. That was actually not the case at all. What I tried to do was to understand where these groups were coming from, and to treat them as collaborators and partners, not as enemies. One thing I am particularly proud of is that we established the Summit Group for DSM-5, which brought together perspectives of the various stakeholders, and our communication both within and outside of the APA improved significantly. It’s gratifying to note that much of the controversy in the media died down after DSM-5 was published. The often-critical New York Times wrote that while DSM-5 is far from perfect, it is the best we have today clinically, and I’m very proud of the work we did on it.

Dr. Aftab: What sort of opportunities lie ahead for psychiatry? What do you envision for the future of the field?

Continue to: Dr. Jeste

Dr. Jeste: As a neuroscientist, I’m excited about the new developments in brain science. Our understanding of the neurobiologic basis of mental illnesses is slowly but surely increasing. I’m also very heartened by all the research going on with regard to the prevention of mental illnesses. I think we will be able to reduce the risk of many psychiatric disorders in the future. This is an exciting time for the field, and psychiatry is going to look very different 20 years from now!

Dr. Aftab: Some people think there’s a conflict between a neuroscientific and psychosocial understanding of psychiatry. How do you think the 2 relate to each other?

Dr. Jeste: The reality, I think, is that there is no conflict. Ultimately, the mind is a function of the brain, and the mind operates within a society. Neuroscientists are also realizing the importance of psychosocial aspects, and there is a growing social neuroscience, looking at the neurobiology of things such as loneliness, social isolation, and wisdom. The effects of psychosocial interventions such as meditation and long-term cognitive-behavioral therapy on the brain are now indisputable. I like to say that psychosocial interventions are often more biological in their effects than the drugs!

Dr. Aftab: Any words of wisdom for psychiatry trainees and early career psychiatrists?

Dr. Jeste: First of all, I congratulate them for going into psychiatry, which is rapidly advancing and is the field of the future. Looking at new developments, such as in artificial intelligence, I wish I could be a young person again just getting into psychiatry! The role of psychiatrists is also evolving, and psychiatrists will become leaders of multidisciplinary teams. I would advise trainees and early career psychiatrists not to get frustrated by issues such as insurance reimbursements; these obstacles will pass. Society is becoming far more conscious of the importance of mental health to our well-being. So I see a reason to be optimistic. I would also mention that the younger generation has a lot to teach the older generation while at the same time benefitting from the wisdom they have to offer. One of the best things we can promote is intergenerational activity, both within and outside of our profession.

Finally, 2020 is coming to an end, but the agony its viral pandemic inflicted on the entire world population will continue for a long time. And much as we would like to forget its damaging effects, it will surely be etched into our brains for the rest of our lives. The children who suffered the pain of the coronavirus disease 2019 (COVID-19) pandemic will endure its emotional scars for the rest of the 21st century.

Reading about the plagues of the past doesn’t come close to experiencing it and suffering through it. COVID-19 will continue to have ripple effects on every aspect of life on this planet, on individuals and on societies all over the world, especially on the biopsychosocial well-being of billions of humans around the globe.

Unprecedented disruptions

Think of the unprecedented disruptions inflicted by the trauma of the COVID-19 pandemic on our neural circuits. One of the wonders of the human brain is its continuous remodeling due to experiential neuroplasticity, and the formation of dendritic spines that immediately encode the memories of every experience. The turmoil of 2020 and its virulent pandemic will be forever etched into our collective brains, especially in our hippocampi and amygdalae. The impact on the developing brains of our children and grandchildren could be profound and may induce epigenetic changes that trigger psychopathology in the future.^1,2

As with the dinosaurs, the 2020 pandemic is like a “viral asteroid” that left devastation on our social fabric and psychological well-being in its wake. We now have deep empathy with our 1918 ancestors and their tribulations, although so far, in the United States the proportion of people infected with COVID-19 (3% as of mid-November 2020³) is dwarfed by the proportion infected with the influenza virus a century ago (30%). As of mid-November 2020, the number of global COVID-19 deaths (1.3 million³) was a tiny fraction of the 1918 influenza pandemic deaths (50 million worldwide and 675,000 in the United States⁴). Amazingly, researchers did not even know whether the killer germ was a virus or a bacterium until 1930, and it then took another 75 years to decode the genome of the influenza virus in 2005. In contrast, it took only a few short weeks to decode the genome of the virus that causes COVID-19 (severe acute respiratory syndrome-related coronavirus 2), and to begin developing multiple vaccines “at warp speed.” No vaccine or therapies were ever developed for victims of the 1918 pandemic.

An abundance of articles has been published about the pandemic since it ambushed us early in 2020, including many in Current Psychiatry.^5-21 But these publications don’t do justice to the emotional toll of living through the pandemic and witnessing its multi­farious repercussions (Table). It was truly bizarre and shocking for us to see our society and all its components literally come to a standstill, forcing the population to stop working, reducing us to simply “existing” inside our homes, with no socializing, traveling, or interacting. More unbearable than the sudden emptiness and paralysis was the unremitting fear, laced with a profound uncertainty of what was to come or when it would end.

Most psychiatrists are familiar with the Holmes and Rahe Stress Scale,²² which contains 43 life events that cumulatively can progressively increase the odds of physical illness. It is likely that most of the world’s population will score very high on the Holmes and Rahe Stress Scale, which would predict an increased risk of medical illness, even after the pandemic subsides.

Exacerbating the situation is that hospitals and clinics had to shut down most of their operations to focus their resources on treating patients with COVID-19 in ICUs. This halted all routine screenings for cancer and heart, kidney, liver, lung, or brain diseases. In addition, diagnostic or therapeutic procedures such as endoscopies, colonoscopies, angiograms, or biopsies abruptly stopped, resulting in a surge of non–COVID-19 medical disorders and mortality as reported in several articles across many specialties.²³ Going forward, in addition to COVID-19 morbidity and mortality, there is a significant likelihood of an increase in myriad medical disorders. The COVID-19 pandemic is obviously inflicting both direct and indirect casualties as it stretches into the next year and perhaps longer. The only hope for the community of nations is the rapid arrival of evidence-based treatments and vaccine(s).

Continue to: A progression of relentless stress

A progression of relentless stress

At the core of this pandemic is relentless stress. When it began in early 2020, the pandemic ignited an acute stress reaction due to the fear of death and the oddness of being isolated at home. Aggravating the acute stress was the realization that life as we knew it suddenly disappeared and all business or social activities had come to a screeching halt. It was almost surreal when streets usually bustling with human activity (such as Times Square in New York or Michigan Avenue in Chicago) became completely deserted and eerily silent. In addition, more stress was generated from watching television or scrolling through social media and being inundated with morbid and frightening news and updates about the number of individuals who became infected or died, and the official projections of tens of thousands or even hundreds of thousands of fatalities. Further intensifying the stress was hearing that there was a shortage of personal protective equipment (even masks), a lack of ventilators, and the absence of any medications to fight the overwhelming viral infection. Especially stressed were the front-line physicians and nurses, who heroically transcended their fears to save their patients’ lives. The sight of refrigerated trucks serving as temporary morgues outside hospital doors was chilling. The world became a macabre place where people died in hospitals without any relative to hold their hands or comfort them, and then were buried quickly without any formal funerals due to mandatory social distancing. The inability of families to grieve for their loved ones added another poignant layer of sadness and distress to the survivors who were unable to bid their loved ones goodbye. This was a jarring example of adding insult to injury.

With the protraction of the exceptional changes imposed by the pandemic, the acute stress reaction transmuted into posttraumatic stress disorder (PTSD) on a wide scale. Millions of previously healthy individuals began to succumb to the symptoms of PTSD (irritability, hypervigilance, intrusive thoughts, avoidance, insomnia, and bad dreams). The heaviest burden was inflicted on our patients, across all ages, with preexisting psychiatric conditions, who comprise approximately 25% of the population per the classic Epidemiological Catchment Area (ECA) study.²⁴ These vulnerable patients, whom we see in our clinics and hospitals every day, had a significant exacerbation of their psychopathology, including anxiety, depression, psychosis, binge eating disorder, obsessive-compulsive disorder, alcohol and substance use disorders, child abuse, and intimate partner violence.^25,26 The saving grace was the rapid adoption of telepsychiatry, which our psychiatric patients rapidly accepted. Many of them found it more convenient than dressing and driving and parking at the clinic. It also enabled psychiatrists to obtain useful collateral information from family members or partners.

If something good comes from this catastrophic social stress that emotionally hobbled the entire population, it would be the dilution of the stigma of mental illness because everyone has become more empathic due to their personal experience. Optimistically, this may also help expedite true health care parity for psychiatric brain disorders. And perhaps the government may see the need to train more psychiatrists and fund a higher number of residency stipends to all training programs.

Quo vadis COVID-19?

So, looking through the dense fog of the pandemic fatigue, what will 2021 bring us? Will waves of COVID-19 lead to pandemic exhaustion? Will the frayed public mental health care system be able to handle the surge of frayed nerves? Will social distancing intensify the widespread emotional disquietude? Will the children be able to manifest resilience and avoid disabling psychiatric disorders? Will the survivors of COVID-19 infections suffer from post–COVD-19 neuropsychiatric and other medical sequelae? Will efficacious therapies and vaccines emerge to blunt the spread of the virus? Will we all be able to gather in stadiums and arenas to enjoy sporting events, shows, and concerts? Will eating at our favorite restaurants become routine again? Will engaged couples be able to organize well-attended weddings and receptions? Will airplanes and hotels be fully booked again? Importantly, will all children and college students be able to resume their education in person and socialize ad lib? Will we be able to shed our masks and hug each other hello and goodbye? Will scientific journals and social media cover a wide array of topics again as before? Will the number of deaths dwindle to zero, and will we return to worrying mainly about the usual seasonal flu? Will everyone be able to leave home and go to work again?

I hope that the thick dust of this 2020 viral asteroid will settle in 2021, and that “normalcy” is eventually restored to our lives, allowing us to deal with other ongoing stresses such as social unrest and political hyperpartisanship.

Finally, 2020 is coming to an end, but the agony its viral pandemic inflicted on the entire world population will continue for a long time. And much as we would like to forget its damaging effects, it will surely be etched into our brains for the rest of our lives. The children who suffered the pain of the coronavirus disease 2019 (COVID-19) pandemic will endure its emotional scars for the rest of the 21st century.

Reading about the plagues of the past doesn’t come close to experiencing it and suffering through it. COVID-19 will continue to have ripple effects on every aspect of life on this planet, on individuals and on societies all over the world, especially on the biopsychosocial well-being of billions of humans around the globe.

