COVID-19 Updates

Words matter. So, hear me when I say: I am Asian. I am American. I am a woman. I am not COVID-19. I did not create this virus. I did not place it in my pocket and bring it to the world, sprinkling it like pixie dust, along each path I’ve crossed.

My words create a story, and not just those of one psychiatrist reaching out to others. It’s the story of how the powerful use of words throughout my life inflicted racism upon me, even when unacknowledged by my conscious self. I share my story to let you know you are not alone in your journey of unwinding the cumulative systemic racist words and actions that might have affected your self-identification and self-love. I hope you channel that renewed sense of discovery to empower you to use your own words to create a positive impact for yourself and others – whether it is for your patients, friends, or community.

Currently, I serve as a physician and an advocate. I lead telehealth and developed software that screens for suicide risk (with support of a digital health grant). I also joined friends to develop a by-clinician, for-clinician telemental health platform.

Outside of my Hippocratic Oath, my mission, at its core, was to destigmatize mental illness through cultivating thoughtful conversations. But I am also so much more; aren’t we all? I am a daughter, a sister, an aunt, a friend, and an American. I am working hard to create a life I love – the embodiment of the American Dream. If you meet me face to face, no curriculum vitae, no email, I’m Vietnamese. However, I am not the color of my skin or the shape of my eyes. I am no more defined by my lingering Vietnamese accent than I am by its Texan counterpart. Yet, throughout my life, my Vietnamese ethnicity has been a marker that others have used to define and objectify me.
 

Trauma emerges on national stage

I never thought it would happen to me, but as a resident physician, one of my most traumatic experiences of abusive power was when Donald Trump was running for president in 2016. He was using words and rhetoric that objectified women by classifying and quantifying their “attractiveness.” This culminated in a scandal surrounding a recording in which he said he would grab women by the $%&#@ ... and had been allowed to do so because he was a celebrity. That episode affected me profoundly, maybe more than most. As a child and adolescent psychiatrist, I knew the impact those words could have on future generations, and, as a woman and an aunt, I was appalled. But then, the effect turned to assault. Words matter.

I was living in New York City and as I made my nightly walk home on the Upper East Side, a man followed me. When I walked up the stairs to my building, he actually grabbed me ... by the $%&#@. He did this with the same casual manner that one might greet a coworker with a high-five. He then turned and walked away, laughing. I was overcome with shock; shocked that I could be so violated and yet thankful that he hadn’t taken any more aggressive liberties. He didn’t run away. He walked out as calmly as he had walked in, despite violating a most private piece of my femininity. And he laughed. As much as it jilted me, angered me, and made me feel demeaned and less-than, I know it’s a blessing that the story ended there; so often attacks against women end so much worse.

I questioned: “Why?” Why would this man do this to me? To anyone? I don’t know the answer, but I do know this: The things we normalize through the words we hear in the world, on the news, and at our dinner tables become action. It happened. This man didn’t skulk off into the alleyway. He didn’t hide. He laughed because he felt entitled. That’s because words matter.

My journey is paved with words that mattered. I was born in Vietnam; my family legally immigrated to the United States when I was 5 years old. Throughout grade school, I began to realize the power of spoken words, especially when I was frequently told to go back to where I came from. Questions flew at me like bullets, and whether innocent or borne of curiosity, were hurtful reminders that, through no choice of my own, I was an unwelcome foreigner. “Where are you from?” ... “No, where are you really, really from?” I felt eyes peering through me when my mother packed for me our culture’s traditional foods for lunch. “Ew, what’s that?” ... “That’s gross it smells.” How I longed for the cloak of a peanut butter and jelly sandwich and blonde hair.

As I approached high school, college, and postgraduate work, the “where are you from?” questions didn’t stop but took on a new connotation, as if I were some exotic pet that men had seen walking down the street. “Ooh, what is that?” While history is riddled with the objectification of women, rarely would any woman expect to have a stranger approach her and objectify her with a statement such as: “I only date girls with breast implants.” For Asian women, however, experiencing verbal objectification has become the norm. Each approach I faced was followed by a story about Asian girlfriends of their past and a request for my phone number that felt more like a demand.

