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September marks 9 months
It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.
In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.
In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.
This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.
John I. Allen, MD, MBA, AGAF
Editor in Chief
It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.
In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.
In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.
This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.
John I. Allen, MD, MBA, AGAF
Editor in Chief
It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.
In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.
In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.
This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Reducing maternal mortality with prenatal care
As in its typical fashion, the question sprang out from a young Black patient after some meandering conversation during preconception counseling: “How do y’all prevent Black maternal mortality?” At the beginning of my career, I used to think preparing a patient for pregnancy involved recommending prenatal vitamins and rubella immunity screening. Now, having worked in a society with substantial racial health disparities for 14 years, there is greater awareness that pregnancy can be a matter of life or death that disproportionately affects people of color.
For Black patients in the United States, the maternal mortality ratio is almost four times higher than the ratio for White patients, 42 deaths versus 13 deaths per 100,000 live births, respectively.1 Georgia has the highest maternal mortality ratio in the United States at 67 maternal deaths per 100,000 live births. However, if you are a Black woman in Georgia, your chance of dying of pregnancy-related causes is 2.7 times that of a non-Hispanic White woman living in Georgia.2
Black patients often are not taken seriously, even when they are wealthy, have attained high levels of education, or are famous. Serena Williams, a Black woman and one of the most talented tennis players of all time, was ignored when complaining that she felt a blood clot had returned in her lungs post partum. As a recognition of this crisis, the Centers for Disease Control and Prevention has a new campaign to improve recognition of the warning signs of problems in pregnancy called the HEAR HER campaign. This issue is a pervasive problem in our lives that runs across the spectrum of Black experience. I have had Black friends, patients, and colleagues who have been ignored when complaining about labor pain, workplace discrimination, and even when trying to advocate for their patients. We need to uplift Black voices so they can be heard and support the initiatives and interventions they are asking for.
We practice standardized responses to emergencies and to health conditions. We use drills to practice our responses to life-threatening emergencies such as STAT cesarean delivery, shoulder dystocia, obstetrical hemorrhage, or treatment of preeclampsia and eclampsia. The Alliance for Innovation on Maternal Health has organized evidence-driven protocols called AIM bundles to reduce preventable maternal morbidity and mortality when implemented. Standardization is an important component of equitable treatment and reduction of disparities. The concept has been used across industries to reduce error and bias. The Alliance for Innovation on Maternal Health bundles even include a section on Reduction of Peripartum and Ethnic Disparities.
We admit that bias exists and that we need training to recognize and eliminate it. According to a study in the Proceedings of the National Academy of Sciences of the United States of America about racial bias in pain assessment more than 20% of White residents and medical students surveyed believed that Black people had less sensitive nerve endings than Whites.3 Studies show that this stereotype leads to inappropriate pain management in Black patients, a chief concern when considering how patients are treated on labor and delivery or after surgery.4 Additionally, unconscious bias can be addressed by hiring a diverse workforce at all levels. Familiarity with a diverse group can help us learn from one another in our day-to-day lives.
We need to offer the same high-quality preconception counseling to all of our patients. A patient’s perceived race or ethnicity is a poor indicator of their actual health needs. The amount of melanin in our skin is highly variable but our genetics are remarkably similar, therefore our health concerns are similar. All patients deserve a focus on prevention. Folic acid supplements in the form of prenatal vitamins should be recommended. Routine vaccinations and rubella immunity checks should be offered. Basic carrier screening for diseases of hemoglobin (which includes sickle cell trait), fragile X, spinomuscular atrophy, and cystic fibrosis should be offered. Finally, an emphasis on safety, mental health, and daily low-level exercise (i.e., walking) should be promoted to help prevent illness and injury in this age group. The leading causes of death for people of reproductive age are accidents, suicide, homicide, and heart disease – all preventable.
We treat the social determinants of health, not just the patient in front of us. When “race” is a risk factor for disease, it’s usually racism that’s the problem. As stated earlier, how much melanin is in our skin has little to do with our genetics – if we removed our skin, we’d have similar life expectancies and die of similar things. However, it has everything to do with how we navigate our society and access health care. The stress associated with being Black in America is the likely cause of preterm birth rates – leading to infant illness and death – and maternal mortality being higher in Black patients. This is referred to as “weathering” – the cumulative effects of stress as we age. It explains why Black women are more likely to die in pregnancy despite higher levels of education and increasing age – factors that are protective for other groups. Improving access to quality education, reforming the criminal justice system, affordable housing and child care, living wages, family planning, and universal basic health care exemplify the intersectionality of some of our greatest societal challenges. Addressing these root causes will reduce weathering and ultimately, save Black lives.
We strive to train more “underrepresented minorities” in medicine. According to the American Association of Medical Colleges, only 7.3% of medical students in 2019-2020 identified as Black or African American. This is way below their representation of 13% of the U.S. population. I’m proud that my division and department as a whole have hired and promoted diverse faculty with 30% of my generalist ob.gyn. colleagues being people of color. This shows that we have the input of diverse experiences as well as recognize the special concerns of patients of color. Underrepresented students interested in the health professions need us to do more to get their “foot in the door.” They are less likely to have connections to the field of medicine (family members, mentors), have access to prep courses or advisors, or have the finances to support the expensive application process. Reach out to your alma maters and ask how you can help mentor students at a young age and continue through adulthood, support scholarships, support unpaid internship recipients, and promote interconnectedness throughout this community.
I hope I answered my patient’s question in that moment, but I know what needs to be done is bigger that taking care of one patient. It will require small progress, by us, every single day. Until these interventions and others reshape our society, I’ll still have Black patients who say: “Don’t let me die, okay?” with a look right into my soul and a tight grip on my hand. And I’ll feel the immense weight of that trust, and squeeze the hand back.
Dr. Collins (she/her/hers) is assistant professor of obstetrics and gynecology, generalist division, at Emory University, Atlanta. She has no relevant financial disclosures. Email Dr. Collins at obnews@mdedge.com.
References
1. CDC Pregnancy Mortality Surveillance System, 2016. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.
2. Maternal Mortality Fact Sheet, 2012-2015. https://dph.georgia.gov/maternal-mortality.
3. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301.
4. Pain Med. 2012 Feb;13(2):150-74.
As in its typical fashion, the question sprang out from a young Black patient after some meandering conversation during preconception counseling: “How do y’all prevent Black maternal mortality?” At the beginning of my career, I used to think preparing a patient for pregnancy involved recommending prenatal vitamins and rubella immunity screening. Now, having worked in a society with substantial racial health disparities for 14 years, there is greater awareness that pregnancy can be a matter of life or death that disproportionately affects people of color.
For Black patients in the United States, the maternal mortality ratio is almost four times higher than the ratio for White patients, 42 deaths versus 13 deaths per 100,000 live births, respectively.1 Georgia has the highest maternal mortality ratio in the United States at 67 maternal deaths per 100,000 live births. However, if you are a Black woman in Georgia, your chance of dying of pregnancy-related causes is 2.7 times that of a non-Hispanic White woman living in Georgia.2
Black patients often are not taken seriously, even when they are wealthy, have attained high levels of education, or are famous. Serena Williams, a Black woman and one of the most talented tennis players of all time, was ignored when complaining that she felt a blood clot had returned in her lungs post partum. As a recognition of this crisis, the Centers for Disease Control and Prevention has a new campaign to improve recognition of the warning signs of problems in pregnancy called the HEAR HER campaign. This issue is a pervasive problem in our lives that runs across the spectrum of Black experience. I have had Black friends, patients, and colleagues who have been ignored when complaining about labor pain, workplace discrimination, and even when trying to advocate for their patients. We need to uplift Black voices so they can be heard and support the initiatives and interventions they are asking for.
We practice standardized responses to emergencies and to health conditions. We use drills to practice our responses to life-threatening emergencies such as STAT cesarean delivery, shoulder dystocia, obstetrical hemorrhage, or treatment of preeclampsia and eclampsia. The Alliance for Innovation on Maternal Health has organized evidence-driven protocols called AIM bundles to reduce preventable maternal morbidity and mortality when implemented. Standardization is an important component of equitable treatment and reduction of disparities. The concept has been used across industries to reduce error and bias. The Alliance for Innovation on Maternal Health bundles even include a section on Reduction of Peripartum and Ethnic Disparities.
We admit that bias exists and that we need training to recognize and eliminate it. According to a study in the Proceedings of the National Academy of Sciences of the United States of America about racial bias in pain assessment more than 20% of White residents and medical students surveyed believed that Black people had less sensitive nerve endings than Whites.3 Studies show that this stereotype leads to inappropriate pain management in Black patients, a chief concern when considering how patients are treated on labor and delivery or after surgery.4 Additionally, unconscious bias can be addressed by hiring a diverse workforce at all levels. Familiarity with a diverse group can help us learn from one another in our day-to-day lives.
We need to offer the same high-quality preconception counseling to all of our patients. A patient’s perceived race or ethnicity is a poor indicator of their actual health needs. The amount of melanin in our skin is highly variable but our genetics are remarkably similar, therefore our health concerns are similar. All patients deserve a focus on prevention. Folic acid supplements in the form of prenatal vitamins should be recommended. Routine vaccinations and rubella immunity checks should be offered. Basic carrier screening for diseases of hemoglobin (which includes sickle cell trait), fragile X, spinomuscular atrophy, and cystic fibrosis should be offered. Finally, an emphasis on safety, mental health, and daily low-level exercise (i.e., walking) should be promoted to help prevent illness and injury in this age group. The leading causes of death for people of reproductive age are accidents, suicide, homicide, and heart disease – all preventable.
We treat the social determinants of health, not just the patient in front of us. When “race” is a risk factor for disease, it’s usually racism that’s the problem. As stated earlier, how much melanin is in our skin has little to do with our genetics – if we removed our skin, we’d have similar life expectancies and die of similar things. However, it has everything to do with how we navigate our society and access health care. The stress associated with being Black in America is the likely cause of preterm birth rates – leading to infant illness and death – and maternal mortality being higher in Black patients. This is referred to as “weathering” – the cumulative effects of stress as we age. It explains why Black women are more likely to die in pregnancy despite higher levels of education and increasing age – factors that are protective for other groups. Improving access to quality education, reforming the criminal justice system, affordable housing and child care, living wages, family planning, and universal basic health care exemplify the intersectionality of some of our greatest societal challenges. Addressing these root causes will reduce weathering and ultimately, save Black lives.
We strive to train more “underrepresented minorities” in medicine. According to the American Association of Medical Colleges, only 7.3% of medical students in 2019-2020 identified as Black or African American. This is way below their representation of 13% of the U.S. population. I’m proud that my division and department as a whole have hired and promoted diverse faculty with 30% of my generalist ob.gyn. colleagues being people of color. This shows that we have the input of diverse experiences as well as recognize the special concerns of patients of color. Underrepresented students interested in the health professions need us to do more to get their “foot in the door.” They are less likely to have connections to the field of medicine (family members, mentors), have access to prep courses or advisors, or have the finances to support the expensive application process. Reach out to your alma maters and ask how you can help mentor students at a young age and continue through adulthood, support scholarships, support unpaid internship recipients, and promote interconnectedness throughout this community.
I hope I answered my patient’s question in that moment, but I know what needs to be done is bigger that taking care of one patient. It will require small progress, by us, every single day. Until these interventions and others reshape our society, I’ll still have Black patients who say: “Don’t let me die, okay?” with a look right into my soul and a tight grip on my hand. And I’ll feel the immense weight of that trust, and squeeze the hand back.
Dr. Collins (she/her/hers) is assistant professor of obstetrics and gynecology, generalist division, at Emory University, Atlanta. She has no relevant financial disclosures. Email Dr. Collins at obnews@mdedge.com.
References
1. CDC Pregnancy Mortality Surveillance System, 2016. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.
2. Maternal Mortality Fact Sheet, 2012-2015. https://dph.georgia.gov/maternal-mortality.
3. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301.