Unprecedented disruptions

Think of the unprecedented disruptions inflicted by the trauma of the COVID-19 pandemic on our neural circuits. One of the wonders of the human brain is its continuous remodeling due to experiential neuroplasticity, and the formation of dendritic spines that immediately encode the memories of every experience. The turmoil of 2020 and its virulent pandemic will be forever etched into our collective brains, especially in our hippocampi and amygdalae. The impact on the developing brains of our children and grandchildren could be profound and may induce epigenetic changes that trigger psychopathology in the future.^1,2

As with the dinosaurs, the 2020 pandemic is like a “viral asteroid” that left devastation on our social fabric and psychological well-being in its wake. We now have deep empathy with our 1918 ancestors and their tribulations, although so far, in the United States the proportion of people infected with COVID-19 (3% as of mid-November 2020³) is dwarfed by the proportion infected with the influenza virus a century ago (30%). As of mid-November 2020, the number of global COVID-19 deaths (1.3 million³) was a tiny fraction of the 1918 influenza pandemic deaths (50 million worldwide and 675,000 in the United States⁴). Amazingly, researchers did not even know whether the killer germ was a virus or a bacterium until 1930, and it then took another 75 years to decode the genome of the influenza virus in 2005. In contrast, it took only a few short weeks to decode the genome of the virus that causes COVID-19 (severe acute respiratory syndrome-related coronavirus 2), and to begin developing multiple vaccines “at warp speed.” No vaccine or therapies were ever developed for victims of the 1918 pandemic.

An abundance of articles has been published about the pandemic since it ambushed us early in 2020, including many in Current Psychiatry.^5-21 But these publications don’t do justice to the emotional toll of living through the pandemic and witnessing its multi­farious repercussions (Table). It was truly bizarre and shocking for us to see our society and all its components literally come to a standstill, forcing the population to stop working, reducing us to simply “existing” inside our homes, with no socializing, traveling, or interacting. More unbearable than the sudden emptiness and paralysis was the unremitting fear, laced with a profound uncertainty of what was to come or when it would end.

Most psychiatrists are familiar with the Holmes and Rahe Stress Scale,²² which contains 43 life events that cumulatively can progressively increase the odds of physical illness. It is likely that most of the world’s population will score very high on the Holmes and Rahe Stress Scale, which would predict an increased risk of medical illness, even after the pandemic subsides.

Exacerbating the situation is that hospitals and clinics had to shut down most of their operations to focus their resources on treating patients with COVID-19 in ICUs. This halted all routine screenings for cancer and heart, kidney, liver, lung, or brain diseases. In addition, diagnostic or therapeutic procedures such as endoscopies, colonoscopies, angiograms, or biopsies abruptly stopped, resulting in a surge of non–COVID-19 medical disorders and mortality as reported in several articles across many specialties.²³ Going forward, in addition to COVID-19 morbidity and mortality, there is a significant likelihood of an increase in myriad medical disorders. The COVID-19 pandemic is obviously inflicting both direct and indirect casualties as it stretches into the next year and perhaps longer. The only hope for the community of nations is the rapid arrival of evidence-based treatments and vaccine(s).

Continue to: A progression of relentless stress

A progression of relentless stress

At the core of this pandemic is relentless stress. When it began in early 2020, the pandemic ignited an acute stress reaction due to the fear of death and the oddness of being isolated at home. Aggravating the acute stress was the realization that life as we knew it suddenly disappeared and all business or social activities had come to a screeching halt. It was almost surreal when streets usually bustling with human activity (such as Times Square in New York or Michigan Avenue in Chicago) became completely deserted and eerily silent. In addition, more stress was generated from watching television or scrolling through social media and being inundated with morbid and frightening news and updates about the number of individuals who became infected or died, and the official projections of tens of thousands or even hundreds of thousands of fatalities. Further intensifying the stress was hearing that there was a shortage of personal protective equipment (even masks), a lack of ventilators, and the absence of any medications to fight the overwhelming viral infection. Especially stressed were the front-line physicians and nurses, who heroically transcended their fears to save their patients’ lives. The sight of refrigerated trucks serving as temporary morgues outside hospital doors was chilling. The world became a macabre place where people died in hospitals without any relative to hold their hands or comfort them, and then were buried quickly without any formal funerals due to mandatory social distancing. The inability of families to grieve for their loved ones added another poignant layer of sadness and distress to the survivors who were unable to bid their loved ones goodbye. This was a jarring example of adding insult to injury.

With the protraction of the exceptional changes imposed by the pandemic, the acute stress reaction transmuted into posttraumatic stress disorder (PTSD) on a wide scale. Millions of previously healthy individuals began to succumb to the symptoms of PTSD (irritability, hypervigilance, intrusive thoughts, avoidance, insomnia, and bad dreams). The heaviest burden was inflicted on our patients, across all ages, with preexisting psychiatric conditions, who comprise approximately 25% of the population per the classic Epidemiological Catchment Area (ECA) study.²⁴ These vulnerable patients, whom we see in our clinics and hospitals every day, had a significant exacerbation of their psychopathology, including anxiety, depression, psychosis, binge eating disorder, obsessive-compulsive disorder, alcohol and substance use disorders, child abuse, and intimate partner violence.^25,26 The saving grace was the rapid adoption of telepsychiatry, which our psychiatric patients rapidly accepted. Many of them found it more convenient than dressing and driving and parking at the clinic. It also enabled psychiatrists to obtain useful collateral information from family members or partners.

If something good comes from this catastrophic social stress that emotionally hobbled the entire population, it would be the dilution of the stigma of mental illness because everyone has become more empathic due to their personal experience. Optimistically, this may also help expedite true health care parity for psychiatric brain disorders. And perhaps the government may see the need to train more psychiatrists and fund a higher number of residency stipends to all training programs.

Quo vadis COVID-19?

So, looking through the dense fog of the pandemic fatigue, what will 2021 bring us? Will waves of COVID-19 lead to pandemic exhaustion? Will the frayed public mental health care system be able to handle the surge of frayed nerves? Will social distancing intensify the widespread emotional disquietude? Will the children be able to manifest resilience and avoid disabling psychiatric disorders? Will the survivors of COVID-19 infections suffer from post–COVD-19 neuropsychiatric and other medical sequelae? Will efficacious therapies and vaccines emerge to blunt the spread of the virus? Will we all be able to gather in stadiums and arenas to enjoy sporting events, shows, and concerts? Will eating at our favorite restaurants become routine again? Will engaged couples be able to organize well-attended weddings and receptions? Will airplanes and hotels be fully booked again? Importantly, will all children and college students be able to resume their education in person and socialize ad lib? Will we be able to shed our masks and hug each other hello and goodbye? Will scientific journals and social media cover a wide array of topics again as before? Will the number of deaths dwindle to zero, and will we return to worrying mainly about the usual seasonal flu? Will everyone be able to leave home and go to work again?

I hope that the thick dust of this 2020 viral asteroid will settle in 2021, and that “normalcy” is eventually restored to our lives, allowing us to deal with other ongoing stresses such as social unrest and political hyperpartisanship.

Finally, 2020 is coming to an end, but the agony its viral pandemic inflicted on the entire world population will continue for a long time. And much as we would like to forget its damaging effects, it will surely be etched into our brains for the rest of our lives. The children who suffered the pain of the coronavirus disease 2019 (COVID-19) pandemic will endure its emotional scars for the rest of the 21st century.

Reading about the plagues of the past doesn’t come close to experiencing it and suffering through it. COVID-19 will continue to have ripple effects on every aspect of life on this planet, on individuals and on societies all over the world, especially on the biopsychosocial well-being of billions of humans around the globe.

Unprecedented disruptions

Think of the unprecedented disruptions inflicted by the trauma of the COVID-19 pandemic on our neural circuits. One of the wonders of the human brain is its continuous remodeling due to experiential neuroplasticity, and the formation of dendritic spines that immediately encode the memories of every experience. The turmoil of 2020 and its virulent pandemic will be forever etched into our collective brains, especially in our hippocampi and amygdalae. The impact on the developing brains of our children and grandchildren could be profound and may induce epigenetic changes that trigger psychopathology in the future.^1,2

As with the dinosaurs, the 2020 pandemic is like a “viral asteroid” that left devastation on our social fabric and psychological well-being in its wake. We now have deep empathy with our 1918 ancestors and their tribulations, although so far, in the United States the proportion of people infected with COVID-19 (3% as of mid-November 2020³) is dwarfed by the proportion infected with the influenza virus a century ago (30%). As of mid-November 2020, the number of global COVID-19 deaths (1.3 million³) was a tiny fraction of the 1918 influenza pandemic deaths (50 million worldwide and 675,000 in the United States⁴). Amazingly, researchers did not even know whether the killer germ was a virus or a bacterium until 1930, and it then took another 75 years to decode the genome of the influenza virus in 2005. In contrast, it took only a few short weeks to decode the genome of the virus that causes COVID-19 (severe acute respiratory syndrome-related coronavirus 2), and to begin developing multiple vaccines “at warp speed.” No vaccine or therapies were ever developed for victims of the 1918 pandemic.

An abundance of articles has been published about the pandemic since it ambushed us early in 2020, including many in Current Psychiatry.^5-21 But these publications don’t do justice to the emotional toll of living through the pandemic and witnessing its multi­farious repercussions (Table). It was truly bizarre and shocking for us to see our society and all its components literally come to a standstill, forcing the population to stop working, reducing us to simply “existing” inside our homes, with no socializing, traveling, or interacting. More unbearable than the sudden emptiness and paralysis was the unremitting fear, laced with a profound uncertainty of what was to come or when it would end.

Most psychiatrists are familiar with the Holmes and Rahe Stress Scale,²² which contains 43 life events that cumulatively can progressively increase the odds of physical illness. It is likely that most of the world’s population will score very high on the Holmes and Rahe Stress Scale, which would predict an increased risk of medical illness, even after the pandemic subsides.

Exacerbating the situation is that hospitals and clinics had to shut down most of their operations to focus their resources on treating patients with COVID-19 in ICUs. This halted all routine screenings for cancer and heart, kidney, liver, lung, or brain diseases. In addition, diagnostic or therapeutic procedures such as endoscopies, colonoscopies, angiograms, or biopsies abruptly stopped, resulting in a surge of non–COVID-19 medical disorders and mortality as reported in several articles across many specialties.²³ Going forward, in addition to COVID-19 morbidity and mortality, there is a significant likelihood of an increase in myriad medical disorders. The COVID-19 pandemic is obviously inflicting both direct and indirect casualties as it stretches into the next year and perhaps longer. The only hope for the community of nations is the rapid arrival of evidence-based treatments and vaccine(s).