What these men probably meant as flirtation, I internalized as inescapable concerns of whether or not they had true desire to get to know me as a person. I became used to unsolicited words and attention from men who objectified me as an exotic fetish. I tried to pretend it was okay, but why? Objectifying Asian women is racism. Their words remind me, and I still hear them, that America has a long history of hypersexualizing Asian women. These words – at their core – dehumanize Asian women, and as we have seen, lead to violence.

Over the past few weeks, there’s been discourse about the mass shooting in Atlanta. We need to pause and remember that the victims, like us, were human. These women killed in Atlanta had husbands, children, siblings, parents, and communities that they were taken away from, senselessly, based solely on their outward appearance. Whether or not this act was perpetrated by someone with a sexual addiction doesn’t matter. What happened is rooted in the systemic racism that has stereotyped Asian women as sexual objects. The perpetrator targeted a group of people because of the systemic racism ingrained in him, plain and simple.

Everybody, no matter how evolved one’s thinking, is influenced by words. You don’t have to have mental illness or malicious intent to fall for propaganda – that’s what makes it so scary, it works so well. Even among my own friends and family, some of the most compassionate people I know, I’ve heard disparaging remarks against Chinese people, from other Asians, repeating the same rhetoric they’ve seen in American newspapers and Asian media outlets, echoing the former president’s coronavirus references to the “Chinese virus.”

But what makes something systemic? What feeds this virus of hate and gives these practices their longevity? Pointing out problems doesn’t make them go away; we have to cultivate conversation based around solutions. And that’s our next step. What can we do to make a positive impact?

Words have affected my life, and my words have given me power. I encourage others to engage in activities where they too can feel empowered. Since the beginning of the pandemic, I’ve leveraged my leadership position with the American Psychiatric Association’s Caucus of Asian American Psychiatrists and used my words to promote advocacy. I’ve also used my voice to raise national attention to the anti-Asian hate activities. Motivated by my own desire to seek a supportive space with others to reflect on our racial identities, I’ve also launched various free support groups for Asian American and Pacific Islanders (AAPI) professionals and health care providers. I want to feel a sense of connection with others who share my experiences, as I never underestimate the phenomenal force of comforting words from a healing community.

Clinicians need their own space for processing, too. It is vitally important for us to take care of ourselves, because our patients’ words can affect our own mental health. My colleagues are shocked by the amount of AAPI patients who are reaching out to them for care. Most of them have not worked with AAPI patients before, because so many people of AAPI descent do not often seek treatment. Many of our patients are dealing with anxiety surrounding their own health and wellness, coupled with financial uncertainties and social unrest. In particular, AAPI clinicians may start to experience bystander trauma, because, for the first time, they are thinking: “It could have been me.” AAPI clinicians are in a unique situation where they have the extra burden of providing a safe space for processing clients’ trauma while also processing their own. We may have experiences of discrimination or racially motivated assaults and can reexperience this trauma through our work. Before we can help others, we have to do a self-check and reflect on how we are doing and seek our own support.

If you are able to take care of yourself and feel empowered to make a difference, there are many ways to help fight against anti-Asian sentiment, both on a personal and more global scale.

We have to check our biases and those of our family, friends, and colleagues. Everyone, even mental health professionals, has biases and is affected by disinformation. We have to dig deep into our own unconscious biases, reflect on them, and commit to changing the biases around us. Do we, or our families, have unconscious biases against a particular minority group? If so, discuss it. No one is to blame. This is systemic, and no one is at fault. White men are not to be vilified. Conservative Republicans are not our enemy. Each of us is human, with our own flaws that can influence our own conscious and unconscious thoughts and actions. Let’s discuss racial issues with our family and friends. Whenever someone says something hateful or discriminatory toward another ethnic group or racial background, we have to call it out, and help them realize their biases and change them.