4. Pain Med. 2012 Feb;13(2):150-74.
As in its typical fashion, the question sprang out from a young Black patient after some meandering conversation during preconception counseling: “How do y’all prevent Black maternal mortality?” At the beginning of my career, I used to think preparing a patient for pregnancy involved recommending prenatal vitamins and rubella immunity screening. Now, having worked in a society with substantial racial health disparities for 14 years, there is greater awareness that pregnancy can be a matter of life or death that disproportionately affects people of color.
For Black patients in the United States, the maternal mortality ratio is almost four times higher than the ratio for White patients, 42 deaths versus 13 deaths per 100,000 live births, respectively.1 Georgia has the highest maternal mortality ratio in the United States at 67 maternal deaths per 100,000 live births. However, if you are a Black woman in Georgia, your chance of dying of pregnancy-related causes is 2.7 times that of a non-Hispanic White woman living in Georgia.2
Black patients often are not taken seriously, even when they are wealthy, have attained high levels of education, or are famous. Serena Williams, a Black woman and one of the most talented tennis players of all time, was ignored when complaining that she felt a blood clot had returned in her lungs post partum. As a recognition of this crisis, the Centers for Disease Control and Prevention has a new campaign to improve recognition of the warning signs of problems in pregnancy called the HEAR HER campaign. This issue is a pervasive problem in our lives that runs across the spectrum of Black experience. I have had Black friends, patients, and colleagues who have been ignored when complaining about labor pain, workplace discrimination, and even when trying to advocate for their patients. We need to uplift Black voices so they can be heard and support the initiatives and interventions they are asking for.
We practice standardized responses to emergencies and to health conditions. We use drills to practice our responses to life-threatening emergencies such as STAT cesarean delivery, shoulder dystocia, obstetrical hemorrhage, or treatment of preeclampsia and eclampsia. The Alliance for Innovation on Maternal Health has organized evidence-driven protocols called AIM bundles to reduce preventable maternal morbidity and mortality when implemented. Standardization is an important component of equitable treatment and reduction of disparities. The concept has been used across industries to reduce error and bias. The Alliance for Innovation on Maternal Health bundles even include a section on Reduction of Peripartum and Ethnic Disparities.
We admit that bias exists and that we need training to recognize and eliminate it. According to a study in the Proceedings of the National Academy of Sciences of the United States of America about racial bias in pain assessment more than 20% of White residents and medical students surveyed believed that Black people had less sensitive nerve endings than Whites.3 Studies show that this stereotype leads to inappropriate pain management in Black patients, a chief concern when considering how patients are treated on labor and delivery or after surgery.4 Additionally, unconscious bias can be addressed by hiring a diverse workforce at all levels. Familiarity with a diverse group can help us learn from one another in our day-to-day lives.
We need to offer the same high-quality preconception counseling to all of our patients. A patient’s perceived race or ethnicity is a poor indicator of their actual health needs. The amount of melanin in our skin is highly variable but our genetics are remarkably similar, therefore our health concerns are similar. All patients deserve a focus on prevention. Folic acid supplements in the form of prenatal vitamins should be recommended. Routine vaccinations and rubella immunity checks should be offered. Basic carrier screening for diseases of hemoglobin (which includes sickle cell trait), fragile X, spinomuscular atrophy, and cystic fibrosis should be offered. Finally, an emphasis on safety, mental health, and daily low-level exercise (i.e., walking) should be promoted to help prevent illness and injury in this age group. The leading causes of death for people of reproductive age are accidents, suicide, homicide, and heart disease – all preventable.
We treat the social determinants of health, not just the patient in front of us. When “race” is a risk factor for disease, it’s usually racism that’s the problem. As stated earlier, how much melanin is in our skin has little to do with our genetics – if we removed our skin, we’d have similar life expectancies and die of similar things. However, it has everything to do with how we navigate our society and access health care. The stress associated with being Black in America is the likely cause of preterm birth rates – leading to infant illness and death – and maternal mortality being higher in Black patients. This is referred to as “weathering” – the cumulative effects of stress as we age. It explains why Black women are more likely to die in pregnancy despite higher levels of education and increasing age – factors that are protective for other groups. Improving access to quality education, reforming the criminal justice system, affordable housing and child care, living wages, family planning, and universal basic health care exemplify the intersectionality of some of our greatest societal challenges. Addressing these root causes will reduce weathering and ultimately, save Black lives.
We strive to train more “underrepresented minorities” in medicine. According to the American Association of Medical Colleges, only 7.3% of medical students in 2019-2020 identified as Black or African American. This is way below their representation of 13% of the U.S. population. I’m proud that my division and department as a whole have hired and promoted diverse faculty with 30% of my generalist ob.gyn. colleagues being people of color. This shows that we have the input of diverse experiences as well as recognize the special concerns of patients of color. Underrepresented students interested in the health professions need us to do more to get their “foot in the door.” They are less likely to have connections to the field of medicine (family members, mentors), have access to prep courses or advisors, or have the finances to support the expensive application process. Reach out to your alma maters and ask how you can help mentor students at a young age and continue through adulthood, support scholarships, support unpaid internship recipients, and promote interconnectedness throughout this community.
I hope I answered my patient’s question in that moment, but I know what needs to be done is bigger that taking care of one patient. It will require small progress, by us, every single day. Until these interventions and others reshape our society, I’ll still have Black patients who say: “Don’t let me die, okay?” with a look right into my soul and a tight grip on my hand. And I’ll feel the immense weight of that trust, and squeeze the hand back.
Dr. Collins (she/her/hers) is assistant professor of obstetrics and gynecology, generalist division, at Emory University, Atlanta. She has no relevant financial disclosures. Email Dr. Collins at obnews@mdedge.com.
References
1. CDC Pregnancy Mortality Surveillance System, 2016. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.
2. Maternal Mortality Fact Sheet, 2012-2015. https://dph.georgia.gov/maternal-mortality.
3. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301.
4. Pain Med. 2012 Feb;13(2):150-74.
Rooting out systemic racism: Equal access to maternal, prenatal care
Against the backdrop of the COVID-19 pandemic and ongoing national conversations around racial injustice, it is more important than ever that we identify and root out systemic discrimination – including in our health care system. As an ob.gyn., I’ve spent my entire career making sure that women receive the best care, and have witnessed firsthand the results of a system that provides differing levels of care based on one’s socioeconomic level, race, or ethnicity.
This disparity is borne out in this country’s maternal health outcomes. For example, the latest figures from the Centers for Disease Control and Prevention indicate that the maternal mortality rate for black women, 37.1 deaths per 100,000 live births, is more than double the rate for white women at 14.7. In addition, the black infant mortality rate, at 11.4 per 1,000 live births, is also more than double the white infant mortality rate, 4.9. While many of these differences stem from discriminatory levels of coverage and care after delivery, just as important is the coverage and care before delivery: prenatal care.
Prenatal care includes a variety of screening tests, including those that can help expecting mothers identify whether the baby is more or less likely to have certain genetic disorders. These tests include traditional and less accurate options like serum or combined screening, and newer noninvasive prenatal testing (NIPT) options that use blood samples from the mother to analyze the baby’s DNA.
Research already has demonstrated that NIPT is the most accurate and effective screening option for common chromosomal abnormalities (Ont Health Technol Assess Ser. 2019;19[4]:1-166). A 2015 New England Journal of Medicine study showed that, without access to NIPT, 22% of pregnancies with Down syndrome were missed. With older screening methods, 5.4% of positive results for Down syndrome were false, compared with 0.06% of the NIPT tests (N Engl J Med 2015;372:1589-97). Older, less accurate screening tests cause unnecessary referrals to specialists for possible invasive testing, resulting in additional costs and undue stress on women and their families.
And yet, troubling new data have shown that black and Hispanic women have less access to NIPT than white women. Currently, NIPT is available to all California women through the state-funded prenatal screening program as a second-tier test. Many women, however, decide to opt out or go outside of the state program to have NIPT as a first-tier test, choosing private payer or other plans instead. New data shared by the California Department of Public Health with ob.gyns. and maternal-fetal medicine physicians in California showed that white women who opted out of California’s state-funded prenatal screening program were more than twice as likely to gain access to NIPT as black and Hispanic women (39%-17%). We can assume this to be true of women outside California as well – women who have no access to a state-funded program like California’s and depend solely on private payer or other health care plans. In fact, although some commercial insurance companies do cover NIPT, noninvasive prenatal screening is not covered by large insurance companies like Aetna and UnitedHealthcare.
As ob.gyns., physicians, and health professionals, we need to ask ourselves: Why is there such a great disparity in the access of superior and more effective NIPT options for black and Hispanic women?
Many reasons are apparent. There are significant differences by ethnic and racial groups in their knowledge of the availability of prenatal testing. Furthermore, there are higher levels of mistrust along certain racial and ethnic lines of the medical system in this country; specific religious or ethnic beliefs also may obviate the use of prenatal testing or diagnosis. Significant differences also exist in the types of health coverage by race and ethnicity, ultimately impacting the ability to have prenatal testing. Finally, there are different physician group recommendations. While medical societies such as the American College of Medical Genetics, International Society for Prenatal Diagnosis, and the American Society of Human Genetics all have long endorsed newer NIPT option for all pregnant women, two of the national physician groups that make recommendations about what care pregnant women should be able to access – the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine – only recently have recommended broad access to NIPT. As a result, some state Medicaid programs have not made NIPT available to patients.
We know that racial disparities are a public health crisis in America. The recent data from the California Department of Public Health, paired with COVID-19’s disproportionate impact on blacks and Hispanics, only further illustrate the existing health disparities experienced by this country’s communities of color.
We need to root out systemic discrimination in health care and we can begin with our maternal health care. Providing equitable access to the most accurate and consistent prenatal screenings, including NIPT options, regardless of insurance plan, socioeconomic level, race, or ethnicity is paramount in starting this work.
Dr. Gaither is a double board–certified physician in ob.gyn. and maternal-fetal medicine. She is director of perinatal services for NYC Health+Hospitals/Lincoln. She reports no conflicts of interest. Email her at obnews@mdedge.com.
Against the backdrop of the COVID-19 pandemic and ongoing national conversations around racial injustice, it is more important than ever that we identify and root out systemic discrimination – including in our health care system. As an ob.gyn., I’ve spent my entire career making sure that women receive the best care, and have witnessed firsthand the results of a system that provides differing levels of care based on one’s socioeconomic level, race, or ethnicity.
This disparity is borne out in this country’s maternal health outcomes. For example, the latest figures from the Centers for Disease Control and Prevention indicate that the maternal mortality rate for black women, 37.1 deaths per 100,000 live births, is more than double the rate for white women at 14.7. In addition, the black infant mortality rate, at 11.4 per 1,000 live births, is also more than double the white infant mortality rate, 4.9. While many of these differences stem from discriminatory levels of coverage and care after delivery, just as important is the coverage and care before delivery: prenatal care.
Prenatal care includes a variety of screening tests, including those that can help expecting mothers identify whether the baby is more or less likely to have certain genetic disorders. These tests include traditional and less accurate options like serum or combined screening, and newer noninvasive prenatal testing (NIPT) options that use blood samples from the mother to analyze the baby’s DNA.
Research already has demonstrated that NIPT is the most accurate and effective screening option for common chromosomal abnormalities (Ont Health Technol Assess Ser. 2019;19[4]:1-166). A 2015 New England Journal of Medicine study showed that, without access to NIPT, 22% of pregnancies with Down syndrome were missed. With older screening methods, 5.4% of positive results for Down syndrome were false, compared with 0.06% of the NIPT tests (N Engl J Med 2015;372:1589-97). Older, less accurate screening tests cause unnecessary referrals to specialists for possible invasive testing, resulting in additional costs and undue stress on women and their families.
And yet, troubling new data have shown that black and Hispanic women have less access to NIPT than white women. Currently, NIPT is available to all California women through the state-funded prenatal screening program as a second-tier test. Many women, however, decide to opt out or go outside of the state program to have NIPT as a first-tier test, choosing private payer or other plans instead. New data shared by the California Department of Public Health with ob.gyns. and maternal-fetal medicine physicians in California showed that white women who opted out of California’s state-funded prenatal screening program were more than twice as likely to gain access to NIPT as black and Hispanic women (39%-17%). We can assume this to be true of women outside California as well – women who have no access to a state-funded program like California’s and depend solely on private payer or other health care plans. In fact, although some commercial insurance companies do cover NIPT, noninvasive prenatal screening is not covered by large insurance companies like Aetna and UnitedHealthcare.