Continue to: A progression of relentless stress

A progression of relentless stress

At the core of this pandemic is relentless stress. When it began in early 2020, the pandemic ignited an acute stress reaction due to the fear of death and the oddness of being isolated at home. Aggravating the acute stress was the realization that life as we knew it suddenly disappeared and all business or social activities had come to a screeching halt. It was almost surreal when streets usually bustling with human activity (such as Times Square in New York or Michigan Avenue in Chicago) became completely deserted and eerily silent. In addition, more stress was generated from watching television or scrolling through social media and being inundated with morbid and frightening news and updates about the number of individuals who became infected or died, and the official projections of tens of thousands or even hundreds of thousands of fatalities. Further intensifying the stress was hearing that there was a shortage of personal protective equipment (even masks), a lack of ventilators, and the absence of any medications to fight the overwhelming viral infection. Especially stressed were the front-line physicians and nurses, who heroically transcended their fears to save their patients’ lives. The sight of refrigerated trucks serving as temporary morgues outside hospital doors was chilling. The world became a macabre place where people died in hospitals without any relative to hold their hands or comfort them, and then were buried quickly without any formal funerals due to mandatory social distancing. The inability of families to grieve for their loved ones added another poignant layer of sadness and distress to the survivors who were unable to bid their loved ones goodbye. This was a jarring example of adding insult to injury.

With the protraction of the exceptional changes imposed by the pandemic, the acute stress reaction transmuted into posttraumatic stress disorder (PTSD) on a wide scale. Millions of previously healthy individuals began to succumb to the symptoms of PTSD (irritability, hypervigilance, intrusive thoughts, avoidance, insomnia, and bad dreams). The heaviest burden was inflicted on our patients, across all ages, with preexisting psychiatric conditions, who comprise approximately 25% of the population per the classic Epidemiological Catchment Area (ECA) study.²⁴ These vulnerable patients, whom we see in our clinics and hospitals every day, had a significant exacerbation of their psychopathology, including anxiety, depression, psychosis, binge eating disorder, obsessive-compulsive disorder, alcohol and substance use disorders, child abuse, and intimate partner violence.^25,26 The saving grace was the rapid adoption of telepsychiatry, which our psychiatric patients rapidly accepted. Many of them found it more convenient than dressing and driving and parking at the clinic. It also enabled psychiatrists to obtain useful collateral information from family members or partners.

If something good comes from this catastrophic social stress that emotionally hobbled the entire population, it would be the dilution of the stigma of mental illness because everyone has become more empathic due to their personal experience. Optimistically, this may also help expedite true health care parity for psychiatric brain disorders. And perhaps the government may see the need to train more psychiatrists and fund a higher number of residency stipends to all training programs.

Quo vadis COVID-19?

So, looking through the dense fog of the pandemic fatigue, what will 2021 bring us? Will waves of COVID-19 lead to pandemic exhaustion? Will the frayed public mental health care system be able to handle the surge of frayed nerves? Will social distancing intensify the widespread emotional disquietude? Will the children be able to manifest resilience and avoid disabling psychiatric disorders? Will the survivors of COVID-19 infections suffer from post–COVD-19 neuropsychiatric and other medical sequelae? Will efficacious therapies and vaccines emerge to blunt the spread of the virus? Will we all be able to gather in stadiums and arenas to enjoy sporting events, shows, and concerts? Will eating at our favorite restaurants become routine again? Will engaged couples be able to organize well-attended weddings and receptions? Will airplanes and hotels be fully booked again? Importantly, will all children and college students be able to resume their education in person and socialize ad lib? Will we be able to shed our masks and hug each other hello and goodbye? Will scientific journals and social media cover a wide array of topics again as before? Will the number of deaths dwindle to zero, and will we return to worrying mainly about the usual seasonal flu? Will everyone be able to leave home and go to work again?

I hope that the thick dust of this 2020 viral asteroid will settle in 2021, and that “normalcy” is eventually restored to our lives, allowing us to deal with other ongoing stresses such as social unrest and political hyperpartisanship.

I am a retired advanced practice psychiatric nurse who has lived and worked on “both sides of the door.” This wording is paraphrased from psychologist and therapist Lauren Slater, PhD, who wrote about a time she went to McLean Hospital in Belmont, Massachusetts, as a therapist after staying there as a patient years earlier: “And now I am standing on the other—the wrong, I mean the right side of the door and I ring the buzzer.”¹ Here I tell my story of the physical and emotional effects of my mental illness and treatment.

Onset of bipolar disorder. My bipolar illness started with a bout of depression in 1963 at age 13, which resulted in a low-key summer of often staying inside. I received no medication, and no one sent me for evaluation. In the fall, I went back to school and finished the year without incident. I continued as a quiet, shy kid through high school in the late 1960s. In my senior year, I decided to take an overload of difficult courses and run on the varsity cross-country team. The amount and intensity of these activities were too much. This resulted in my first manic episode, which started during a weekend visit to a college I hoped to attend. I became excitable, grandiose, and had delusions. A day later, I returned home, and my parents had me admitted to a psychiatric hospital, where I remained for 3 months.

At first, my diagnosis was unclear, and initially no one considered what at the time was called manic depression. At that point, I was unaware of my extensive family psychiatric history. My pharmacologic treatment consisted of chlorpromazine, trifluoperazine, and procyclidine. I returned home just before Christmas and barely finished my senior year of high school. A good college accepted me. But during the orientation, I was asked to leave because I experienced a second manic episode. After 4 more psychiatric hospitalizations, I finally stabilized.

During one of my hospitalizations, I had the good fortune to be interviewed by Dr. Thomas Detre. During this interview, I talked expansively about Don Quixote, Aldonza, and Sancho Panza. Dr. Detre diagnosed me with manic depression, and suggested that I see Dr. Christiaan van der Velde, who was researching lithium carbonate.² In 1970, I was hospitalized at Norwich State Hospital in Preston, Connecticut and was started on lithium, even though it had not yet been FDA-approved. I responded well to lithium monotherapy.

An extensive family history. Having bipolar disorder was not something I would discuss with others because I felt ashamed. I commonly hid my medication during college, especially from my roommates or other friends. By then, I had learned a little about my family’s psychiatric history, but I knew few specifics. Over time, I became aware of a dense familial cluster of affective illness going back several generations. My maternal grandmother was hospitalized for depression in 1921 after her husband suddenly died during her fourth pregnancy. She became bereft and suicidal because she had no one to support her 4 children. During my grandmother’s hospitalization, her sister and sister’s husband took care of her children. My grandmother remained hospitalized until she died in 1943. At that time, no medications were available to treat her illness. Over the next 2 generations, 2 of her 4 children and 6 of her 12 grandchildren (including me) developed bipolar disorder.

A career and family. In 1970, I started to work as a nursing assistant, then as a nursing technician for 1.5 years in a specialty hospital in New England. In 1973, I began nursing school at a junior college. I received my RN in 1975, a BS in nursing in 1979, and an MS in psychiatric nursing in 1982. I worked steadily as a psychiatric nurse in both inpatient and outpatient settings from 1975 until I retired in 2019.

In the early 1980s, I married my first wife and had 2 wonderful children. During our courtship in 1981 and 1982, I became hypomanic, which perhaps made me more outgoing and sociable. In 1985, after my father required open heart surgery, I had a manic episode that lasted 1 week. Over the next 20 years, although I was not happy with my marriage, I remained euthymic and productive at work. My marriage ended in 2012.

Continue to: By the end of 2012...

By the end of 2012, I had been taking lithium continuously for 42 years. My laboratory tests showed peak lithium levels between 0.6 and 1.2 mmol/L. I remained otherwise healthy, as demonstrated by annual physical exams and laboratory test results. In 2015, I developed an increase in my blood pressure and my primary care physician (PCP) prescribed oral lisinopril, initially 10 mg/d, and later 10 mg twice daily. My blood pressure improved and ranged from 120/74 to 130/82 mm Hg.

Hyperparathyroidism. By 2016, my psychiatrist, PCP, and nephrologist all urged me to consider parathyroid surgery.^3-5 Hypercalcemia and hyperparathyroidism caused the most worry. Laboratory tests indicated calcium 11.2 mg/dL, parathyroid hormone (PTH) 88 pg/mL, estimated glomerular filtration rate (eGFR) 59 mL/min, and thyroid-stimulating hormone (TSH) 0.78 mIU/L. Electrocardiographysometimes showed a slight QT elongation. A right bundle branch block, which was first noted in 2015, continued. Due to my elevated calcium levels, I eliminated most calcium from my diet. My psychiatrist began to speak more strongly of parathyroid surgery. I then consulted a senior endocrinologist and a senior nephrologist, who each recommended parathyroid surgery.

I remarried in July 2016, and we moved to a different area of the country. My second wife became a stabilizing force for me. My new PCP, however, found elevated high-density lipoproteins during a routine physical examination, and started me on simvastatin, 10 mg/d. My calcium and PTH levels continued to be elevated. My PCP, nephrologist, therapist, and wife urged me to proceed with the parathyroidectomy. After a short period of watchful waiting and a second consultation with a nephrologist, I agreed to schedule a subtotal parathyroidectomy.

Surgery. In spring 2017, I began preparation for parathyroidectomy. At the time, my lithium carbonate dose was 600 mg/d, alternating with 900 mg/d. My peak level of lithium was 0.6 mmol/L. Lisinopril is synergistic, which allowed me to take a smaller effective dose of lithium.

My parathyroid surgery occurred on June 28, 2017 at Norman Parathyroid Center in Tampa, Florida.⁶ The surgeon recorded my parathyroid glands as 136, 602, and 348 units using a measure developed at Norman Parathyroid Center. No reading was given for my fourth parathyroid gland, which they did not remove. Following the surgery, I resumed my previous functions, including employment as a visiting nurse. I initially took calcium supplements after surgery, and my lithium dose was reduced to 300 mg orally, twice daily, which I have continued. I have remained euthymic. On August 3, 2017 my laboratory workup showed an eGFR of 64 mL/min, calcium 10.0 mg/dL, and PTH 17 pg/mL. Vitamin D25 OH 33, glucose, BUN/Cr, electrolytes, complete blood count, and albumin were all within normal limits. Repeat bloodwork on September 19, 2017 showed Ca⁺⁺ 10.1 mg/dL and PTH 18 pg/mL. Nine months after the surgery, I showed an incredibly positive physical and mental response, which has continued to this day.