If you are able, use your words to write to your elected representatives. Send them a short email, no need to be fancy. For example, you can send a note of support for legislation that is similar to the COVID-19 Hate Crimes Act, which passed the Senate on Thursday, April 22, with 94:1 bipartisan support. This kind of legislation is a step in the right direction, but there is still more we must do to stop anti-Asian biases and hate. There is empowerment and healing through making your own voice heard. I hope that these tragic incidents will lead to impactful policy changes.

The next step in this journey of empowerment is speaking about your lived experiences publicly and promoting the voices of others. I dedicated a section of my social media platforms to amplifying Asian voices, sharing news, and updating my hashtags to support the #StopAsianHate movement. I made it a point to form relationships with other advocates, AAPI mental health professionals and those personally affected by anti-Asian hate. Speaking up and speaking out didn’t take away my worries, but it did remind me that I’m powerful and that I am not alone. I can take action and demand action. I do not have to hide in the shadows but can stand in the light, using my voice like a megaphone to call out injustice and intolerance.

I hope that, for AAPI clinicians who may be affected by these current events, this validates your experiences. You are not alone. This is a reminder to treat yourself with empathy as you would your patients. For others, I hope this helps you to learn the plight of many AAPI community members in this country. Together, we can use words to create better neighborhoods, a better country, and safe spaces for all communities, especially the marginalized. As we know, words matter.

Dr. Vo is a board-certified psychiatrist and is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is also a faculty member at the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of telemental health software, Orchid, that eliminates burdensome administrative tasks so that clinicians can focus on their patients and have time for their loved ones.
 

Words matter. So, hear me when I say: I am Asian. I am American. I am a woman. I am not COVID-19. I did not create this virus. I did not place it in my pocket and bring it to the world, sprinkling it like pixie dust, along each path I’ve crossed.

My words create a story, and not just those of one psychiatrist reaching out to others. It’s the story of how the powerful use of words throughout my life inflicted racism upon me, even when unacknowledged by my conscious self. I share my story to let you know you are not alone in your journey of unwinding the cumulative systemic racist words and actions that might have affected your self-identification and self-love. I hope you channel that renewed sense of discovery to empower you to use your own words to create a positive impact for yourself and others – whether it is for your patients, friends, or community.

Currently, I serve as a physician and an advocate. I lead telehealth and developed software that screens for suicide risk (with support of a digital health grant). I also joined friends to develop a by-clinician, for-clinician telemental health platform.

Outside of my Hippocratic Oath, my mission, at its core, was to destigmatize mental illness through cultivating thoughtful conversations. But I am also so much more; aren’t we all? I am a daughter, a sister, an aunt, a friend, and an American. I am working hard to create a life I love – the embodiment of the American Dream. If you meet me face to face, no curriculum vitae, no email, I’m Vietnamese. However, I am not the color of my skin or the shape of my eyes. I am no more defined by my lingering Vietnamese accent than I am by its Texan counterpart. Yet, throughout my life, my Vietnamese ethnicity has been a marker that others have used to define and objectify me.
 

Trauma emerges on national stage

I never thought it would happen to me, but as a resident physician, one of my most traumatic experiences of abusive power was when Donald Trump was running for president in 2016. He was using words and rhetoric that objectified women by classifying and quantifying their “attractiveness.” This culminated in a scandal surrounding a recording in which he said he would grab women by the $%&#@ ... and had been allowed to do so because he was a celebrity. That episode affected me profoundly, maybe more than most. As a child and adolescent psychiatrist, I knew the impact those words could have on future generations, and, as a woman and an aunt, I was appalled. But then, the effect turned to assault. Words matter.