As ob.gyns., physicians, and health professionals, we need to ask ourselves: Why is there such a great disparity in the access of superior and more effective NIPT options for black and Hispanic women?
Many reasons are apparent. There are significant differences by ethnic and racial groups in their knowledge of the availability of prenatal testing. Furthermore, there are higher levels of mistrust along certain racial and ethnic lines of the medical system in this country; specific religious or ethnic beliefs also may obviate the use of prenatal testing or diagnosis. Significant differences also exist in the types of health coverage by race and ethnicity, ultimately impacting the ability to have prenatal testing. Finally, there are different physician group recommendations. While medical societies such as the American College of Medical Genetics, International Society for Prenatal Diagnosis, and the American Society of Human Genetics all have long endorsed newer NIPT option for all pregnant women, two of the national physician groups that make recommendations about what care pregnant women should be able to access – the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine – only recently have recommended broad access to NIPT. As a result, some state Medicaid programs have not made NIPT available to patients.
We know that racial disparities are a public health crisis in America. The recent data from the California Department of Public Health, paired with COVID-19’s disproportionate impact on blacks and Hispanics, only further illustrate the existing health disparities experienced by this country’s communities of color.
We need to root out systemic discrimination in health care and we can begin with our maternal health care. Providing equitable access to the most accurate and consistent prenatal screenings, including NIPT options, regardless of insurance plan, socioeconomic level, race, or ethnicity is paramount in starting this work.
Dr. Gaither is a double board–certified physician in ob.gyn. and maternal-fetal medicine. She is director of perinatal services for NYC Health+Hospitals/Lincoln. She reports no conflicts of interest. Email her at obnews@mdedge.com.
Against the backdrop of the COVID-19 pandemic and ongoing national conversations around racial injustice, it is more important than ever that we identify and root out systemic discrimination – including in our health care system. As an ob.gyn., I’ve spent my entire career making sure that women receive the best care, and have witnessed firsthand the results of a system that provides differing levels of care based on one’s socioeconomic level, race, or ethnicity.
This disparity is borne out in this country’s maternal health outcomes. For example, the latest figures from the Centers for Disease Control and Prevention indicate that the maternal mortality rate for black women, 37.1 deaths per 100,000 live births, is more than double the rate for white women at 14.7. In addition, the black infant mortality rate, at 11.4 per 1,000 live births, is also more than double the white infant mortality rate, 4.9. While many of these differences stem from discriminatory levels of coverage and care after delivery, just as important is the coverage and care before delivery: prenatal care.
Prenatal care includes a variety of screening tests, including those that can help expecting mothers identify whether the baby is more or less likely to have certain genetic disorders. These tests include traditional and less accurate options like serum or combined screening, and newer noninvasive prenatal testing (NIPT) options that use blood samples from the mother to analyze the baby’s DNA.
Research already has demonstrated that NIPT is the most accurate and effective screening option for common chromosomal abnormalities (Ont Health Technol Assess Ser. 2019;19[4]:1-166). A 2015 New England Journal of Medicine study showed that, without access to NIPT, 22% of pregnancies with Down syndrome were missed. With older screening methods, 5.4% of positive results for Down syndrome were false, compared with 0.06% of the NIPT tests (N Engl J Med 2015;372:1589-97). Older, less accurate screening tests cause unnecessary referrals to specialists for possible invasive testing, resulting in additional costs and undue stress on women and their families.
And yet, troubling new data have shown that black and Hispanic women have less access to NIPT than white women. Currently, NIPT is available to all California women through the state-funded prenatal screening program as a second-tier test. Many women, however, decide to opt out or go outside of the state program to have NIPT as a first-tier test, choosing private payer or other plans instead. New data shared by the California Department of Public Health with ob.gyns. and maternal-fetal medicine physicians in California showed that white women who opted out of California’s state-funded prenatal screening program were more than twice as likely to gain access to NIPT as black and Hispanic women (39%-17%). We can assume this to be true of women outside California as well – women who have no access to a state-funded program like California’s and depend solely on private payer or other health care plans. In fact, although some commercial insurance companies do cover NIPT, noninvasive prenatal screening is not covered by large insurance companies like Aetna and UnitedHealthcare.
As ob.gyns., physicians, and health professionals, we need to ask ourselves: Why is there such a great disparity in the access of superior and more effective NIPT options for black and Hispanic women?
Many reasons are apparent. There are significant differences by ethnic and racial groups in their knowledge of the availability of prenatal testing. Furthermore, there are higher levels of mistrust along certain racial and ethnic lines of the medical system in this country; specific religious or ethnic beliefs also may obviate the use of prenatal testing or diagnosis. Significant differences also exist in the types of health coverage by race and ethnicity, ultimately impacting the ability to have prenatal testing. Finally, there are different physician group recommendations. While medical societies such as the American College of Medical Genetics, International Society for Prenatal Diagnosis, and the American Society of Human Genetics all have long endorsed newer NIPT option for all pregnant women, two of the national physician groups that make recommendations about what care pregnant women should be able to access – the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine – only recently have recommended broad access to NIPT. As a result, some state Medicaid programs have not made NIPT available to patients.
We know that racial disparities are a public health crisis in America. The recent data from the California Department of Public Health, paired with COVID-19’s disproportionate impact on blacks and Hispanics, only further illustrate the existing health disparities experienced by this country’s communities of color.
We need to root out systemic discrimination in health care and we can begin with our maternal health care. Providing equitable access to the most accurate and consistent prenatal screenings, including NIPT options, regardless of insurance plan, socioeconomic level, race, or ethnicity is paramount in starting this work.
Dr. Gaither is a double board–certified physician in ob.gyn. and maternal-fetal medicine. She is director of perinatal services for NYC Health+Hospitals/Lincoln. She reports no conflicts of interest. Email her at obnews@mdedge.com.
Vitamin D pearls
Case: A 56-year-old man with a history of type 2 diabetes, hypertension, hyperlipidemia, and obesity calls clinic to discuss concerns about COVID-19, stating: “I want to do everything I can to reduce my risk of infection.” In addition to physical distancing, mask wearing, hand hygiene, and control of chronic conditions, which of the following supplements would you recommend for this patient?
1. Coenzyme Q10 160 mg twice a day
2. Vitamin D 2,000 IU daily
3. Vitamin E 400 IU daily
4. Vitamin B12 1,000 mcg daily
Of these choices, vitamin D supplementation is likely the best option, based on the limited data that is available.
Risk factors for worse COVID-19 outcome, such as older age, obesity, and more pigmented skin are also risk factors for vitamin D deficiency. This makes the study of vitamin D and COVID-19 both challenging and relevant.
In a recent study of 7,807 people living in Israel, Merzon and colleagues found that low plasma vitamin D level was an independent risk factor for COVID-19 infection. Mean plasma vitamin D level was significantly lower among those who tested positive for COVID-19 (19.00 ng/mL) than negative (20.55 ng/ mL). After controlling for demographic variables and several medical conditions, the adjusted odds ratio of COVID-19 infection in those with lower vitamin D was 1.45 (95% confidence interval, 1.08-1.95; P < .001). However, the odds of hospitalization for COVID-19 was not significantly associated with vitamin D level.1
Prior studies have also looked at vitamin D and respiratory infection. Martineau and colleagues analyzed 25 randomized, controlled trials with a pooled number of 11,321 individuals, including healthy ones and those with comorbidities, and found that oral vitamin D supplementation in daily or weekly doses had a protective effect against acute respiratory infection (adjusted odds ratio, 0.88; 95% CI, 0.81-0.96; P < .001). Patients with vitamin D deficiency (less than 25 nmol/L) experienced the most protective benefit. Vitamin D did not influence respiratory infection outcome.2
These studies suggest an adequate vitamin D level may be protective against infection with COVID-19, but who will benefit from vitamin D supplementation, and in what dose? Per U.S. Preventive Services Task Force guidelines, there is insufficient evidence to recommend screening for vitamin D deficiency in asymptomatic adults. Regarding daily dietary intake, the Institute of Medicine recommends 600 IU for persons aged 1-70, and 800 IU for those aged over 70 years. Salmon (447 IU per 3 oz serving), tuna (154 IU), and fortified milk (116 IU) are among the most vitamin D–rich foods.3 The recommended upper level of intake is 4,000 IU/day.
Too much of a good thing?
Extra vitamin D is stored in adipose tissue. If it builds up over time, storage sites may be overwhelmed, causing a rise in serum D level. While one might expect a subsequent rise in calcium levels, studies have shown this happens inconsistently, and at very high vitamin D levels, over 120 ng/mL.4 Most people would have to take at least 50,000 IU daily for several months to see an effect. The main adverse outcome of vitamin D toxicity is kidney stones, mediated by increased calcium in the blood and urine.
Several animal models have demonstrated hypervitaminosis D–induced aortic and coronary artery calcification. Like with kidney stones, the mechanism appears to be through increased calcium and phosphate levels. Shroff and colleagues studied serum vitamin D levels and vascular disease in children with renal disease on dialysis and found a U-shaped distribution: Children with both low and high vitamin D levels had significantly increased carotid artery intima-media thickness and calcification.5 Given the specialized nature of this population, it’s unclear whether these results can be generalized to most people. More studies are warranted on this topic.
Other benefits
Vitamin D is perhaps most famous for helping to build strong bones. Avenell and colleagues performed a Cochrane meta-analysis of vitamin D supplementation in older adults and found that vitamin D alone did not significantly reduce the risk of hip or other new fracture. Vitamin D plus calcium supplementation did reduce the risk of hip fracture (nine trials, pooled number of individuals was 49,853; relative risk, 0.84; P = .01).6
A lesser-known benefit of vitamin D is muscle protection. A prospective study out of the Jewish Hospital of Cincinnati followed 146 adults who were intolerant to two or more statins because of muscle side effects and found to have a vitamin D level below 32 ng per mL. Subjects were given vitamin D replacement (50,000 units weekly) and followed for 2 years. On statin rechallenge, 88-95% tolerated a statin with vitamin D levels 53-55 ng/mL.7
Pearl
Vitamin D supplementation may protect against COVID-19 infection and has very low chance of harm at daily doses at or below 4,000 IU. Other benefits of taking vitamin D include bone protection and reduction in statin-induced myopathy. The main adverse effect is kidney stones.
Ms. Sharninghausen is a medical student at the University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. Merzon E et al. Low plasma 25(OH) vitamin D level is associated with increased risk of COVID‐19 infection: An Israeli population‐based study. FEBS J. 2020. doi: 10.1111/febs.15495.
2. Martineau AR et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. doi:10.1136/bmj.i6583
3. “How to Get More Vitamin D From Your Food,” Cleveland Clinic. 2019 Oct 23. https://health.clevelandclinic.org/how-to-get-more-vitamin-d-from-your-food/.
4. Galior K et al. Development of vitamin d toxicity from overcorrection of vitamin D Deficiency: A review of case reports. Nutrients. 2018;10(8):953. doi: 10.3390/nu10080953
5. Shroff R et al. A bimodal association of vitamin D levels and vascular disease in children on dialysis. J Am Soc Nephrol. 2008;19(6):1239-46. doi: 10.1681/ASN.2007090993.
6. Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures in post‐menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 14;2014(4):CD000227. doi: 10.1002/14651858.CD000227.pub4.
7. Khayznikov M et al. Statin intolerance because of myalgia, myositis, myopathy, or myonecrosis can in most cases be safely resolved by vitamin D supplementation. N Am J Med Sci. 2015;7(3):86-93. doi:10.4103/1947-2714.153919
Case: A 56-year-old man with a history of type 2 diabetes, hypertension, hyperlipidemia, and obesity calls clinic to discuss concerns about COVID-19, stating: “I want to do everything I can to reduce my risk of infection.” In addition to physical distancing, mask wearing, hand hygiene, and control of chronic conditions, which of the following supplements would you recommend for this patient?