Continue to: Clinical implications

Clinical implications. This is a single case study. However, it is important for clinicians treating patients with lithium carbonate to regularly order laboratory testing, including for lithium levels, PTH, and calcium, to detect early signs of complications from treatment, including hyperparathyroidism and hypercalcemia.⁷ These levels could be obtained every 6 months. If a patient’s PTH levels are >70 pg/mL and calcium levels are >11.0 mg/dL, it would be prudent to refer him/her for further medical evaluation. Additionally, it would be helpful to counsel the patient about considering alternative medication and adjunct mental health treatment. At some future point, it could be useful for the clinician and his/her patient to explore the idea of parathyroid surgery.

In addition to chronic lithium use, other causes of hyperparathyroidism include an adenoma on a gland, hyperplasia of ≥2 parathyroid glands, a malignant tumor, severe calcium deficiency, severe vitamin D deficiency, chronic renal failure, and (rarely) an inherited gene that causes hyperparathyroidism.

How I’m doing today. Currently, I am euthymic and in a happy marriage. My laboratory workup in May 2020 included glucose 107 mg/dL, Ca⁺⁺ 9.5 mg/dL, eGFR 61 mL/min, PTH 32 pg/mL, lithium 0.3 mmol/L (300 mg twice daily), and TSH 1.79 mIU/L. A comprehensive metabolic panel, complete blood count, and lipid panel were all within normal limits.

I am fortunate to continue having excellent care provided by my PCP, nephrologist, urologist, and psychiatric APRN. Together with these wonderful professionals, I have been able to maintain my physical and mental health.

Acknowledgment: I gratefully acknowledge the help and skills of Robin Scharak and Gary Blake for providing some of the editing on this article.

Bill Greenberg MS, RN, APRN
Delray Beach, Florida

I am a retired advanced practice psychiatric nurse who has lived and worked on “both sides of the door.” This wording is paraphrased from psychologist and therapist Lauren Slater, PhD, who wrote about a time she went to McLean Hospital in Belmont, Massachusetts, as a therapist after staying there as a patient years earlier: “And now I am standing on the other—the wrong, I mean the right side of the door and I ring the buzzer.”¹ Here I tell my story of the physical and emotional effects of my mental illness and treatment.

Onset of bipolar disorder. My bipolar illness started with a bout of depression in 1963 at age 13, which resulted in a low-key summer of often staying inside. I received no medication, and no one sent me for evaluation. In the fall, I went back to school and finished the year without incident. I continued as a quiet, shy kid through high school in the late 1960s. In my senior year, I decided to take an overload of difficult courses and run on the varsity cross-country team. The amount and intensity of these activities were too much. This resulted in my first manic episode, which started during a weekend visit to a college I hoped to attend. I became excitable, grandiose, and had delusions. A day later, I returned home, and my parents had me admitted to a psychiatric hospital, where I remained for 3 months.

At first, my diagnosis was unclear, and initially no one considered what at the time was called manic depression. At that point, I was unaware of my extensive family psychiatric history. My pharmacologic treatment consisted of chlorpromazine, trifluoperazine, and procyclidine. I returned home just before Christmas and barely finished my senior year of high school. A good college accepted me. But during the orientation, I was asked to leave because I experienced a second manic episode. After 4 more psychiatric hospitalizations, I finally stabilized.

During one of my hospitalizations, I had the good fortune to be interviewed by Dr. Thomas Detre. During this interview, I talked expansively about Don Quixote, Aldonza, and Sancho Panza. Dr. Detre diagnosed me with manic depression, and suggested that I see Dr. Christiaan van der Velde, who was researching lithium carbonate.² In 1970, I was hospitalized at Norwich State Hospital in Preston, Connecticut and was started on lithium, even though it had not yet been FDA-approved. I responded well to lithium monotherapy.

An extensive family history. Having bipolar disorder was not something I would discuss with others because I felt ashamed. I commonly hid my medication during college, especially from my roommates or other friends. By then, I had learned a little about my family’s psychiatric history, but I knew few specifics. Over time, I became aware of a dense familial cluster of affective illness going back several generations. My maternal grandmother was hospitalized for depression in 1921 after her husband suddenly died during her fourth pregnancy. She became bereft and suicidal because she had no one to support her 4 children. During my grandmother’s hospitalization, her sister and sister’s husband took care of her children. My grandmother remained hospitalized until she died in 1943. At that time, no medications were available to treat her illness. Over the next 2 generations, 2 of her 4 children and 6 of her 12 grandchildren (including me) developed bipolar disorder.

A career and family. In 1970, I started to work as a nursing assistant, then as a nursing technician for 1.5 years in a specialty hospital in New England. In 1973, I began nursing school at a junior college. I received my RN in 1975, a BS in nursing in 1979, and an MS in psychiatric nursing in 1982. I worked steadily as a psychiatric nurse in both inpatient and outpatient settings from 1975 until I retired in 2019.

In the early 1980s, I married my first wife and had 2 wonderful children. During our courtship in 1981 and 1982, I became hypomanic, which perhaps made me more outgoing and sociable. In 1985, after my father required open heart surgery, I had a manic episode that lasted 1 week. Over the next 20 years, although I was not happy with my marriage, I remained euthymic and productive at work. My marriage ended in 2012.

Continue to: By the end of 2012...

By the end of 2012, I had been taking lithium continuously for 42 years. My laboratory tests showed peak lithium levels between 0.6 and 1.2 mmol/L. I remained otherwise healthy, as demonstrated by annual physical exams and laboratory test results. In 2015, I developed an increase in my blood pressure and my primary care physician (PCP) prescribed oral lisinopril, initially 10 mg/d, and later 10 mg twice daily. My blood pressure improved and ranged from 120/74 to 130/82 mm Hg.

Hyperparathyroidism. By 2016, my psychiatrist, PCP, and nephrologist all urged me to consider parathyroid surgery.^3-5 Hypercalcemia and hyperparathyroidism caused the most worry. Laboratory tests indicated calcium 11.2 mg/dL, parathyroid hormone (PTH) 88 pg/mL, estimated glomerular filtration rate (eGFR) 59 mL/min, and thyroid-stimulating hormone (TSH) 0.78 mIU/L. Electrocardiographysometimes showed a slight QT elongation. A right bundle branch block, which was first noted in 2015, continued. Due to my elevated calcium levels, I eliminated most calcium from my diet. My psychiatrist began to speak more strongly of parathyroid surgery. I then consulted a senior endocrinologist and a senior nephrologist, who each recommended parathyroid surgery.

I remarried in July 2016, and we moved to a different area of the country. My second wife became a stabilizing force for me. My new PCP, however, found elevated high-density lipoproteins during a routine physical examination, and started me on simvastatin, 10 mg/d. My calcium and PTH levels continued to be elevated. My PCP, nephrologist, therapist, and wife urged me to proceed with the parathyroidectomy. After a short period of watchful waiting and a second consultation with a nephrologist, I agreed to schedule a subtotal parathyroidectomy.

Surgery. In spring 2017, I began preparation for parathyroidectomy. At the time, my lithium carbonate dose was 600 mg/d, alternating with 900 mg/d. My peak level of lithium was 0.6 mmol/L. Lisinopril is synergistic, which allowed me to take a smaller effective dose of lithium.

My parathyroid surgery occurred on June 28, 2017 at Norman Parathyroid Center in Tampa, Florida.⁶ The surgeon recorded my parathyroid glands as 136, 602, and 348 units using a measure developed at Norman Parathyroid Center. No reading was given for my fourth parathyroid gland, which they did not remove. Following the surgery, I resumed my previous functions, including employment as a visiting nurse. I initially took calcium supplements after surgery, and my lithium dose was reduced to 300 mg orally, twice daily, which I have continued. I have remained euthymic. On August 3, 2017 my laboratory workup showed an eGFR of 64 mL/min, calcium 10.0 mg/dL, and PTH 17 pg/mL. Vitamin D25 OH 33, glucose, BUN/Cr, electrolytes, complete blood count, and albumin were all within normal limits. Repeat bloodwork on September 19, 2017 showed Ca⁺⁺ 10.1 mg/dL and PTH 18 pg/mL. Nine months after the surgery, I showed an incredibly positive physical and mental response, which has continued to this day.

Continue to: Clinical implications

Clinical implications. This is a single case study. However, it is important for clinicians treating patients with lithium carbonate to regularly order laboratory testing, including for lithium levels, PTH, and calcium, to detect early signs of complications from treatment, including hyperparathyroidism and hypercalcemia.⁷ These levels could be obtained every 6 months. If a patient’s PTH levels are >70 pg/mL and calcium levels are >11.0 mg/dL, it would be prudent to refer him/her for further medical evaluation. Additionally, it would be helpful to counsel the patient about considering alternative medication and adjunct mental health treatment. At some future point, it could be useful for the clinician and his/her patient to explore the idea of parathyroid surgery.

In addition to chronic lithium use, other causes of hyperparathyroidism include an adenoma on a gland, hyperplasia of ≥2 parathyroid glands, a malignant tumor, severe calcium deficiency, severe vitamin D deficiency, chronic renal failure, and (rarely) an inherited gene that causes hyperparathyroidism.

How I’m doing today. Currently, I am euthymic and in a happy marriage. My laboratory workup in May 2020 included glucose 107 mg/dL, Ca⁺⁺ 9.5 mg/dL, eGFR 61 mL/min, PTH 32 pg/mL, lithium 0.3 mmol/L (300 mg twice daily), and TSH 1.79 mIU/L. A comprehensive metabolic panel, complete blood count, and lipid panel were all within normal limits.

I am fortunate to continue having excellent care provided by my PCP, nephrologist, urologist, and psychiatric APRN. Together with these wonderful professionals, I have been able to maintain my physical and mental health.

Acknowledgment: I gratefully acknowledge the help and skills of Robin Scharak and Gary Blake for providing some of the editing on this article.

Bill Greenberg MS, RN, APRN
Delray Beach, Florida

I am a retired advanced practice psychiatric nurse who has lived and worked on “both sides of the door.” This wording is paraphrased from psychologist and therapist Lauren Slater, PhD, who wrote about a time she went to McLean Hospital in Belmont, Massachusetts, as a therapist after staying there as a patient years earlier: “And now I am standing on the other—the wrong, I mean the right side of the door and I ring the buzzer.”¹ Here I tell my story of the physical and emotional effects of my mental illness and treatment.

Onset of bipolar disorder. My bipolar illness started with a bout of depression in 1963 at age 13, which resulted in a low-key summer of often staying inside. I received no medication, and no one sent me for evaluation. In the fall, I went back to school and finished the year without incident. I continued as a quiet, shy kid through high school in the late 1960s. In my senior year, I decided to take an overload of difficult courses and run on the varsity cross-country team. The amount and intensity of these activities were too much. This resulted in my first manic episode, which started during a weekend visit to a college I hoped to attend. I became excitable, grandiose, and had delusions. A day later, I returned home, and my parents had me admitted to a psychiatric hospital, where I remained for 3 months.