I was living in New York City and as I made my nightly walk home on the Upper East Side, a man followed me. When I walked up the stairs to my building, he actually grabbed me ... by the $%&#@. He did this with the same casual manner that one might greet a coworker with a high-five. He then turned and walked away, laughing. I was overcome with shock; shocked that I could be so violated and yet thankful that he hadn’t taken any more aggressive liberties. He didn’t run away. He walked out as calmly as he had walked in, despite violating a most private piece of my femininity. And he laughed. As much as it jilted me, angered me, and made me feel demeaned and less-than, I know it’s a blessing that the story ended there; so often attacks against women end so much worse.

I questioned: “Why?” Why would this man do this to me? To anyone? I don’t know the answer, but I do know this: The things we normalize through the words we hear in the world, on the news, and at our dinner tables become action. It happened. This man didn’t skulk off into the alleyway. He didn’t hide. He laughed because he felt entitled. That’s because words matter.

My journey is paved with words that mattered. I was born in Vietnam; my family legally immigrated to the United States when I was 5 years old. Throughout grade school, I began to realize the power of spoken words, especially when I was frequently told to go back to where I came from. Questions flew at me like bullets, and whether innocent or borne of curiosity, were hurtful reminders that, through no choice of my own, I was an unwelcome foreigner. “Where are you from?” ... “No, where are you really, really from?” I felt eyes peering through me when my mother packed for me our culture’s traditional foods for lunch. “Ew, what’s that?” ... “That’s gross it smells.” How I longed for the cloak of a peanut butter and jelly sandwich and blonde hair.

As I approached high school, college, and postgraduate work, the “where are you from?” questions didn’t stop but took on a new connotation, as if I were some exotic pet that men had seen walking down the street. “Ooh, what is that?” While history is riddled with the objectification of women, rarely would any woman expect to have a stranger approach her and objectify her with a statement such as: “I only date girls with breast implants.” For Asian women, however, experiencing verbal objectification has become the norm. Each approach I faced was followed by a story about Asian girlfriends of their past and a request for my phone number that felt more like a demand.

What these men probably meant as flirtation, I internalized as inescapable concerns of whether or not they had true desire to get to know me as a person. I became used to unsolicited words and attention from men who objectified me as an exotic fetish. I tried to pretend it was okay, but why? Objectifying Asian women is racism. Their words remind me, and I still hear them, that America has a long history of hypersexualizing Asian women. These words – at their core – dehumanize Asian women, and as we have seen, lead to violence.

Over the past few weeks, there’s been discourse about the mass shooting in Atlanta. We need to pause and remember that the victims, like us, were human. These women killed in Atlanta had husbands, children, siblings, parents, and communities that they were taken away from, senselessly, based solely on their outward appearance. Whether or not this act was perpetrated by someone with a sexual addiction doesn’t matter. What happened is rooted in the systemic racism that has stereotyped Asian women as sexual objects. The perpetrator targeted a group of people because of the systemic racism ingrained in him, plain and simple.

Everybody, no matter how evolved one’s thinking, is influenced by words. You don’t have to have mental illness or malicious intent to fall for propaganda – that’s what makes it so scary, it works so well. Even among my own friends and family, some of the most compassionate people I know, I’ve heard disparaging remarks against Chinese people, from other Asians, repeating the same rhetoric they’ve seen in American newspapers and Asian media outlets, echoing the former president’s coronavirus references to the “Chinese virus.”

But what makes something systemic? What feeds this virus of hate and gives these practices their longevity? Pointing out problems doesn’t make them go away; we have to cultivate conversation based around solutions. And that’s our next step. What can we do to make a positive impact?

Words have affected my life, and my words have given me power. I encourage others to engage in activities where they too can feel empowered. Since the beginning of the pandemic, I’ve leveraged my leadership position with the American Psychiatric Association’s Caucus of Asian American Psychiatrists and used my words to promote advocacy. I’ve also used my voice to raise national attention to the anti-Asian hate activities. Motivated by my own desire to seek a supportive space with others to reflect on our racial identities, I’ve also launched various free support groups for Asian American and Pacific Islanders (AAPI) professionals and health care providers. I want to feel a sense of connection with others who share my experiences, as I never underestimate the phenomenal force of comforting words from a healing community.