1. Coenzyme Q10 160 mg twice a day
2. Vitamin D 2,000 IU daily
3. Vitamin E 400 IU daily
4. Vitamin B12 1,000 mcg daily
Of these choices, vitamin D supplementation is likely the best option, based on the limited data that is available.
Risk factors for worse COVID-19 outcome, such as older age, obesity, and more pigmented skin are also risk factors for vitamin D deficiency. This makes the study of vitamin D and COVID-19 both challenging and relevant.
In a recent study of 7,807 people living in Israel, Merzon and colleagues found that low plasma vitamin D level was an independent risk factor for COVID-19 infection. Mean plasma vitamin D level was significantly lower among those who tested positive for COVID-19 (19.00 ng/mL) than negative (20.55 ng/ mL). After controlling for demographic variables and several medical conditions, the adjusted odds ratio of COVID-19 infection in those with lower vitamin D was 1.45 (95% confidence interval, 1.08-1.95; P < .001). However, the odds of hospitalization for COVID-19 was not significantly associated with vitamin D level.1
Prior studies have also looked at vitamin D and respiratory infection. Martineau and colleagues analyzed 25 randomized, controlled trials with a pooled number of 11,321 individuals, including healthy ones and those with comorbidities, and found that oral vitamin D supplementation in daily or weekly doses had a protective effect against acute respiratory infection (adjusted odds ratio, 0.88; 95% CI, 0.81-0.96; P < .001). Patients with vitamin D deficiency (less than 25 nmol/L) experienced the most protective benefit. Vitamin D did not influence respiratory infection outcome.2
These studies suggest an adequate vitamin D level may be protective against infection with COVID-19, but who will benefit from vitamin D supplementation, and in what dose? Per U.S. Preventive Services Task Force guidelines, there is insufficient evidence to recommend screening for vitamin D deficiency in asymptomatic adults. Regarding daily dietary intake, the Institute of Medicine recommends 600 IU for persons aged 1-70, and 800 IU for those aged over 70 years. Salmon (447 IU per 3 oz serving), tuna (154 IU), and fortified milk (116 IU) are among the most vitamin D–rich foods.3 The recommended upper level of intake is 4,000 IU/day.
Too much of a good thing?
Extra vitamin D is stored in adipose tissue. If it builds up over time, storage sites may be overwhelmed, causing a rise in serum D level. While one might expect a subsequent rise in calcium levels, studies have shown this happens inconsistently, and at very high vitamin D levels, over 120 ng/mL.4 Most people would have to take at least 50,000 IU daily for several months to see an effect. The main adverse outcome of vitamin D toxicity is kidney stones, mediated by increased calcium in the blood and urine.
Several animal models have demonstrated hypervitaminosis D–induced aortic and coronary artery calcification. Like with kidney stones, the mechanism appears to be through increased calcium and phosphate levels. Shroff and colleagues studied serum vitamin D levels and vascular disease in children with renal disease on dialysis and found a U-shaped distribution: Children with both low and high vitamin D levels had significantly increased carotid artery intima-media thickness and calcification.5 Given the specialized nature of this population, it’s unclear whether these results can be generalized to most people. More studies are warranted on this topic.
Other benefits
Vitamin D is perhaps most famous for helping to build strong bones. Avenell and colleagues performed a Cochrane meta-analysis of vitamin D supplementation in older adults and found that vitamin D alone did not significantly reduce the risk of hip or other new fracture. Vitamin D plus calcium supplementation did reduce the risk of hip fracture (nine trials, pooled number of individuals was 49,853; relative risk, 0.84; P = .01).6
A lesser-known benefit of vitamin D is muscle protection. A prospective study out of the Jewish Hospital of Cincinnati followed 146 adults who were intolerant to two or more statins because of muscle side effects and found to have a vitamin D level below 32 ng per mL. Subjects were given vitamin D replacement (50,000 units weekly) and followed for 2 years. On statin rechallenge, 88-95% tolerated a statin with vitamin D levels 53-55 ng/mL.7
Pearl
Vitamin D supplementation may protect against COVID-19 infection and has very low chance of harm at daily doses at or below 4,000 IU. Other benefits of taking vitamin D include bone protection and reduction in statin-induced myopathy. The main adverse effect is kidney stones.
Ms. Sharninghausen is a medical student at the University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. Merzon E et al. Low plasma 25(OH) vitamin D level is associated with increased risk of COVID‐19 infection: An Israeli population‐based study. FEBS J. 2020. doi: 10.1111/febs.15495.
2. Martineau AR et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. doi:10.1136/bmj.i6583
3. “How to Get More Vitamin D From Your Food,” Cleveland Clinic. 2019 Oct 23. https://health.clevelandclinic.org/how-to-get-more-vitamin-d-from-your-food/.
4. Galior K et al. Development of vitamin d toxicity from overcorrection of vitamin D Deficiency: A review of case reports. Nutrients. 2018;10(8):953. doi: 10.3390/nu10080953
5. Shroff R et al. A bimodal association of vitamin D levels and vascular disease in children on dialysis. J Am Soc Nephrol. 2008;19(6):1239-46. doi: 10.1681/ASN.2007090993.
6. Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures in post‐menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 14;2014(4):CD000227. doi: 10.1002/14651858.CD000227.pub4.
7. Khayznikov M et al. Statin intolerance because of myalgia, myositis, myopathy, or myonecrosis can in most cases be safely resolved by vitamin D supplementation. N Am J Med Sci. 2015;7(3):86-93. doi:10.4103/1947-2714.153919
Case: A 56-year-old man with a history of type 2 diabetes, hypertension, hyperlipidemia, and obesity calls clinic to discuss concerns about COVID-19, stating: “I want to do everything I can to reduce my risk of infection.” In addition to physical distancing, mask wearing, hand hygiene, and control of chronic conditions, which of the following supplements would you recommend for this patient?
1. Coenzyme Q10 160 mg twice a day
2. Vitamin D 2,000 IU daily
3. Vitamin E 400 IU daily
4. Vitamin B12 1,000 mcg daily
Of these choices, vitamin D supplementation is likely the best option, based on the limited data that is available.
Risk factors for worse COVID-19 outcome, such as older age, obesity, and more pigmented skin are also risk factors for vitamin D deficiency. This makes the study of vitamin D and COVID-19 both challenging and relevant.
In a recent study of 7,807 people living in Israel, Merzon and colleagues found that low plasma vitamin D level was an independent risk factor for COVID-19 infection. Mean plasma vitamin D level was significantly lower among those who tested positive for COVID-19 (19.00 ng/mL) than negative (20.55 ng/ mL). After controlling for demographic variables and several medical conditions, the adjusted odds ratio of COVID-19 infection in those with lower vitamin D was 1.45 (95% confidence interval, 1.08-1.95; P < .001). However, the odds of hospitalization for COVID-19 was not significantly associated with vitamin D level.1
Prior studies have also looked at vitamin D and respiratory infection. Martineau and colleagues analyzed 25 randomized, controlled trials with a pooled number of 11,321 individuals, including healthy ones and those with comorbidities, and found that oral vitamin D supplementation in daily or weekly doses had a protective effect against acute respiratory infection (adjusted odds ratio, 0.88; 95% CI, 0.81-0.96; P < .001). Patients with vitamin D deficiency (less than 25 nmol/L) experienced the most protective benefit. Vitamin D did not influence respiratory infection outcome.2
These studies suggest an adequate vitamin D level may be protective against infection with COVID-19, but who will benefit from vitamin D supplementation, and in what dose? Per U.S. Preventive Services Task Force guidelines, there is insufficient evidence to recommend screening for vitamin D deficiency in asymptomatic adults. Regarding daily dietary intake, the Institute of Medicine recommends 600 IU for persons aged 1-70, and 800 IU for those aged over 70 years. Salmon (447 IU per 3 oz serving), tuna (154 IU), and fortified milk (116 IU) are among the most vitamin D–rich foods.3 The recommended upper level of intake is 4,000 IU/day.
Too much of a good thing?
Extra vitamin D is stored in adipose tissue. If it builds up over time, storage sites may be overwhelmed, causing a rise in serum D level. While one might expect a subsequent rise in calcium levels, studies have shown this happens inconsistently, and at very high vitamin D levels, over 120 ng/mL.4 Most people would have to take at least 50,000 IU daily for several months to see an effect. The main adverse outcome of vitamin D toxicity is kidney stones, mediated by increased calcium in the blood and urine.
Several animal models have demonstrated hypervitaminosis D–induced aortic and coronary artery calcification. Like with kidney stones, the mechanism appears to be through increased calcium and phosphate levels. Shroff and colleagues studied serum vitamin D levels and vascular disease in children with renal disease on dialysis and found a U-shaped distribution: Children with both low and high vitamin D levels had significantly increased carotid artery intima-media thickness and calcification.5 Given the specialized nature of this population, it’s unclear whether these results can be generalized to most people. More studies are warranted on this topic.
Other benefits
Vitamin D is perhaps most famous for helping to build strong bones. Avenell and colleagues performed a Cochrane meta-analysis of vitamin D supplementation in older adults and found that vitamin D alone did not significantly reduce the risk of hip or other new fracture. Vitamin D plus calcium supplementation did reduce the risk of hip fracture (nine trials, pooled number of individuals was 49,853; relative risk, 0.84; P = .01).6
A lesser-known benefit of vitamin D is muscle protection. A prospective study out of the Jewish Hospital of Cincinnati followed 146 adults who were intolerant to two or more statins because of muscle side effects and found to have a vitamin D level below 32 ng per mL. Subjects were given vitamin D replacement (50,000 units weekly) and followed for 2 years. On statin rechallenge, 88-95% tolerated a statin with vitamin D levels 53-55 ng/mL.7
Pearl
Vitamin D supplementation may protect against COVID-19 infection and has very low chance of harm at daily doses at or below 4,000 IU. Other benefits of taking vitamin D include bone protection and reduction in statin-induced myopathy. The main adverse effect is kidney stones.
Ms. Sharninghausen is a medical student at the University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. Merzon E et al. Low plasma 25(OH) vitamin D level is associated with increased risk of COVID‐19 infection: An Israeli population‐based study. FEBS J. 2020. doi: 10.1111/febs.15495.
2. Martineau AR et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. doi:10.1136/bmj.i6583
3. “How to Get More Vitamin D From Your Food,” Cleveland Clinic. 2019 Oct 23. https://health.clevelandclinic.org/how-to-get-more-vitamin-d-from-your-food/.
4. Galior K et al. Development of vitamin d toxicity from overcorrection of vitamin D Deficiency: A review of case reports. Nutrients. 2018;10(8):953. doi: 10.3390/nu10080953
5. Shroff R et al. A bimodal association of vitamin D levels and vascular disease in children on dialysis. J Am Soc Nephrol. 2008;19(6):1239-46. doi: 10.1681/ASN.2007090993.
6. Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures in post‐menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 14;2014(4):CD000227. doi: 10.1002/14651858.CD000227.pub4.
7. Khayznikov M et al. Statin intolerance because of myalgia, myositis, myopathy, or myonecrosis can in most cases be safely resolved by vitamin D supplementation. N Am J Med Sci. 2015;7(3):86-93. doi:10.4103/1947-2714.153919
Mitigating psychiatric disorder relapse in pregnancy during pandemic
In a previous column, I addressed some of the issues that quickly arose in the context of the COVID-19 pandemic and their implications for reproductive psychiatry. These issues ranged from the importance of sustaining well-being in pregnant and postpartum women during the pandemic, to temporary restrictions that were in place during the early part of the pandemic with respect to performing infertility procedures, to the practical issues of limiting the number of people who could attend to women during labor and delivery in the hospital.