At first, my diagnosis was unclear, and initially no one considered what at the time was called manic depression. At that point, I was unaware of my extensive family psychiatric history. My pharmacologic treatment consisted of chlorpromazine, trifluoperazine, and procyclidine. I returned home just before Christmas and barely finished my senior year of high school. A good college accepted me. But during the orientation, I was asked to leave because I experienced a second manic episode. After 4 more psychiatric hospitalizations, I finally stabilized.

During one of my hospitalizations, I had the good fortune to be interviewed by Dr. Thomas Detre. During this interview, I talked expansively about Don Quixote, Aldonza, and Sancho Panza. Dr. Detre diagnosed me with manic depression, and suggested that I see Dr. Christiaan van der Velde, who was researching lithium carbonate.² In 1970, I was hospitalized at Norwich State Hospital in Preston, Connecticut and was started on lithium, even though it had not yet been FDA-approved. I responded well to lithium monotherapy.

An extensive family history. Having bipolar disorder was not something I would discuss with others because I felt ashamed. I commonly hid my medication during college, especially from my roommates or other friends. By then, I had learned a little about my family’s psychiatric history, but I knew few specifics. Over time, I became aware of a dense familial cluster of affective illness going back several generations. My maternal grandmother was hospitalized for depression in 1921 after her husband suddenly died during her fourth pregnancy. She became bereft and suicidal because she had no one to support her 4 children. During my grandmother’s hospitalization, her sister and sister’s husband took care of her children. My grandmother remained hospitalized until she died in 1943. At that time, no medications were available to treat her illness. Over the next 2 generations, 2 of her 4 children and 6 of her 12 grandchildren (including me) developed bipolar disorder.

A career and family. In 1970, I started to work as a nursing assistant, then as a nursing technician for 1.5 years in a specialty hospital in New England. In 1973, I began nursing school at a junior college. I received my RN in 1975, a BS in nursing in 1979, and an MS in psychiatric nursing in 1982. I worked steadily as a psychiatric nurse in both inpatient and outpatient settings from 1975 until I retired in 2019.

In the early 1980s, I married my first wife and had 2 wonderful children. During our courtship in 1981 and 1982, I became hypomanic, which perhaps made me more outgoing and sociable. In 1985, after my father required open heart surgery, I had a manic episode that lasted 1 week. Over the next 20 years, although I was not happy with my marriage, I remained euthymic and productive at work. My marriage ended in 2012.

Continue to: By the end of 2012...

By the end of 2012, I had been taking lithium continuously for 42 years. My laboratory tests showed peak lithium levels between 0.6 and 1.2 mmol/L. I remained otherwise healthy, as demonstrated by annual physical exams and laboratory test results. In 2015, I developed an increase in my blood pressure and my primary care physician (PCP) prescribed oral lisinopril, initially 10 mg/d, and later 10 mg twice daily. My blood pressure improved and ranged from 120/74 to 130/82 mm Hg.

Hyperparathyroidism. By 2016, my psychiatrist, PCP, and nephrologist all urged me to consider parathyroid surgery.^3-5 Hypercalcemia and hyperparathyroidism caused the most worry. Laboratory tests indicated calcium 11.2 mg/dL, parathyroid hormone (PTH) 88 pg/mL, estimated glomerular filtration rate (eGFR) 59 mL/min, and thyroid-stimulating hormone (TSH) 0.78 mIU/L. Electrocardiographysometimes showed a slight QT elongation. A right bundle branch block, which was first noted in 2015, continued. Due to my elevated calcium levels, I eliminated most calcium from my diet. My psychiatrist began to speak more strongly of parathyroid surgery. I then consulted a senior endocrinologist and a senior nephrologist, who each recommended parathyroid surgery.

I remarried in July 2016, and we moved to a different area of the country. My second wife became a stabilizing force for me. My new PCP, however, found elevated high-density lipoproteins during a routine physical examination, and started me on simvastatin, 10 mg/d. My calcium and PTH levels continued to be elevated. My PCP, nephrologist, therapist, and wife urged me to proceed with the parathyroidectomy. After a short period of watchful waiting and a second consultation with a nephrologist, I agreed to schedule a subtotal parathyroidectomy.

Surgery. In spring 2017, I began preparation for parathyroidectomy. At the time, my lithium carbonate dose was 600 mg/d, alternating with 900 mg/d. My peak level of lithium was 0.6 mmol/L. Lisinopril is synergistic, which allowed me to take a smaller effective dose of lithium.

My parathyroid surgery occurred on June 28, 2017 at Norman Parathyroid Center in Tampa, Florida.⁶ The surgeon recorded my parathyroid glands as 136, 602, and 348 units using a measure developed at Norman Parathyroid Center. No reading was given for my fourth parathyroid gland, which they did not remove. Following the surgery, I resumed my previous functions, including employment as a visiting nurse. I initially took calcium supplements after surgery, and my lithium dose was reduced to 300 mg orally, twice daily, which I have continued. I have remained euthymic. On August 3, 2017 my laboratory workup showed an eGFR of 64 mL/min, calcium 10.0 mg/dL, and PTH 17 pg/mL. Vitamin D25 OH 33, glucose, BUN/Cr, electrolytes, complete blood count, and albumin were all within normal limits. Repeat bloodwork on September 19, 2017 showed Ca⁺⁺ 10.1 mg/dL and PTH 18 pg/mL. Nine months after the surgery, I showed an incredibly positive physical and mental response, which has continued to this day.

Continue to: Clinical implications

Clinical implications. This is a single case study. However, it is important for clinicians treating patients with lithium carbonate to regularly order laboratory testing, including for lithium levels, PTH, and calcium, to detect early signs of complications from treatment, including hyperparathyroidism and hypercalcemia.⁷ These levels could be obtained every 6 months. If a patient’s PTH levels are >70 pg/mL and calcium levels are >11.0 mg/dL, it would be prudent to refer him/her for further medical evaluation. Additionally, it would be helpful to counsel the patient about considering alternative medication and adjunct mental health treatment. At some future point, it could be useful for the clinician and his/her patient to explore the idea of parathyroid surgery.

In addition to chronic lithium use, other causes of hyperparathyroidism include an adenoma on a gland, hyperplasia of ≥2 parathyroid glands, a malignant tumor, severe calcium deficiency, severe vitamin D deficiency, chronic renal failure, and (rarely) an inherited gene that causes hyperparathyroidism.

How I’m doing today. Currently, I am euthymic and in a happy marriage. My laboratory workup in May 2020 included glucose 107 mg/dL, Ca⁺⁺ 9.5 mg/dL, eGFR 61 mL/min, PTH 32 pg/mL, lithium 0.3 mmol/L (300 mg twice daily), and TSH 1.79 mIU/L. A comprehensive metabolic panel, complete blood count, and lipid panel were all within normal limits.

I am fortunate to continue having excellent care provided by my PCP, nephrologist, urologist, and psychiatric APRN. Together with these wonderful professionals, I have been able to maintain my physical and mental health.

Acknowledgment: I gratefully acknowledge the help and skills of Robin Scharak and Gary Blake for providing some of the editing on this article.

Bill Greenberg MS, RN, APRN
Delray Beach, Florida

The coronavirus disease 2019 (COVID-19) pandemic has evoked extreme fear at a collective level. In the current health care climate of quick fixes and high-acuity workloads, there is a potential to value efficiency over the process. Such demands can endanger clinicians’ internal emotional needs, create conflicts, and potentially impact their relationships with patients and families. What does this mean for a psychiatry trainee? Here I share some insights about death anxiety, and how psychiatry training promotes self-reflection, which shapes our relationship with death.

The far-reaching effects of death anxiety

Postgraduate psychiatry training may expose one to stressful situations with adverse psychologic consequences.¹ Further­more, when caring for patients, psychiatry trainees frequently need to face issues of death and dying in the form of suicide risk assessments, grief and bereavement processes, near-death experiences, posttraumatic stress disorder, and psycho-oncology rotations. Because these interactions are incredibly personal, the emotions they provoke inevitably affect every interaction, theoretical discussion, diagnostic work-up, and treatment plan.

How each of us experiences death anxiety is unique. For some, it could be a fear of nonexistence, ultimate loss, disruption of the flow of life, worry about leaving loved ones behind, or fear of pain or loneliness in dying. Some might fear an untimely or violent death and subsequent judgment and retributions. The literature suggests that fear of death may be at the root of various mental health problems and, if left unaddressed, may adversely impact long-term treatment outcomes.² Despite this, many standard treatment approaches typically do not target death anxiety, which potentially contributes to a “revolving door” of mental health problems.³

American existential psychiatrist Irvin Yalom, MD, cautioned psychiatrists not to “scratch where it does not itch.”⁴ Yet death, according to Dr. Yalom, does itch. Violent death is that caused by human intent or negligence, and is characterized by feeling helpless and terrorized at the time of dying. It may occur as an acute incident that denies the dying individual and his/her family members the time and space to prepare for the death.⁵ For survivors, accommodating the mental, emotional, psychological, and spiritual effects of violent death is a complex process that rarely has a conclusion. It often is accompanied by survivors’ guilt, which is replayed in the form of flashbacks and nightmares.⁶ With this understanding, I view COVID-19 deaths as violent deaths.

Pay close attention to countertransference

As much as we influence our patients and their families, we also are profoundly influenced by them. We need to pay attention to any feelings our clinical encounters generate within us, and to carefully use these feelings in our clinical judgment, and not just make causal inferences. For instance, if a clinician thinks that a patient with suicidal ideation would be better off dead, these feelings are a reliable indicator that the patient is, indeed, at a high risk of completing suicide.⁷ It is our ethical and moral responsibility towards our patients to listen to our countertransference responses. The aim is to identify countertransference and use it to inform us, not to rule us. By taking an active role in managing our emotional responses in the face of loss, we can harness the spirit of resilience. This is not always as easy as it seems. We need our peers, experienced clinicians, and supervisors to help us explore our feelings, resistances, and counter­transference reactions.

Strategies to combat burnout

Psychiatric trainees must be encouraged to establish and maintain rigorous plans of self-care to prevent compassion fatigue and burnout. Most importantly, training programs must diversify residents’ clinical exposure by providing activities that promote mental health promotion activities, scholarly endeavors, and peer support groups. This will help trainees to restore meaning and purpose in life beyond.

The coronavirus disease 2019 (COVID-19) pandemic has evoked extreme fear at a collective level. In the current health care climate of quick fixes and high-acuity workloads, there is a potential to value efficiency over the process. Such demands can endanger clinicians’ internal emotional needs, create conflicts, and potentially impact their relationships with patients and families. What does this mean for a psychiatry trainee? Here I share some insights about death anxiety, and how psychiatry training promotes self-reflection, which shapes our relationship with death.

The far-reaching effects of death anxiety

Postgraduate psychiatry training may expose one to stressful situations with adverse psychologic consequences.¹ Further­more, when caring for patients, psychiatry trainees frequently need to face issues of death and dying in the form of suicide risk assessments, grief and bereavement processes, near-death experiences, posttraumatic stress disorder, and psycho-oncology rotations. Because these interactions are incredibly personal, the emotions they provoke inevitably affect every interaction, theoretical discussion, diagnostic work-up, and treatment plan.

How each of us experiences death anxiety is unique. For some, it could be a fear of nonexistence, ultimate loss, disruption of the flow of life, worry about leaving loved ones behind, or fear of pain or loneliness in dying. Some might fear an untimely or violent death and subsequent judgment and retributions. The literature suggests that fear of death may be at the root of various mental health problems and, if left unaddressed, may adversely impact long-term treatment outcomes.² Despite this, many standard treatment approaches typically do not target death anxiety, which potentially contributes to a “revolving door” of mental health problems.³

American existential psychiatrist Irvin Yalom, MD, cautioned psychiatrists not to “scratch where it does not itch.”⁴ Yet death, according to Dr. Yalom, does itch. Violent death is that caused by human intent or negligence, and is characterized by feeling helpless and terrorized at the time of dying. It may occur as an acute incident that denies the dying individual and his/her family members the time and space to prepare for the death.⁵ For survivors, accommodating the mental, emotional, psychological, and spiritual effects of violent death is a complex process that rarely has a conclusion. It often is accompanied by survivors’ guilt, which is replayed in the form of flashbacks and nightmares.⁶ With this understanding, I view COVID-19 deaths as violent deaths.

Pay close attention to countertransference

As much as we influence our patients and their families, we also are profoundly influenced by them. We need to pay attention to any feelings our clinical encounters generate within us, and to carefully use these feelings in our clinical judgment, and not just make causal inferences. For instance, if a clinician thinks that a patient with suicidal ideation would be better off dead, these feelings are a reliable indicator that the patient is, indeed, at a high risk of completing suicide.⁷ It is our ethical and moral responsibility towards our patients to listen to our countertransference responses. The aim is to identify countertransference and use it to inform us, not to rule us. By taking an active role in managing our emotional responses in the face of loss, we can harness the spirit of resilience. This is not always as easy as it seems. We need our peers, experienced clinicians, and supervisors to help us explore our feelings, resistances, and counter­transference reactions.

Strategies to combat burnout

Psychiatric trainees must be encouraged to establish and maintain rigorous plans of self-care to prevent compassion fatigue and burnout. Most importantly, training programs must diversify residents’ clinical exposure by providing activities that promote mental health promotion activities, scholarly endeavors, and peer support groups. This will help trainees to restore meaning and purpose in life beyond.

The coronavirus disease 2019 (COVID-19) pandemic has evoked extreme fear at a collective level. In the current health care climate of quick fixes and high-acuity workloads, there is a potential to value efficiency over the process. Such demands can endanger clinicians’ internal emotional needs, create conflicts, and potentially impact their relationships with patients and families. What does this mean for a psychiatry trainee? Here I share some insights about death anxiety, and how psychiatry training promotes self-reflection, which shapes our relationship with death.

The far-reaching effects of death anxiety

Postgraduate psychiatry training may expose one to stressful situations with adverse psychologic consequences.¹ Further­more, when caring for patients, psychiatry trainees frequently need to face issues of death and dying in the form of suicide risk assessments, grief and bereavement processes, near-death experiences, posttraumatic stress disorder, and psycho-oncology rotations. Because these interactions are incredibly personal, the emotions they provoke inevitably affect every interaction, theoretical discussion, diagnostic work-up, and treatment plan.

How each of us experiences death anxiety is unique. For some, it could be a fear of nonexistence, ultimate loss, disruption of the flow of life, worry about leaving loved ones behind, or fear of pain or loneliness in dying. Some might fear an untimely or violent death and subsequent judgment and retributions. The literature suggests that fear of death may be at the root of various mental health problems and, if left unaddressed, may adversely impact long-term treatment outcomes.² Despite this, many standard treatment approaches typically do not target death anxiety, which potentially contributes to a “revolving door” of mental health problems.³

American existential psychiatrist Irvin Yalom, MD, cautioned psychiatrists not to “scratch where it does not itch.”⁴ Yet death, according to Dr. Yalom, does itch. Violent death is that caused by human intent or negligence, and is characterized by feeling helpless and terrorized at the time of dying. It may occur as an acute incident that denies the dying individual and his/her family members the time and space to prepare for the death.⁵ For survivors, accommodating the mental, emotional, psychological, and spiritual effects of violent death is a complex process that rarely has a conclusion. It often is accompanied by survivors’ guilt, which is replayed in the form of flashbacks and nightmares.⁶ With this understanding, I view COVID-19 deaths as violent deaths.

Pay close attention to countertransference

As much as we influence our patients and their families, we also are profoundly influenced by them. We need to pay attention to any feelings our clinical encounters generate within us, and to carefully use these feelings in our clinical judgment, and not just make causal inferences. For instance, if a clinician thinks that a patient with suicidal ideation would be better off dead, these feelings are a reliable indicator that the patient is, indeed, at a high risk of completing suicide.⁷ It is our ethical and moral responsibility towards our patients to listen to our countertransference responses. The aim is to identify countertransference and use it to inform us, not to rule us. By taking an active role in managing our emotional responses in the face of loss, we can harness the spirit of resilience. This is not always as easy as it seems. We need our peers, experienced clinicians, and supervisors to help us explore our feelings, resistances, and counter­transference reactions.

Strategies to combat burnout

Psychiatric trainees must be encouraged to establish and maintain rigorous plans of self-care to prevent compassion fatigue and burnout. Most importantly, training programs must diversify residents’ clinical exposure by providing activities that promote mental health promotion activities, scholarly endeavors, and peer support groups. This will help trainees to restore meaning and purpose in life beyond.

Since the start of the pandemic, we have been conducting an extra hour of Virtual Rounds at the Center for Women’s Mental Health. Virtual Rounds has been an opportunity to discuss cases around a spectrum of clinical management issues with respect to depression, bipolar disorder, and a spectrum of anxiety disorders like obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and generalized anxiety disorder. How to apply the calculus of risk-benefit decision-making around management of psychiatric disorder during pregnancy and the postpartum period has been the cornerstone of the work at our center for over 2 decades.

When we went virtual at our center in the early Spring, we decided to keep the format of our faculty rounds the way they have been for years and to sustain cohesiveness of our program during the pandemic. But we thought the needs of pregnant and postpartum women warranted being addressed in a context more specific to COVID-19, and also that reproductive psychiatrists and other clinicians could learn from each other about novel issues coming up for this group of patients during the pandemic. With that backdrop, Marlene Freeman, MD, and I founded “Virtual Rounds at the Center” to respond to queries from our colleagues across the country; we do this just after our own rounds on Wednesdays at 2:00 p.m.

As the pandemic has progressed, Virtual Rounds has blossomed into a virtual community on the Zoom platform, where social workers, psychologists, nurse prescribers, psychiatrists, and obstetricians discuss the needs of pregnant and postpartum women specific to COVID-19. Frequently, our discussions involve a review of the risks and benefits of treatment before, during, and after pregnancy.

Seemingly, week to week, more and more colleagues raise questions about the treatment of anxiety and insomnia during pregnancy and the postpartum period. I’ve spoken in previous columns about the enhanced use of telemedicine. Telemedicine not only facilitates efforts like Virtual Rounds and our ability to reach out to colleagues across the country and share cases, but also has allowed us to keep even closer tabs on the emotional well-being of our pregnant and postpartum women during COVID-19.

The question is not just about the effects of a medicine that a woman might take to treat anxiety or insomnia during pregnancy, but the experience of the pandemic per se, which we are measuring in multiple studies now using a variety of psychological instruments that patients complete. The pandemic is unequivocally taking a still unquantified toll on the mental health of Americans and potentially on the next generation to come.

Midcycle awakening during pregnancy

Complaints of insomnia and midcycle awakening during pregnancy are not new – it is the rule, rather than the exception for many pregnant women, particularly later in pregnancy. We have unequivocally seen a worsening of complaints of sleep disruption including insomnia and midcycle awakening during the pandemic that is greater than what we have seen previously. Both patients and colleagues have asked us the safest ways to manage it. One of the first things we consider when we hear about insomnia is whether it is part of an underlying mood disorder. While we see primary insomnia clinically, it really is important to remember that insomnia can be part and parcel of an underlying mood disorder.

With that in mind, what are the options? During the pandemic, we’ve seen an increased use of digital cognitive behavioral therapy for insomnia (CBT-I) for patients who cannot initiate sleep, which has a very strong evidence base for effectiveness as a first-line intervention for many.

If a patient has an incomplete response to CBT-I, what might be pursued next? In our center, we have a low threshold for using low doses of benzodiazepines, such as lorazepam or clonazepam, because the majority of data do not support an increased risk of major congenital malformations even when used in the first trimester. It is quite common to see medicines such as newer nonbenzodiazepine sedative hypnotics such as Ambien CR (zolpidem) or Lunesta (eszopiclone) used by our colleagues in ob.gyn. The reproductive safety data on those medicines are particularly sparse, and they may have greater risk of cognitive side effects the next day, so we tend to avoid them.

Another sometimes-forgotten option to consider is using low doses of tricyclic antidepressants (i.e., 10-25 mg of nortriptyline at bedtime), with tricyclics having a 40-year history and at least one pooled analysis showing the absence of increased risk for major congenital malformations when used. This may be a very easy way of managing insomnia, with low-dose tricyclics having an anxiolytic effect as well.

Anxiety during pregnancy

The most common rise in symptoms during COVID-19 for women who are pregnant or post partum has been an increase in anxiety. Women present with a spectrum of concerns leading to anxiety symptoms in the context of the pandemic. Earlier on in the pandemic, concerns focused mostly on how to stay healthy, and how to mitigate risk and not catch SARS-CoV-2 during pregnancy, as well as the very complex issues that were playing out in real time as hospital systems were figuring out how to manage pregnant women in labor and to keep both them and staff safe. Over time, anxiety has shifted to still staying safe during the pandemic and the potential impact of SARS-CoV-2 infection on pregnancy outcomes. The No. 1 concern is what the implications of COVID-19 disease are on mother and child. New mothers also are anxious about how they will practically navigate life with a newborn in the postpartum setting.