Five months later, we’ve learned a great deal about trying to sustain emotional well-being among pregnant women during COVID-19. There is a high rate of anxiety among women who are pregnant and women who have particularly young children around the various issues of juggling activities of daily living during the pandemic, including switching to remote work and homeschooling children. There is fear of contracting COVID-19 during pregnancy, the exact effects of which are still somewhat unknown. We have seen a shift to telemedicine for prenatal and postpartum obstetrics visits, and a change with respect to visitors and even in-home nurses that would help during the first weeks of life for some couples.
We wondered whether we would see a falloff in the numbers of women presenting to our clinic with questions about the reproductive safety of taking psychiatric medications during pregnancy. We were unclear as to whether women would defer plans to get pregnant given some of the uncertainties that have come with COVID-19. What we’ve seen, at least early on in the pandemic in Massachusetts, has been the opposite. More women during the first 4 months of the pandemic have been seen in our center compared with the same corresponding period over the last 5 years. The precise reasons for this are unclear, but one reason may be that shifting the practice of reproductive psychiatry and pregnancy planning for reproductive-age women to full virtual care has dropped the number of missed appointments to essentially zero. Women perhaps feel an urgency to have a plan for using psychiatric medication during pregnancy. They may also see the benefit of being able to have extended telemedicine consultations that frequently involve their partners, a practice we have always supported, but posed logistical challenges for some.
As our colleagues learned that we had shifted our clinical rounds at the Center for Women’s Mental Health, which we’ve been doing for 25 years, to a virtual format, we began offering a free 1-hour forum to discuss relevant issues around caring for psychiatrically ill women, with a focus on some of the issues that were particularly relevant during the pandemic. The most common reasons for consultation on our service are the appropriate, safest use of antidepressants and mood stabilizers during pregnancy, and that continues to be the case.
If there has been one guiding principle in treating perinatal depression during pregnancy, it has been our long-standing, laser-like focus on keeping women emotionally well during pregnancy, and to highlight the importance of this with women during consultations prior to and during pregnancy. Relapse of psychiatric disorder during pregnancy is one the strongest predictors of postpartum depression, and the impact of untreated depression during pregnancy has been described in the literature and over the years in this column. However, where we want to minimize, if possible, severe onset of illness requiring hospitalization or emergent attention considering it may make social distancing and some of the other mitigating factors vis-à-vis COVID-19 more challenging.
Despite the accumulated data over the last 2 decades on the reproductive safety of antidepressants, women continue to have questions about the safety of these medications during pregnancy. Studies show now that many women would prefer, if at all possible, to defer treatment with antidepressants, and so they come to us with questions about their reproductive safety, the potential of switching to nonpharmacologic interventions, and the use of alternative interventions that might be used to treat their underlying mood disorder.
Investigators at the University of British Columbia recently have tried to inform the field with still another look, not at reproductive safety per se, but at risk of relapse of depression if women discontinue those medicines during pregnancy.1 There is a timeliness to this investigation, which was a systematic review and meta-analysis of studies that met a priori criteria for inclusion. Since some of our own group’s early work over 15 years ago on relapse of psychiatric disorder during pregnancy,2 which indicated a substantial difference in risk of relapse between women who continued versus who discontinued antidepressants, other investigators have showed the difference in risk for relapse is not as substantial, and that continuation of medication did not appear to mitigate risk for relapse. In fact, in the systematic review, the investigators demonstrated that as a group, maintaining medicine did not appear to confer particular benefit to patients relative to risk for relapse compared to discontinuation of antidepressants.
However, looking more closely, Bayrampour and colleagues note for women with histories of more severe recurrent, major depression, relapse did in fact appear to be greater in women who discontinued compared with those with cases of mild to moderate depression. It is noteworthy that in both our early and later work, and certainly dovetailing with our clinical practice, we have noted severity of illness does not appear to correlate with the actual decisions women ultimately make regarding what they will do with antidepressants. Specifically, some women with very severe illness histories will discontinue antidepressants regardless of their risk for relapse. Alternatively, women with mild to moderate illness will sometimes elect to stay on antidepressant therapy. With all the information that we have about fetal exposure to antidepressants on one hand, the “unknown unknowns” are an understandable concern to both patients and clinicians. Clinicians are faced with the dilemma of how to best counsel women on continuing or discontinuing antidepressants as they plan to conceive or during pregnancy and in the postpartum period.
The literature cited and clinical experience over the last 3 decades suggests rather strongly that there is a relatively low likelihood women with histories of severe recurrent disease will be able to successfully discontinue antidepressants in the absence of relapse. A greater question is, what is the best way to proceed for women who have been on maintenance therapy and had more moderate symptoms?
I am inspired by some of the more recent literature that has tried to elucidate the role of nonpharmacologic interventions such as mindfulness-based cognitive therapy (MBCT) in an effort to mitigate risk for depressive relapse in pregnant women who are well with histories of depression. To date, data do not inform the question as to whether MBCT can be used to mitigate risk of depressive relapse in pregnant women who continue or discontinue antidepressants. That research question is actively being studied by several investigators, including ourselves.
Of particular interest is whether the addition of mindfulness practices such as MBCT in treatment could mitigate risk for depressive relapse in pregnant women who continue or discontinue antidepressant treatment, as that would certainly be a no-harm intervention that could mitigate risk even in a lower risk sample of patients. The question of how to “thread the needle” during the pandemic and best approach woman with a history of recurrent major depression on antidepressants is particularly timely and critical.
Regardless, we make clinical decisions collaboratively with patients based on their histories and individual wishes, and perhaps what we have learned over the last 5 months is the use of telemedicine does afford us the opportunity, regardless of the decisions that patients make, to more closely follow the clinical trajectory of women during pregnancy and the postpartum period so that regardless of treatment, we have an opportunity to intervene early when needed and to ascertain changes in clinical status early to mitigate the risk of frank relapse. From a reproductive psychiatric point of view, that is a silver lining with respect to the associated challenges that have come along with the pandemic.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital 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.
References
1. J Clin Psychiatry 2020;81(4):19r13134.
2. JAMA. 2006 Feb 1;295(5):499-507.
In a previous column, I addressed some of the issues that quickly arose in the context of the COVID-19 pandemic and their implications for reproductive psychiatry. These issues ranged from the importance of sustaining well-being in pregnant and postpartum women during the pandemic, to temporary restrictions that were in place during the early part of the pandemic with respect to performing infertility procedures, to the practical issues of limiting the number of people who could attend to women during labor and delivery in the hospital.
Five months later, we’ve learned a great deal about trying to sustain emotional well-being among pregnant women during COVID-19. There is a high rate of anxiety among women who are pregnant and women who have particularly young children around the various issues of juggling activities of daily living during the pandemic, including switching to remote work and homeschooling children. There is fear of contracting COVID-19 during pregnancy, the exact effects of which are still somewhat unknown. We have seen a shift to telemedicine for prenatal and postpartum obstetrics visits, and a change with respect to visitors and even in-home nurses that would help during the first weeks of life for some couples.
We wondered whether we would see a falloff in the numbers of women presenting to our clinic with questions about the reproductive safety of taking psychiatric medications during pregnancy. We were unclear as to whether women would defer plans to get pregnant given some of the uncertainties that have come with COVID-19. What we’ve seen, at least early on in the pandemic in Massachusetts, has been the opposite. More women during the first 4 months of the pandemic have been seen in our center compared with the same corresponding period over the last 5 years. The precise reasons for this are unclear, but one reason may be that shifting the practice of reproductive psychiatry and pregnancy planning for reproductive-age women to full virtual care has dropped the number of missed appointments to essentially zero. Women perhaps feel an urgency to have a plan for using psychiatric medication during pregnancy. They may also see the benefit of being able to have extended telemedicine consultations that frequently involve their partners, a practice we have always supported, but posed logistical challenges for some.
As our colleagues learned that we had shifted our clinical rounds at the Center for Women’s Mental Health, which we’ve been doing for 25 years, to a virtual format, we began offering a free 1-hour forum to discuss relevant issues around caring for psychiatrically ill women, with a focus on some of the issues that were particularly relevant during the pandemic. The most common reasons for consultation on our service are the appropriate, safest use of antidepressants and mood stabilizers during pregnancy, and that continues to be the case.
If there has been one guiding principle in treating perinatal depression during pregnancy, it has been our long-standing, laser-like focus on keeping women emotionally well during pregnancy, and to highlight the importance of this with women during consultations prior to and during pregnancy. Relapse of psychiatric disorder during pregnancy is one the strongest predictors of postpartum depression, and the impact of untreated depression during pregnancy has been described in the literature and over the years in this column. However, where we want to minimize, if possible, severe onset of illness requiring hospitalization or emergent attention considering it may make social distancing and some of the other mitigating factors vis-à-vis COVID-19 more challenging.
Despite the accumulated data over the last 2 decades on the reproductive safety of antidepressants, women continue to have questions about the safety of these medications during pregnancy. Studies show now that many women would prefer, if at all possible, to defer treatment with antidepressants, and so they come to us with questions about their reproductive safety, the potential of switching to nonpharmacologic interventions, and the use of alternative interventions that might be used to treat their underlying mood disorder.
Investigators at the University of British Columbia recently have tried to inform the field with still another look, not at reproductive safety per se, but at risk of relapse of depression if women discontinue those medicines during pregnancy.1 There is a timeliness to this investigation, which was a systematic review and meta-analysis of studies that met a priori criteria for inclusion. Since some of our own group’s early work over 15 years ago on relapse of psychiatric disorder during pregnancy,2 which indicated a substantial difference in risk of relapse between women who continued versus who discontinued antidepressants, other investigators have showed the difference in risk for relapse is not as substantial, and that continuation of medication did not appear to mitigate risk for relapse. In fact, in the systematic review, the investigators demonstrated that as a group, maintaining medicine did not appear to confer particular benefit to patients relative to risk for relapse compared to discontinuation of antidepressants.
However, looking more closely, Bayrampour and colleagues note for women with histories of more severe recurrent, major depression, relapse did in fact appear to be greater in women who discontinued compared with those with cases of mild to moderate depression. It is noteworthy that in both our early and later work, and certainly dovetailing with our clinical practice, we have noted severity of illness does not appear to correlate with the actual decisions women ultimately make regarding what they will do with antidepressants. Specifically, some women with very severe illness histories will discontinue antidepressants regardless of their risk for relapse. Alternatively, women with mild to moderate illness will sometimes elect to stay on antidepressant therapy. With all the information that we have about fetal exposure to antidepressants on one hand, the “unknown unknowns” are an understandable concern to both patients and clinicians. Clinicians are faced with the dilemma of how to best counsel women on continuing or discontinuing antidepressants as they plan to conceive or during pregnancy and in the postpartum period.
The literature cited and clinical experience over the last 3 decades suggests rather strongly that there is a relatively low likelihood women with histories of severe recurrent disease will be able to successfully discontinue antidepressants in the absence of relapse. A greater question is, what is the best way to proceed for women who have been on maintenance therapy and had more moderate symptoms?
I am inspired by some of the more recent literature that has tried to elucidate the role of nonpharmacologic interventions such as mindfulness-based cognitive therapy (MBCT) in an effort to mitigate risk for depressive relapse in pregnant women who are well with histories of depression. To date, data do not inform the question as to whether MBCT can be used to mitigate risk of depressive relapse in pregnant women who continue or discontinue antidepressants. That research question is actively being studied by several investigators, including ourselves.
Of particular interest is whether the addition of mindfulness practices such as MBCT in treatment could mitigate risk for depressive relapse in pregnant women who continue or discontinue antidepressant treatment, as that would certainly be a no-harm intervention that could mitigate risk even in a lower risk sample of patients. The question of how to “thread the needle” during the pandemic and best approach woman with a history of recurrent major depression on antidepressants is particularly timely and critical.
Regardless, we make clinical decisions collaboratively with patients based on their histories and individual wishes, and perhaps what we have learned over the last 5 months is the use of telemedicine does afford us the opportunity, regardless of the decisions that patients make, to more closely follow the clinical trajectory of women during pregnancy and the postpartum period so that regardless of treatment, we have an opportunity to intervene early when needed and to ascertain changes in clinical status early to mitigate the risk of frank relapse. From a reproductive psychiatric point of view, that is a silver lining with respect to the associated challenges that have come along with the pandemic.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital 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.