Early on in the pandemic, some hospital systems severely limited who was in the room with a woman during labor, potentially impeding the wishes of women during delivery who would have wanted their loved ones and/or a doula present, as an example. With enhanced testing available now, protocols have since relaxed in many hospitals to allow partners – but not a team – to remain in the hospital during the labor process. Still, the prospect of delivering during a pandemic is undoubtedly a source of anxiety for some women.

This sort of anxiety, particularly in patients with preexisting anxiety disorders, can be particularly challenging. Fortunately, there has been a rapid increase over the last several years of digital apps to mitigate anxiety. While many of them have not been systematically studied, the data on biobehavioral intervention for anxiety is enormous, and this should be used as first-line treatment for patients with mild to moderate symptoms; so many women would prefer to avoid pharmacological intervention during pregnancy, if possible, to avoid fetal drug exposure. For patients who meet criteria for frank anxiety disorder, other nonpharmacologic interventions such as CBT have been shown to be effective.

Frequently, we see women who are experiencing levels of anxiety where nonpharmacological interventions have an incomplete response, and colleagues have asked about the safest way to treat these patients. As has been discussed in multiple previous columns, selective serotonin reuptake inhibitors (SSRIs) should be thought of sooner rather than later, particularly with medicines with good reproductive safety data such as sertraline, citalopram, or fluoxetine.

We also reported over 15 years ago that at least 30%-40% of women presenting with histories of recurrent major depression at the beginning of pregnancy had comorbid anxiety disorders, and that the use of benzodiazepines in that population in addition to SSRIs was exceedingly common, with doses of approximately 0.5-1.5 mg of clonazepam or lorazepam being standard fare. Again, this is very appropriate treatment to mitigate anxiety symptoms because now have enough data as a field that support the existence of adverse outcomes associated with untreated anxiety during pregnancy in terms of both adverse obstetric and neonatal outcomes, higher rates of preterm birth, and other obstetric complications. Hence, managing anxiety during pregnancy should be considered like managing a toxic exposure – the same way that one would be concerned about anything else that a pregnant woman could be exposed to.

Lastly, although no atypical antipsychotic has been approved for the treatment of anxiety, its use off label is extremely common. More and more data support the absence of a signal of teratogenicity across the family of molecules including atypical antipsychotics. Beyond potential use of atypical antipsychotics, at Virtual Rounds last week, a colleague asked about the use of gabapentin in a patient who was diagnosed with substance use disorder and who had inadvertently conceived on gabapentin, which was being used to treat both anxiety and insomnia. We have typically avoided the use of gabapentin during pregnancy because prospective data have been limited to relatively small case series and one report, with a total of exposures in roughly the 300 range.

However, our colleagues at the Harvard School of Public Health have recently published an article that looked at the United States Medicaid Analytic eXtract (MAX) dataset, which has been used to publish other articles addressing atypical antipsychotics, SSRIs, lithium, and pharmacovigilance investigations among other important topics. In this study, the database was used to look specifically at 4,642 pregnancies with gabapentin exposure relative to 1,744,447 unexposed pregnancies, without a significant finding for increased risk for major congenital malformations.

The question of an increased risk of cardiac malformations and of increased risk for obstetric complications are difficult to untangle from anxiety and depression, as they also are associated with those same outcomes. With that said, the analysis is a welcome addition to our knowledge base for a medicine used more widely to treat symptoms such as anxiety and insomnia in the general population, with a question mark around where it may fit into the algorithm during pregnancy.

In our center, gabapentin still would not be used as a first-line treatment for the management of anxiety or insomnia during pregnancy. But these new data still are reassuring for patients who come in, frequently with unplanned pregnancies. It is an important reminder to those of us taking care of patients during the pandemic to review use of contraception, because although data are unavailable specific to the period of the pandemic, what is clear is that, even prior to COVID-19, 50% of pregnancies in America were unplanned. Addressing issues of reliable use of contraception, particularly during the pandemic, is that much more important.

In this particular case, our clinician colleague in Virtual Rounds decided to continue gabapentin across pregnancy in the context of these reassuring data, but others may choose to discontinue or pursue some of the other treatment options noted above.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.

Since the start of the pandemic, we have been conducting an extra hour of Virtual Rounds at the Center for Women’s Mental Health. Virtual Rounds has been an opportunity to discuss cases around a spectrum of clinical management issues with respect to depression, bipolar disorder, and a spectrum of anxiety disorders like obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and generalized anxiety disorder. How to apply the calculus of risk-benefit decision-making around management of psychiatric disorder during pregnancy and the postpartum period has been the cornerstone of the work at our center for over 2 decades.

When we went virtual at our center in the early Spring, we decided to keep the format of our faculty rounds the way they have been for years and to sustain cohesiveness of our program during the pandemic. But we thought the needs of pregnant and postpartum women warranted being addressed in a context more specific to COVID-19, and also that reproductive psychiatrists and other clinicians could learn from each other about novel issues coming up for this group of patients during the pandemic. With that backdrop, Marlene Freeman, MD, and I founded “Virtual Rounds at the Center” to respond to queries from our colleagues across the country; we do this just after our own rounds on Wednesdays at 2:00 p.m.

As the pandemic has progressed, Virtual Rounds has blossomed into a virtual community on the Zoom platform, where social workers, psychologists, nurse prescribers, psychiatrists, and obstetricians discuss the needs of pregnant and postpartum women specific to COVID-19. Frequently, our discussions involve a review of the risks and benefits of treatment before, during, and after pregnancy.

Seemingly, week to week, more and more colleagues raise questions about the treatment of anxiety and insomnia during pregnancy and the postpartum period. I’ve spoken in previous columns about the enhanced use of telemedicine. Telemedicine not only facilitates efforts like Virtual Rounds and our ability to reach out to colleagues across the country and share cases, but also has allowed us to keep even closer tabs on the emotional well-being of our pregnant and postpartum women during COVID-19.

The question is not just about the effects of a medicine that a woman might take to treat anxiety or insomnia during pregnancy, but the experience of the pandemic per se, which we are measuring in multiple studies now using a variety of psychological instruments that patients complete. The pandemic is unequivocally taking a still unquantified toll on the mental health of Americans and potentially on the next generation to come.

Midcycle awakening during pregnancy

Complaints of insomnia and midcycle awakening during pregnancy are not new – it is the rule, rather than the exception for many pregnant women, particularly later in pregnancy. We have unequivocally seen a worsening of complaints of sleep disruption including insomnia and midcycle awakening during the pandemic that is greater than what we have seen previously. Both patients and colleagues have asked us the safest ways to manage it. One of the first things we consider when we hear about insomnia is whether it is part of an underlying mood disorder. While we see primary insomnia clinically, it really is important to remember that insomnia can be part and parcel of an underlying mood disorder.

With that in mind, what are the options? During the pandemic, we’ve seen an increased use of digital cognitive behavioral therapy for insomnia (CBT-I) for patients who cannot initiate sleep, which has a very strong evidence base for effectiveness as a first-line intervention for many.

If a patient has an incomplete response to CBT-I, what might be pursued next? In our center, we have a low threshold for using low doses of benzodiazepines, such as lorazepam or clonazepam, because the majority of data do not support an increased risk of major congenital malformations even when used in the first trimester. It is quite common to see medicines such as newer nonbenzodiazepine sedative hypnotics such as Ambien CR (zolpidem) or Lunesta (eszopiclone) used by our colleagues in ob.gyn. The reproductive safety data on those medicines are particularly sparse, and they may have greater risk of cognitive side effects the next day, so we tend to avoid them.

Another sometimes-forgotten option to consider is using low doses of tricyclic antidepressants (i.e., 10-25 mg of nortriptyline at bedtime), with tricyclics having a 40-year history and at least one pooled analysis showing the absence of increased risk for major congenital malformations when used. This may be a very easy way of managing insomnia, with low-dose tricyclics having an anxiolytic effect as well.

Anxiety during pregnancy

The most common rise in symptoms during COVID-19 for women who are pregnant or post partum has been an increase in anxiety. Women present with a spectrum of concerns leading to anxiety symptoms in the context of the pandemic. Earlier on in the pandemic, concerns focused mostly on how to stay healthy, and how to mitigate risk and not catch SARS-CoV-2 during pregnancy, as well as the very complex issues that were playing out in real time as hospital systems were figuring out how to manage pregnant women in labor and to keep both them and staff safe. Over time, anxiety has shifted to still staying safe during the pandemic and the potential impact of SARS-CoV-2 infection on pregnancy outcomes. The No. 1 concern is what the implications of COVID-19 disease are on mother and child. New mothers also are anxious about how they will practically navigate life with a newborn in the postpartum setting.

Early on in the pandemic, some hospital systems severely limited who was in the room with a woman during labor, potentially impeding the wishes of women during delivery who would have wanted their loved ones and/or a doula present, as an example. With enhanced testing available now, protocols have since relaxed in many hospitals to allow partners – but not a team – to remain in the hospital during the labor process. Still, the prospect of delivering during a pandemic is undoubtedly a source of anxiety for some women.

This sort of anxiety, particularly in patients with preexisting anxiety disorders, can be particularly challenging. Fortunately, there has been a rapid increase over the last several years of digital apps to mitigate anxiety. While many of them have not been systematically studied, the data on biobehavioral intervention for anxiety is enormous, and this should be used as first-line treatment for patients with mild to moderate symptoms; so many women would prefer to avoid pharmacological intervention during pregnancy, if possible, to avoid fetal drug exposure. For patients who meet criteria for frank anxiety disorder, other nonpharmacologic interventions such as CBT have been shown to be effective.

Frequently, we see women who are experiencing levels of anxiety where nonpharmacological interventions have an incomplete response, and colleagues have asked about the safest way to treat these patients. As has been discussed in multiple previous columns, selective serotonin reuptake inhibitors (SSRIs) should be thought of sooner rather than later, particularly with medicines with good reproductive safety data such as sertraline, citalopram, or fluoxetine.

We also reported over 15 years ago that at least 30%-40% of women presenting with histories of recurrent major depression at the beginning of pregnancy had comorbid anxiety disorders, and that the use of benzodiazepines in that population in addition to SSRIs was exceedingly common, with doses of approximately 0.5-1.5 mg of clonazepam or lorazepam being standard fare. Again, this is very appropriate treatment to mitigate anxiety symptoms because now have enough data as a field that support the existence of adverse outcomes associated with untreated anxiety during pregnancy in terms of both adverse obstetric and neonatal outcomes, higher rates of preterm birth, and other obstetric complications. Hence, managing anxiety during pregnancy should be considered like managing a toxic exposure – the same way that one would be concerned about anything else that a pregnant woman could be exposed to.

Lastly, although no atypical antipsychotic has been approved for the treatment of anxiety, its use off label is extremely common. More and more data support the absence of a signal of teratogenicity across the family of molecules including atypical antipsychotics. Beyond potential use of atypical antipsychotics, at Virtual Rounds last week, a colleague asked about the use of gabapentin in a patient who was diagnosed with substance use disorder and who had inadvertently conceived on gabapentin, which was being used to treat both anxiety and insomnia. We have typically avoided the use of gabapentin during pregnancy because prospective data have been limited to relatively small case series and one report, with a total of exposures in roughly the 300 range.

However, our colleagues at the Harvard School of Public Health have recently published an article that looked at the United States Medicaid Analytic eXtract (MAX) dataset, which has been used to publish other articles addressing atypical antipsychotics, SSRIs, lithium, and pharmacovigilance investigations among other important topics. In this study, the database was used to look specifically at 4,642 pregnancies with gabapentin exposure relative to 1,744,447 unexposed pregnancies, without a significant finding for increased risk for major congenital malformations.

The question of an increased risk of cardiac malformations and of increased risk for obstetric complications are difficult to untangle from anxiety and depression, as they also are associated with those same outcomes. With that said, the analysis is a welcome addition to our knowledge base for a medicine used more widely to treat symptoms such as anxiety and insomnia in the general population, with a question mark around where it may fit into the algorithm during pregnancy.

In our center, gabapentin still would not be used as a first-line treatment for the management of anxiety or insomnia during pregnancy. But these new data still are reassuring for patients who come in, frequently with unplanned pregnancies. It is an important reminder to those of us taking care of patients during the pandemic to review use of contraception, because although data are unavailable specific to the period of the pandemic, what is clear is that, even prior to COVID-19, 50% of pregnancies in America were unplanned. Addressing issues of reliable use of contraception, particularly during the pandemic, is that much more important.

In this particular case, our clinician colleague in Virtual Rounds decided to continue gabapentin across pregnancy in the context of these reassuring data, but others may choose to discontinue or pursue some of the other treatment options noted above.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.

Since the start of the pandemic, we have been conducting an extra hour of Virtual Rounds at the Center for Women’s Mental Health. Virtual Rounds has been an opportunity to discuss cases around a spectrum of clinical management issues with respect to depression, bipolar disorder, and a spectrum of anxiety disorders like obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and generalized anxiety disorder. How to apply the calculus of risk-benefit decision-making around management of psychiatric disorder during pregnancy and the postpartum period has been the cornerstone of the work at our center for over 2 decades.

When we went virtual at our center in the early Spring, we decided to keep the format of our faculty rounds the way they have been for years and to sustain cohesiveness of our program during the pandemic. But we thought the needs of pregnant and postpartum women warranted being addressed in a context more specific to COVID-19, and also that reproductive psychiatrists and other clinicians could learn from each other about novel issues coming up for this group of patients during the pandemic. With that backdrop, Marlene Freeman, MD, and I founded “Virtual Rounds at the Center” to respond to queries from our colleagues across the country; we do this just after our own rounds on Wednesdays at 2:00 p.m.

As the pandemic has progressed, Virtual Rounds has blossomed into a virtual community on the Zoom platform, where social workers, psychologists, nurse prescribers, psychiatrists, and obstetricians discuss the needs of pregnant and postpartum women specific to COVID-19. Frequently, our discussions involve a review of the risks and benefits of treatment before, during, and after pregnancy.

Seemingly, week to week, more and more colleagues raise questions about the treatment of anxiety and insomnia during pregnancy and the postpartum period. I’ve spoken in previous columns about the enhanced use of telemedicine. Telemedicine not only facilitates efforts like Virtual Rounds and our ability to reach out to colleagues across the country and share cases, but also has allowed us to keep even closer tabs on the emotional well-being of our pregnant and postpartum women during COVID-19.

The question is not just about the effects of a medicine that a woman might take to treat anxiety or insomnia during pregnancy, but the experience of the pandemic per se, which we are measuring in multiple studies now using a variety of psychological instruments that patients complete. The pandemic is unequivocally taking a still unquantified toll on the mental health of Americans and potentially on the next generation to come.

Midcycle awakening during pregnancy

Complaints of insomnia and midcycle awakening during pregnancy are not new – it is the rule, rather than the exception for many pregnant women, particularly later in pregnancy. We have unequivocally seen a worsening of complaints of sleep disruption including insomnia and midcycle awakening during the pandemic that is greater than what we have seen previously. Both patients and colleagues have asked us the safest ways to manage it. One of the first things we consider when we hear about insomnia is whether it is part of an underlying mood disorder. While we see primary insomnia clinically, it really is important to remember that insomnia can be part and parcel of an underlying mood disorder.

With that in mind, what are the options? During the pandemic, we’ve seen an increased use of digital cognitive behavioral therapy for insomnia (CBT-I) for patients who cannot initiate sleep, which has a very strong evidence base for effectiveness as a first-line intervention for many.

If a patient has an incomplete response to CBT-I, what might be pursued next? In our center, we have a low threshold for using low doses of benzodiazepines, such as lorazepam or clonazepam, because the majority of data do not support an increased risk of major congenital malformations even when used in the first trimester. It is quite common to see medicines such as newer nonbenzodiazepine sedative hypnotics such as Ambien CR (zolpidem) or Lunesta (eszopiclone) used by our colleagues in ob.gyn. The reproductive safety data on those medicines are particularly sparse, and they may have greater risk of cognitive side effects the next day, so we tend to avoid them.

Another sometimes-forgotten option to consider is using low doses of tricyclic antidepressants (i.e., 10-25 mg of nortriptyline at bedtime), with tricyclics having a 40-year history and at least one pooled analysis showing the absence of increased risk for major congenital malformations when used. This may be a very easy way of managing insomnia, with low-dose tricyclics having an anxiolytic effect as well.

Anxiety during pregnancy

The most common rise in symptoms during COVID-19 for women who are pregnant or post partum has been an increase in anxiety. Women present with a spectrum of concerns leading to anxiety symptoms in the context of the pandemic. Earlier on in the pandemic, concerns focused mostly on how to stay healthy, and how to mitigate risk and not catch SARS-CoV-2 during pregnancy, as well as the very complex issues that were playing out in real time as hospital systems were figuring out how to manage pregnant women in labor and to keep both them and staff safe. Over time, anxiety has shifted to still staying safe during the pandemic and the potential impact of SARS-CoV-2 infection on pregnancy outcomes. The No. 1 concern is what the implications of COVID-19 disease are on mother and child. New mothers also are anxious about how they will practically navigate life with a newborn in the postpartum setting.

Early on in the pandemic, some hospital systems severely limited who was in the room with a woman during labor, potentially impeding the wishes of women during delivery who would have wanted their loved ones and/or a doula present, as an example. With enhanced testing available now, protocols have since relaxed in many hospitals to allow partners – but not a team – to remain in the hospital during the labor process. Still, the prospect of delivering during a pandemic is undoubtedly a source of anxiety for some women.

This sort of anxiety, particularly in patients with preexisting anxiety disorders, can be particularly challenging. Fortunately, there has been a rapid increase over the last several years of digital apps to mitigate anxiety. While many of them have not been systematically studied, the data on biobehavioral intervention for anxiety is enormous, and this should be used as first-line treatment for patients with mild to moderate symptoms; so many women would prefer to avoid pharmacological intervention during pregnancy, if possible, to avoid fetal drug exposure. For patients who meet criteria for frank anxiety disorder, other nonpharmacologic interventions such as CBT have been shown to be effective.

Frequently, we see women who are experiencing levels of anxiety where nonpharmacological interventions have an incomplete response, and colleagues have asked about the safest way to treat these patients. As has been discussed in multiple previous columns, selective serotonin reuptake inhibitors (SSRIs) should be thought of sooner rather than later, particularly with medicines with good reproductive safety data such as sertraline, citalopram, or fluoxetine.

We also reported over 15 years ago that at least 30%-40% of women presenting with histories of recurrent major depression at the beginning of pregnancy had comorbid anxiety disorders, and that the use of benzodiazepines in that population in addition to SSRIs was exceedingly common, with doses of approximately 0.5-1.5 mg of clonazepam or lorazepam being standard fare. Again, this is very appropriate treatment to mitigate anxiety symptoms because now have enough data as a field that support the existence of adverse outcomes associated with untreated anxiety during pregnancy in terms of both adverse obstetric and neonatal outcomes, higher rates of preterm birth, and other obstetric complications. Hence, managing anxiety during pregnancy should be considered like managing a toxic exposure – the same way that one would be concerned about anything else that a pregnant woman could be exposed to.

Lastly, although no atypical antipsychotic has been approved for the treatment of anxiety, its use off label is extremely common. More and more data support the absence of a signal of teratogenicity across the family of molecules including atypical antipsychotics. Beyond potential use of atypical antipsychotics, at Virtual Rounds last week, a colleague asked about the use of gabapentin in a patient who was diagnosed with substance use disorder and who had inadvertently conceived on gabapentin, which was being used to treat both anxiety and insomnia. We have typically avoided the use of gabapentin during pregnancy because prospective data have been limited to relatively small case series and one report, with a total of exposures in roughly the 300 range.

However, our colleagues at the Harvard School of Public Health have recently published an article that looked at the United States Medicaid Analytic eXtract (MAX) dataset, which has been used to publish other articles addressing atypical antipsychotics, SSRIs, lithium, and pharmacovigilance investigations among other important topics. In this study, the database was used to look specifically at 4,642 pregnancies with gabapentin exposure relative to 1,744,447 unexposed pregnancies, without a significant finding for increased risk for major congenital malformations.

The question of an increased risk of cardiac malformations and of increased risk for obstetric complications are difficult to untangle from anxiety and depression, as they also are associated with those same outcomes. With that said, the analysis is a welcome addition to our knowledge base for a medicine used more widely to treat symptoms such as anxiety and insomnia in the general population, with a question mark around where it may fit into the algorithm during pregnancy.

In our center, gabapentin still would not be used as a first-line treatment for the management of anxiety or insomnia during pregnancy. But these new data still are reassuring for patients who come in, frequently with unplanned pregnancies. It is an important reminder to those of us taking care of patients during the pandemic to review use of contraception, because although data are unavailable specific to the period of the pandemic, what is clear is that, even prior to COVID-19, 50% of pregnancies in America were unplanned. Addressing issues of reliable use of contraception, particularly during the pandemic, is that much more important.

In this particular case, our clinician colleague in Virtual Rounds decided to continue gabapentin across pregnancy in the context of these reassuring data, but others may choose to discontinue or pursue some of the other treatment options noted above.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.