References
1. J Clin Psychiatry 2020;81(4):19r13134.
2. JAMA. 2006 Feb 1;295(5):499-507.
In a previous column, I addressed some of the issues that quickly arose in the context of the COVID-19 pandemic and their implications for reproductive psychiatry. These issues ranged from the importance of sustaining well-being in pregnant and postpartum women during the pandemic, to temporary restrictions that were in place during the early part of the pandemic with respect to performing infertility procedures, to the practical issues of limiting the number of people who could attend to women during labor and delivery in the hospital.
Five months later, we’ve learned a great deal about trying to sustain emotional well-being among pregnant women during COVID-19. There is a high rate of anxiety among women who are pregnant and women who have particularly young children around the various issues of juggling activities of daily living during the pandemic, including switching to remote work and homeschooling children. There is fear of contracting COVID-19 during pregnancy, the exact effects of which are still somewhat unknown. We have seen a shift to telemedicine for prenatal and postpartum obstetrics visits, and a change with respect to visitors and even in-home nurses that would help during the first weeks of life for some couples.
We wondered whether we would see a falloff in the numbers of women presenting to our clinic with questions about the reproductive safety of taking psychiatric medications during pregnancy. We were unclear as to whether women would defer plans to get pregnant given some of the uncertainties that have come with COVID-19. What we’ve seen, at least early on in the pandemic in Massachusetts, has been the opposite. More women during the first 4 months of the pandemic have been seen in our center compared with the same corresponding period over the last 5 years. The precise reasons for this are unclear, but one reason may be that shifting the practice of reproductive psychiatry and pregnancy planning for reproductive-age women to full virtual care has dropped the number of missed appointments to essentially zero. Women perhaps feel an urgency to have a plan for using psychiatric medication during pregnancy. They may also see the benefit of being able to have extended telemedicine consultations that frequently involve their partners, a practice we have always supported, but posed logistical challenges for some.
As our colleagues learned that we had shifted our clinical rounds at the Center for Women’s Mental Health, which we’ve been doing for 25 years, to a virtual format, we began offering a free 1-hour forum to discuss relevant issues around caring for psychiatrically ill women, with a focus on some of the issues that were particularly relevant during the pandemic. The most common reasons for consultation on our service are the appropriate, safest use of antidepressants and mood stabilizers during pregnancy, and that continues to be the case.
If there has been one guiding principle in treating perinatal depression during pregnancy, it has been our long-standing, laser-like focus on keeping women emotionally well during pregnancy, and to highlight the importance of this with women during consultations prior to and during pregnancy. Relapse of psychiatric disorder during pregnancy is one the strongest predictors of postpartum depression, and the impact of untreated depression during pregnancy has been described in the literature and over the years in this column. However, where we want to minimize, if possible, severe onset of illness requiring hospitalization or emergent attention considering it may make social distancing and some of the other mitigating factors vis-à-vis COVID-19 more challenging.
Despite the accumulated data over the last 2 decades on the reproductive safety of antidepressants, women continue to have questions about the safety of these medications during pregnancy. Studies show now that many women would prefer, if at all possible, to defer treatment with antidepressants, and so they come to us with questions about their reproductive safety, the potential of switching to nonpharmacologic interventions, and the use of alternative interventions that might be used to treat their underlying mood disorder.
Investigators at the University of British Columbia recently have tried to inform the field with still another look, not at reproductive safety per se, but at risk of relapse of depression if women discontinue those medicines during pregnancy.1 There is a timeliness to this investigation, which was a systematic review and meta-analysis of studies that met a priori criteria for inclusion. Since some of our own group’s early work over 15 years ago on relapse of psychiatric disorder during pregnancy,2 which indicated a substantial difference in risk of relapse between women who continued versus who discontinued antidepressants, other investigators have showed the difference in risk for relapse is not as substantial, and that continuation of medication did not appear to mitigate risk for relapse. In fact, in the systematic review, the investigators demonstrated that as a group, maintaining medicine did not appear to confer particular benefit to patients relative to risk for relapse compared to discontinuation of antidepressants.
However, looking more closely, Bayrampour and colleagues note for women with histories of more severe recurrent, major depression, relapse did in fact appear to be greater in women who discontinued compared with those with cases of mild to moderate depression. It is noteworthy that in both our early and later work, and certainly dovetailing with our clinical practice, we have noted severity of illness does not appear to correlate with the actual decisions women ultimately make regarding what they will do with antidepressants. Specifically, some women with very severe illness histories will discontinue antidepressants regardless of their risk for relapse. Alternatively, women with mild to moderate illness will sometimes elect to stay on antidepressant therapy. With all the information that we have about fetal exposure to antidepressants on one hand, the “unknown unknowns” are an understandable concern to both patients and clinicians. Clinicians are faced with the dilemma of how to best counsel women on continuing or discontinuing antidepressants as they plan to conceive or during pregnancy and in the postpartum period.
The literature cited and clinical experience over the last 3 decades suggests rather strongly that there is a relatively low likelihood women with histories of severe recurrent disease will be able to successfully discontinue antidepressants in the absence of relapse. A greater question is, what is the best way to proceed for women who have been on maintenance therapy and had more moderate symptoms?
I am inspired by some of the more recent literature that has tried to elucidate the role of nonpharmacologic interventions such as mindfulness-based cognitive therapy (MBCT) in an effort to mitigate risk for depressive relapse in pregnant women who are well with histories of depression. To date, data do not inform the question as to whether MBCT can be used to mitigate risk of depressive relapse in pregnant women who continue or discontinue antidepressants. That research question is actively being studied by several investigators, including ourselves.
Of particular interest is whether the addition of mindfulness practices such as MBCT in treatment could mitigate risk for depressive relapse in pregnant women who continue or discontinue antidepressant treatment, as that would certainly be a no-harm intervention that could mitigate risk even in a lower risk sample of patients. The question of how to “thread the needle” during the pandemic and best approach woman with a history of recurrent major depression on antidepressants is particularly timely and critical.
Regardless, we make clinical decisions collaboratively with patients based on their histories and individual wishes, and perhaps what we have learned over the last 5 months is the use of telemedicine does afford us the opportunity, regardless of the decisions that patients make, to more closely follow the clinical trajectory of women during pregnancy and the postpartum period so that regardless of treatment, we have an opportunity to intervene early when needed and to ascertain changes in clinical status early to mitigate the risk of frank relapse. From a reproductive psychiatric point of view, that is a silver lining with respect to the associated challenges that have come along with the pandemic.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital 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.
References
1. J Clin Psychiatry 2020;81(4):19r13134.
2. JAMA. 2006 Feb 1;295(5):499-507.
Why are many of my patients doing better during the pandemic?
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
Reflections on life before and during COVID-19
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
COVID-19, school reopenings, and safety: What should we tell parents?
Parents, teachers, children, and adolescents are facing stress and anxiety as K-12 school districts across the country debate whether to return to in-person instruction amid the COVID-19 pandemic. As we approach the opening of schools, the stress and anxiety seem to be heightening.
According to Education Week, which is tracking the reopening plans of public schools across the United States, 21 of the 25 largest school districts are opting to implement remote learning only as their model. I would like to see all of those districts adopt that model until we understand more about this illness, and can prevent and treat it.
Yes, it’s true – I am a psychiatrist – not an infectious disease specialist. And I realize that the American Academy of Pediatrics and the Centers for Disease Control and Prevention have taken nuanced positions on this issue. Their positions make it clear that it is within a child’s best interests – from an educational and social point of view – to attend school in person. Not only is the classroom experience important, but so is the socialization and the exercise. However, when I look at the science on children who have been exposed to the coronavirus, I worry.
For example, a study by Lael M. Yonker, MD, and associates on pediatric SARS-CoV-2 found that the children in days 0-2 of illness have far higher viral loads than adults who have been hospitalized for severe disease. “This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious [multisystem inflammatory syndrome in children],” Dr. Yonker and associates wrote, referring to the illness associated with COVID-19 in children. Their study was published recently in the Journal of Pediatrics (2020 Aug 19. doi: 10.1016/j.jpeds.2020.08.037).
In my state, where positivity rates are fairly low, Gov. Andrew Cuomo admitted in an interview recently that sending children to school in New York City is a “tricky proposition.” At this point, New York City public schools are scheduled to open in mid-September using a hybrid mixture of in-person and remote learning.
And look at what happened several weeks ago in Israel, where schools reopened after the virus was beaten back. At one high school in Jerusalem, just days after the reopening, the virus spread so prolifically to students, teachers, and relatives that the schools had to be closed again. Other countries should not follow Israel’s example, Eli Weizmann, who chairs the team advising Israel’s National Security Council on the pandemic, reportedly told the New York Times. “It was a major failure.”
But I must be honest: I was worried about children returning to school before I heard about the study by Dr. Yonker and associates, Gov. Cuomo’s comments, and what happened in Israel. So far, here in the Northeast, particularly in New York, New Jersey, and Connecticut, we have managed to get COVID-19 under control. Perhaps, in this part of the country, opening classroom education might be feasible – with close monitoring and proper precautions.
But COVID-19 has taken the lives of hundreds of thousands of Americans – more than 176,000 as of this writing. A new model from the University of Washington’s Institute for Health Metrics and Evaluation projects that COVID-19 could lead to more than 300,000 U.S. deaths by Dec. 1. Thankfully, the number of COVID-19–positive children who have died has been low. But they could still pass on the virus to adults.
To get a better understanding of COVID-19, I spoke with Sheryl L. Wulkan, MD, an internist and expert in personal protective equipment (PPE) who has consulted for numerous health care agencies about these issues. Dr. Wulkan said that, in some areas with low infection rates, school openings might be appropriate. However, she said, without proper testing and contact tracing, we are at a loss of controlling the spread.
What we should tell patients, family, and friends
From a psychiatric point of view, how should we advise our patients, family, and friends about sending their children back to school? Is on-site learning better than remote learning? It is. Do our children need the socialization that a school brings? Yes, they do.
Socialization and relating to peers are, indeed, important, but today’s children socialize in many ways beyond attending school – and they have peer friendships and interactions with electronic devices at their disposal.
Can remote learning cause social isolation – an isolation so profound that school is necessary not only for learning but the psyche as well? A meta-analysis of 80 studies that looked at the impact of social isolation and loneliness on adolescents and children who were previously healthy found that the young people “are probably more likely to experience high rates of depression and probably anxiety during and after enforced isolation ends. This may increase as enforced isolation continues,” wrote Maria Elizabeth Loades, PhD, and associates (J Am Acad Child Adolesc Psychiatry. 2020 Jun 3. S0890-8567[20]30337-3).
I am concerned about young people who experience anxiety and depression, and agree with Dr. Loades that we mental health professionals need to be ready to intervene early and provide preventive support. To do this, we should encourage parents to keep us informed about how their children are doing.
So my advice is that, in the absence of a vaccine and an effective treatment like we have for influenza – such as Tamiflu – and effective testing, such the saliva-based test developed by Yale University researchers, if I had school-aged children, I would continue to keep them home from school. Ultimately, however, parents must look at the science and make their decisions based on that. My children are adults with their own children, and only they can make informed decisions about which options are best for their families.
Interestingly, Sanjay Gupta, MD, the neurosurgeon who works as chief medical correspondent of CNN, recently discussed the thought process he and his wife used to determine whether their daughters would return to the classroom. After weighing many factors, including the viral spread in Fulton County, Ga., where they live, the Guptas decided that, at this time, the risks of allowing the girls to return to the classroom outweigh the benefits. “This was not an easy decision, but one that we believe best respects the science, decreases the risk of further spread, and follows the task force criteria,” wrote Dr. Gupta, who is affiliated with Emory University in Atlanta. “After 2 weeks, we will reassess.”
I understand that parents worry about the social and psychological costs of remote learning. And I can only imagine the difficulty of those who must balance homeschooling with working. And frankly, remote learning is not an option for all students. For those less fortunate, substantial governmental aid is important to assist these people and to keep them safe and on their feet until this pandemic is done. Also, those who were under the care of a psychiatrist should continue to receive care during the pandemic. We must be prepared to step in with interventions that can address the suffering that is inevitable, such as the use of targeted cognitive-behavioral therapy.
Public TV as an educational tool
Families with Internet access and those without it could benefit from using public television as a tool.
I would advise educators and the entertainment industry to harness the wonder of TV to develop curricula that can be used to educate children. As we know, Sesame Street proved to be an effective early childhood intervention, particularly for boys (Am Econ J: Applied Economics. 2019;11[1]:318-50). I would like to see programming that goes beyond Sesame Street. Learning from watching this kind of programming would be no substitute for engaging with teachers in real, live classrooms, however.
Children and adolescents will be changed by learning remotely. They will miss their friends, teachers, and other staff members, but their lives will not be ruined. Mental health professionals should be prepared to intervene to address depression, anxiety, and other sequelae and problematic behaviors that could result from social isolation. Schools, businesses, and the economy will again flourish after we get the virus behind us but controlling and eliminating this pandemic need to come first. Let’s keep our children home – to the extent that we can – until we move beyond this pandemic.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
Parents, teachers, children, and adolescents are facing stress and anxiety as K-12 school districts across the country debate whether to return to in-person instruction amid the COVID-19 pandemic. As we approach the opening of schools, the stress and anxiety seem to be heightening.
According to Education Week, which is tracking the reopening plans of public schools across the United States, 21 of the 25 largest school districts are opting to implement remote learning only as their model. I would like to see all of those districts adopt that model until we understand more about this illness, and can prevent and treat it.
Yes, it’s true – I am a psychiatrist – not an infectious disease specialist. And I realize that the American Academy of Pediatrics and the Centers for Disease Control and Prevention have taken nuanced positions on this issue. Their positions make it clear that it is within a child’s best interests – from an educational and social point of view – to attend school in person. Not only is the classroom experience important, but so is the socialization and the exercise. However, when I look at the science on children who have been exposed to the coronavirus, I worry.
For example, a study by Lael M. Yonker, MD, and associates on pediatric SARS-CoV-2 found that the children in days 0-2 of illness have far higher viral loads than adults who have been hospitalized for severe disease. “This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious [multisystem inflammatory syndrome in children],” Dr. Yonker and associates wrote, referring to the illness associated with COVID-19 in children. Their study was published recently in the Journal of Pediatrics (2020 Aug 19. doi: 10.1016/j.jpeds.2020.08.037).
In my state, where positivity rates are fairly low, Gov. Andrew Cuomo admitted in an interview recently that sending children to school in New York City is a “tricky proposition.” At this point, New York City public schools are scheduled to open in mid-September using a hybrid mixture of in-person and remote learning.
And look at what happened several weeks ago in Israel, where schools reopened after the virus was beaten back. At one high school in Jerusalem, just days after the reopening, the virus spread so prolifically to students, teachers, and relatives that the schools had to be closed again. Other countries should not follow Israel’s example, Eli Weizmann, who chairs the team advising Israel’s National Security Council on the pandemic, reportedly told the New York Times. “It was a major failure.”
But I must be honest: I was worried about children returning to school before I heard about the study by Dr. Yonker and associates, Gov. Cuomo’s comments, and what happened in Israel. So far, here in the Northeast, particularly in New York, New Jersey, and Connecticut, we have managed to get COVID-19 under control. Perhaps, in this part of the country, opening classroom education might be feasible – with close monitoring and proper precautions.
But COVID-19 has taken the lives of hundreds of thousands of Americans – more than 176,000 as of this writing. A new model from the University of Washington’s Institute for Health Metrics and Evaluation projects that COVID-19 could lead to more than 300,000 U.S. deaths by Dec. 1. Thankfully, the number of COVID-19–positive children who have died has been low. But they could still pass on the virus to adults.
To get a better understanding of COVID-19, I spoke with Sheryl L. Wulkan, MD, an internist and expert in personal protective equipment (PPE) who has consulted for numerous health care agencies about these issues. Dr. Wulkan said that, in some areas with low infection rates, school openings might be appropriate. However, she said, without proper testing and contact tracing, we are at a loss of controlling the spread.
What we should tell patients, family, and friends
From a psychiatric point of view, how should we advise our patients, family, and friends about sending their children back to school? Is on-site learning better than remote learning? It is. Do our children need the socialization that a school brings? Yes, they do.
Socialization and relating to peers are, indeed, important, but today’s children socialize in many ways beyond attending school – and they have peer friendships and interactions with electronic devices at their disposal.
Can remote learning cause social isolation – an isolation so profound that school is necessary not only for learning but the psyche as well? A meta-analysis of 80 studies that looked at the impact of social isolation and loneliness on adolescents and children who were previously healthy found that the young people “are probably more likely to experience high rates of depression and probably anxiety during and after enforced isolation ends. This may increase as enforced isolation continues,” wrote Maria Elizabeth Loades, PhD, and associates (J Am Acad Child Adolesc Psychiatry. 2020 Jun 3. S0890-8567[20]30337-3).
I am concerned about young people who experience anxiety and depression, and agree with Dr. Loades that we mental health professionals need to be ready to intervene early and provide preventive support. To do this, we should encourage parents to keep us informed about how their children are doing.
So my advice is that, in the absence of a vaccine and an effective treatment like we have for influenza – such as Tamiflu – and effective testing, such the saliva-based test developed by Yale University researchers, if I had school-aged children, I would continue to keep them home from school. Ultimately, however, parents must look at the science and make their decisions based on that. My children are adults with their own children, and only they can make informed decisions about which options are best for their families.
Interestingly, Sanjay Gupta, MD, the neurosurgeon who works as chief medical correspondent of CNN, recently discussed the thought process he and his wife used to determine whether their daughters would return to the classroom. After weighing many factors, including the viral spread in Fulton County, Ga., where they live, the Guptas decided that, at this time, the risks of allowing the girls to return to the classroom outweigh the benefits. “This was not an easy decision, but one that we believe best respects the science, decreases the risk of further spread, and follows the task force criteria,” wrote Dr. Gupta, who is affiliated with Emory University in Atlanta. “After 2 weeks, we will reassess.”
I understand that parents worry about the social and psychological costs of remote learning. And I can only imagine the difficulty of those who must balance homeschooling with working. And frankly, remote learning is not an option for all students. For those less fortunate, substantial governmental aid is important to assist these people and to keep them safe and on their feet until this pandemic is done. Also, those who were under the care of a psychiatrist should continue to receive care during the pandemic. We must be prepared to step in with interventions that can address the suffering that is inevitable, such as the use of targeted cognitive-behavioral therapy.
Public TV as an educational tool
Families with Internet access and those without it could benefit from using public television as a tool.
I would advise educators and the entertainment industry to harness the wonder of TV to develop curricula that can be used to educate children. As we know, Sesame Street proved to be an effective early childhood intervention, particularly for boys (Am Econ J: Applied Economics. 2019;11[1]:318-50). I would like to see programming that goes beyond Sesame Street. Learning from watching this kind of programming would be no substitute for engaging with teachers in real, live classrooms, however.
Children and adolescents will be changed by learning remotely. They will miss their friends, teachers, and other staff members, but their lives will not be ruined. Mental health professionals should be prepared to intervene to address depression, anxiety, and other sequelae and problematic behaviors that could result from social isolation. Schools, businesses, and the economy will again flourish after we get the virus behind us but controlling and eliminating this pandemic need to come first. Let’s keep our children home – to the extent that we can – until we move beyond this pandemic.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
Parents, teachers, children, and adolescents are facing stress and anxiety as K-12 school districts across the country debate whether to return to in-person instruction amid the COVID-19 pandemic. As we approach the opening of schools, the stress and anxiety seem to be heightening.
According to Education Week, which is tracking the reopening plans of public schools across the United States, 21 of the 25 largest school districts are opting to implement remote learning only as their model. I would like to see all of those districts adopt that model until we understand more about this illness, and can prevent and treat it.
Yes, it’s true – I am a psychiatrist – not an infectious disease specialist. And I realize that the American Academy of Pediatrics and the Centers for Disease Control and Prevention have taken nuanced positions on this issue. Their positions make it clear that it is within a child’s best interests – from an educational and social point of view – to attend school in person. Not only is the classroom experience important, but so is the socialization and the exercise. However, when I look at the science on children who have been exposed to the coronavirus, I worry.
For example, a study by Lael M. Yonker, MD, and associates on pediatric SARS-CoV-2 found that the children in days 0-2 of illness have far higher viral loads than adults who have been hospitalized for severe disease. “This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious [multisystem inflammatory syndrome in children],” Dr. Yonker and associates wrote, referring to the illness associated with COVID-19 in children. Their study was published recently in the Journal of Pediatrics (2020 Aug 19. doi: 10.1016/j.jpeds.2020.08.037).
In my state, where positivity rates are fairly low, Gov. Andrew Cuomo admitted in an interview recently that sending children to school in New York City is a “tricky proposition.” At this point, New York City public schools are scheduled to open in mid-September using a hybrid mixture of in-person and remote learning.
And look at what happened several weeks ago in Israel, where schools reopened after the virus was beaten back. At one high school in Jerusalem, just days after the reopening, the virus spread so prolifically to students, teachers, and relatives that the schools had to be closed again. Other countries should not follow Israel’s example, Eli Weizmann, who chairs the team advising Israel’s National Security Council on the pandemic, reportedly told the New York Times. “It was a major failure.”
But I must be honest: I was worried about children returning to school before I heard about the study by Dr. Yonker and associates, Gov. Cuomo’s comments, and what happened in Israel. So far, here in the Northeast, particularly in New York, New Jersey, and Connecticut, we have managed to get COVID-19 under control. Perhaps, in this part of the country, opening classroom education might be feasible – with close monitoring and proper precautions.
But COVID-19 has taken the lives of hundreds of thousands of Americans – more than 176,000 as of this writing. A new model from the University of Washington’s Institute for Health Metrics and Evaluation projects that COVID-19 could lead to more than 300,000 U.S. deaths by Dec. 1. Thankfully, the number of COVID-19–positive children who have died has been low. But they could still pass on the virus to adults.
To get a better understanding of COVID-19, I spoke with Sheryl L. Wulkan, MD, an internist and expert in personal protective equipment (PPE) who has consulted for numerous health care agencies about these issues. Dr. Wulkan said that, in some areas with low infection rates, school openings might be appropriate. However, she said, without proper testing and contact tracing, we are at a loss of controlling the spread.
What we should tell patients, family, and friends
From a psychiatric point of view, how should we advise our patients, family, and friends about sending their children back to school? Is on-site learning better than remote learning? It is. Do our children need the socialization that a school brings? Yes, they do.
Socialization and relating to peers are, indeed, important, but today’s children socialize in many ways beyond attending school – and they have peer friendships and interactions with electronic devices at their disposal.
Can remote learning cause social isolation – an isolation so profound that school is necessary not only for learning but the psyche as well? A meta-analysis of 80 studies that looked at the impact of social isolation and loneliness on adolescents and children who were previously healthy found that the young people “are probably more likely to experience high rates of depression and probably anxiety during and after enforced isolation ends. This may increase as enforced isolation continues,” wrote Maria Elizabeth Loades, PhD, and associates (J Am Acad Child Adolesc Psychiatry. 2020 Jun 3. S0890-8567[20]30337-3).
I am concerned about young people who experience anxiety and depression, and agree with Dr. Loades that we mental health professionals need to be ready to intervene early and provide preventive support. To do this, we should encourage parents to keep us informed about how their children are doing.
So my advice is that, in the absence of a vaccine and an effective treatment like we have for influenza – such as Tamiflu – and effective testing, such the saliva-based test developed by Yale University researchers, if I had school-aged children, I would continue to keep them home from school. Ultimately, however, parents must look at the science and make their decisions based on that. My children are adults with their own children, and only they can make informed decisions about which options are best for their families.
Interestingly, Sanjay Gupta, MD, the neurosurgeon who works as chief medical correspondent of CNN, recently discussed the thought process he and his wife used to determine whether their daughters would return to the classroom. After weighing many factors, including the viral spread in Fulton County, Ga., where they live, the Guptas decided that, at this time, the risks of allowing the girls to return to the classroom outweigh the benefits. “This was not an easy decision, but one that we believe best respects the science, decreases the risk of further spread, and follows the task force criteria,” wrote Dr. Gupta, who is affiliated with Emory University in Atlanta. “After 2 weeks, we will reassess.”
I understand that parents worry about the social and psychological costs of remote learning. And I can only imagine the difficulty of those who must balance homeschooling with working. And frankly, remote learning is not an option for all students. For those less fortunate, substantial governmental aid is important to assist these people and to keep them safe and on their feet until this pandemic is done. Also, those who were under the care of a psychiatrist should continue to receive care during the pandemic. We must be prepared to step in with interventions that can address the suffering that is inevitable, such as the use of targeted cognitive-behavioral therapy.
Public TV as an educational tool
Families with Internet access and those without it could benefit from using public television as a tool.
I would advise educators and the entertainment industry to harness the wonder of TV to develop curricula that can be used to educate children. As we know, Sesame Street proved to be an effective early childhood intervention, particularly for boys (Am Econ J: Applied Economics. 2019;11[1]:318-50). I would like to see programming that goes beyond Sesame Street. Learning from watching this kind of programming would be no substitute for engaging with teachers in real, live classrooms, however.
Children and adolescents will be changed by learning remotely. They will miss their friends, teachers, and other staff members, but their lives will not be ruined. Mental health professionals should be prepared to intervene to address depression, anxiety, and other sequelae and problematic behaviors that could result from social isolation. Schools, businesses, and the economy will again flourish after we get the virus behind us but controlling and eliminating this pandemic need to come first. Let’s keep our children home – to the extent that we can – until we move beyond this pandemic.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
Weighing children in school: No good can come of it
The United Kingdom’s National Obesity Forum has apparently decided that returning to school this fall in the middle of a pandemic isn’t stressful enough for kids, and is recommending that its National Child Measurement Programme be expanded to have 4- to 5-year-old and 10- to 11-year-old children weighed when they return to the classroom – and then weighed again in the spring – in a bid to tackle COVID-19–related gains.
It’s difficult to conceive a single plausible mechanism by which this recommendation could be helpful. Given that weight is, by a substantial margin, the No. 1 reported cause of schoolyard bullying, it’s certainly unlikely that children with obesity don’t already know that they have it. It’s also unlikely that they don’t know that obesity confers risks to health, given the near constant drumbeats of concern percussed by the media and public health authorities, and the fact that watching people with obesity be blamed, shamed, and berated for their condition has in the past 2 decades become a regularly repeated prime-time reality show spectacle.
It’s also unlikely, especially in younger grades, to be something within a child’s direct control.
What about the parents? Well, given that they dress their children and that changes in weight affect clothing sizes and fit, they’re already aware if their kids are gaining weight. And like their children, they have been exposed to constant public health alarms around obesity.
Many parents will have seen their time and resources, both real and mental, become significantly impaired during the time of COVID-19, which in turn understandably challenges change. Simply put, permanent intentional behavior change in the name of health requires tremendous privilege and is elusive for many people even during easier times. For non–evidence-based proof of this assertion, simply reflect on all of your own best-laid intentions and plans that might have been good for your health (fitness, relationships, CME, etc.) that you let slide despite probably having far more privilege than the average person.
Then, of course, there is the hugely inconvenient truth that we have yet to see the development of a parent- or child-based educational intervention or directive for weight gain that has shown itself to be beneficial on a population level.
Can something else be done instead?
At this point, we can only speculate about the potential risks associated with school room weigh-ins because randomized controlled trials, thankfully, have not been conducted to explore this area. But I can certainly tell you that I have met many adult patients in my office who traced their lifetime of yo-yo dieting – along with a history of teenage eating disorders, at times – to their well-intentioned physician, school nurse, gym teacher, or parent using a scale to measure their weights. And in doing so, they were teaching that scales measure health, happiness, success, self-worth, and effort.
If governments are concerned about weight gain in children, they need to look to initiatives that will help all children and parents. Weighing them will not somehow inspire parents or kids to discover an as-yet unknown effective childhood obesity treatment. Changes that would be helpful may include:
- Banning food advertisements to children.
- Reforming school cafeteria meals and then ensuring that school meals are made available to children during COVID-19–related school shutdowns.
- Bringing back home economics classes to teach children how to cook (and perhaps doing the same for parents during school off-hours or in community centers).
- Enacting sugar-sweetened beverage taxes and using revenues to fund aforementioned reforms and programs, along with others, which might include the subsidization of fresh produce.
- Reforming front-of-package health claims for foods with questionable nutritional quality.
Given that there is literally no age category in any country on the planet that hasn’t seen rising weights, this is clearly not a disease reflecting a pandemic loss of willpower. Rather, this is a disease of the world’s changing food environments and culture, and until we address both through systemic changes, schemes such as the one being proposed by the UK National Obesity Forum are far more likely to do harm than good.
Yoni Freedhoff is associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada’s most outspoken obesity experts and the author of “The Diet Fix: Why Diets Fail and How to Make Yours Work.” A version of this article originally appeared on Medscape.com.
The United Kingdom’s National Obesity Forum has apparently decided that returning to school this fall in the middle of a pandemic isn’t stressful enough for kids, and is recommending that its National Child Measurement Programme be expanded to have 4- to 5-year-old and 10- to 11-year-old children weighed when they return to the classroom – and then weighed again in the spring – in a bid to tackle COVID-19–related gains.
It’s difficult to conceive a single plausible mechanism by which this recommendation could be helpful. Given that weight is, by a substantial margin, the No. 1 reported cause of schoolyard bullying, it’s certainly unlikely that children with obesity don’t already know that they have it. It’s also unlikely that they don’t know that obesity confers risks to health, given the near constant drumbeats of concern percussed by the media and public health authorities, and the fact that watching people with obesity be blamed, shamed, and berated for their condition has in the past 2 decades become a regularly repeated prime-time reality show spectacle.
It’s also unlikely, especially in younger grades, to be something within a child’s direct control.
What about the parents? Well, given that they dress their children and that changes in weight affect clothing sizes and fit, they’re already aware if their kids are gaining weight. And like their children, they have been exposed to constant public health alarms around obesity.
Many parents will have seen their time and resources, both real and mental, become significantly impaired during the time of COVID-19, which in turn understandably challenges change. Simply put, permanent intentional behavior change in the name of health requires tremendous privilege and is elusive for many people even during easier times. For non–evidence-based proof of this assertion, simply reflect on all of your own best-laid intentions and plans that might have been good for your health (fitness, relationships, CME, etc.) that you let slide despite probably having far more privilege than the average person.
Then, of course, there is the hugely inconvenient truth that we have yet to see the development of a parent- or child-based educational intervention or directive for weight gain that has shown itself to be beneficial on a population level.
Can something else be done instead?
At this point, we can only speculate about the potential risks associated with school room weigh-ins because randomized controlled trials, thankfully, have not been conducted to explore this area. But I can certainly tell you that I have met many adult patients in my office who traced their lifetime of yo-yo dieting – along with a history of teenage eating disorders, at times – to their well-intentioned physician, school nurse, gym teacher, or parent using a scale to measure their weights. And in doing so, they were teaching that scales measure health, happiness, success, self-worth, and effort.
If governments are concerned about weight gain in children, they need to look to initiatives that will help all children and parents. Weighing them will not somehow inspire parents or kids to discover an as-yet unknown effective childhood obesity treatment. Changes that would be helpful may include:
- Banning food advertisements to children.
- Reforming school cafeteria meals and then ensuring that school meals are made available to children during COVID-19–related school shutdowns.
- Bringing back home economics classes to teach children how to cook (and perhaps doing the same for parents during school off-hours or in community centers).
- Enacting sugar-sweetened beverage taxes and using revenues to fund aforementioned reforms and programs, along with others, which might include the subsidization of fresh produce.
- Reforming front-of-package health claims for foods with questionable nutritional quality.
Given that there is literally no age category in any country on the planet that hasn’t seen rising weights, this is clearly not a disease reflecting a pandemic loss of willpower. Rather, this is a disease of the world’s changing food environments and culture, and until we address both through systemic changes, schemes such as the one being proposed by the UK National Obesity Forum are far more likely to do harm than good.
Yoni Freedhoff is associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada’s most outspoken obesity experts and the author of “The Diet Fix: Why Diets Fail and How to Make Yours Work.” A version of this article originally appeared on Medscape.com.
The United Kingdom’s National Obesity Forum has apparently decided that returning to school this fall in the middle of a pandemic isn’t stressful enough for kids, and is recommending that its National Child Measurement Programme be expanded to have 4- to 5-year-old and 10- to 11-year-old children weighed when they return to the classroom – and then weighed again in the spring – in a bid to tackle COVID-19–related gains.
It’s difficult to conceive a single plausible mechanism by which this recommendation could be helpful. Given that weight is, by a substantial margin, the No. 1 reported cause of schoolyard bullying, it’s certainly unlikely that children with obesity don’t already know that they have it. It’s also unlikely that they don’t know that obesity confers risks to health, given the near constant drumbeats of concern percussed by the media and public health authorities, and the fact that watching people with obesity be blamed, shamed, and berated for their condition has in the past 2 decades become a regularly repeated prime-time reality show spectacle.
It’s also unlikely, especially in younger grades, to be something within a child’s direct control.
What about the parents? Well, given that they dress their children and that changes in weight affect clothing sizes and fit, they’re already aware if their kids are gaining weight. And like their children, they have been exposed to constant public health alarms around obesity.
Many parents will have seen their time and resources, both real and mental, become significantly impaired during the time of COVID-19, which in turn understandably challenges change. Simply put, permanent intentional behavior change in the name of health requires tremendous privilege and is elusive for many people even during easier times. For non–evidence-based proof of this assertion, simply reflect on all of your own best-laid intentions and plans that might have been good for your health (fitness, relationships, CME, etc.) that you let slide despite probably having far more privilege than the average person.
Then, of course, there is the hugely inconvenient truth that we have yet to see the development of a parent- or child-based educational intervention or directive for weight gain that has shown itself to be beneficial on a population level.
Can something else be done instead?
At this point, we can only speculate about the potential risks associated with school room weigh-ins because randomized controlled trials, thankfully, have not been conducted to explore this area. But I can certainly tell you that I have met many adult patients in my office who traced their lifetime of yo-yo dieting – along with a history of teenage eating disorders, at times – to their well-intentioned physician, school nurse, gym teacher, or parent using a scale to measure their weights. And in doing so, they were teaching that scales measure health, happiness, success, self-worth, and effort.
If governments are concerned about weight gain in children, they need to look to initiatives that will help all children and parents. Weighing them will not somehow inspire parents or kids to discover an as-yet unknown effective childhood obesity treatment. Changes that would be helpful may include:
- Banning food advertisements to children.
- Reforming school cafeteria meals and then ensuring that school meals are made available to children during COVID-19–related school shutdowns.
- Bringing back home economics classes to teach children how to cook (and perhaps doing the same for parents during school off-hours or in community centers).
- Enacting sugar-sweetened beverage taxes and using revenues to fund aforementioned reforms and programs, along with others, which might include the subsidization of fresh produce.
- Reforming front-of-package health claims for foods with questionable nutritional quality.
Given that there is literally no age category in any country on the planet that hasn’t seen rising weights, this is clearly not a disease reflecting a pandemic loss of willpower. Rather, this is a disease of the world’s changing food environments and culture, and until we address both through systemic changes, schemes such as the one being proposed by the UK National Obesity Forum are far more likely to do harm than good.
Yoni Freedhoff is associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada’s most outspoken obesity experts and the author of “The Diet Fix: Why Diets Fail and How to Make Yours Work.” A version of this article originally appeared on Medscape.com.