Clinicians need their own space for processing, too. It is vitally important for us to take care of ourselves, because our patients’ words can affect our own mental health. My colleagues are shocked by the amount of AAPI patients who are reaching out to them for care. Most of them have not worked with AAPI patients before, because so many people of AAPI descent do not often seek treatment. Many of our patients are dealing with anxiety surrounding their own health and wellness, coupled with financial uncertainties and social unrest. In particular, AAPI clinicians may start to experience bystander trauma, because, for the first time, they are thinking: “It could have been me.” AAPI clinicians are in a unique situation where they have the extra burden of providing a safe space for processing clients’ trauma while also processing their own. We may have experiences of discrimination or racially motivated assaults and can reexperience this trauma through our work. Before we can help others, we have to do a self-check and reflect on how we are doing and seek our own support.

If you are able to take care of yourself and feel empowered to make a difference, there are many ways to help fight against anti-Asian sentiment, both on a personal and more global scale.

We have to check our biases and those of our family, friends, and colleagues. Everyone, even mental health professionals, has biases and is affected by disinformation. We have to dig deep into our own unconscious biases, reflect on them, and commit to changing the biases around us. Do we, or our families, have unconscious biases against a particular minority group? If so, discuss it. No one is to blame. This is systemic, and no one is at fault. White men are not to be vilified. Conservative Republicans are not our enemy. Each of us is human, with our own flaws that can influence our own conscious and unconscious thoughts and actions. Let’s discuss racial issues with our family and friends. Whenever someone says something hateful or discriminatory toward another ethnic group or racial background, we have to call it out, and help them realize their biases and change them.

If you are able, use your words to write to your elected representatives. Send them a short email, no need to be fancy. For example, you can send a note of support for legislation that is similar to the COVID-19 Hate Crimes Act, which passed the Senate on Thursday, April 22, with 94:1 bipartisan support. This kind of legislation is a step in the right direction, but there is still more we must do to stop anti-Asian biases and hate. There is empowerment and healing through making your own voice heard. I hope that these tragic incidents will lead to impactful policy changes.

The next step in this journey of empowerment is speaking about your lived experiences publicly and promoting the voices of others. I dedicated a section of my social media platforms to amplifying Asian voices, sharing news, and updating my hashtags to support the #StopAsianHate movement. I made it a point to form relationships with other advocates, AAPI mental health professionals and those personally affected by anti-Asian hate. Speaking up and speaking out didn’t take away my worries, but it did remind me that I’m powerful and that I am not alone. I can take action and demand action. I do not have to hide in the shadows but can stand in the light, using my voice like a megaphone to call out injustice and intolerance.

I hope that, for AAPI clinicians who may be affected by these current events, this validates your experiences. You are not alone. This is a reminder to treat yourself with empathy as you would your patients. For others, I hope this helps you to learn the plight of many AAPI community members in this country. Together, we can use words to create better neighborhoods, a better country, and safe spaces for all communities, especially the marginalized. As we know, words matter.

Dr. Vo is a board-certified psychiatrist and is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is also a faculty member at the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of telemental health software, Orchid, that eliminates burdensome administrative tasks so that clinicians can focus on their patients and have time for their loved ones.
 

Words matter. So, hear me when I say: I am Asian. I am American. I am a woman. I am not COVID-19. I did not create this virus. I did not place it in my pocket and bring it to the world, sprinkling it like pixie dust, along each path I’ve crossed.

My words create a story, and not just those of one psychiatrist reaching out to others. It’s the story of how the powerful use of words throughout my life inflicted racism upon me, even when unacknowledged by my conscious self. I share my story to let you know you are not alone in your journey of unwinding the cumulative systemic racist words and actions that might have affected your self-identification and self-love. I hope you channel that renewed sense of discovery to empower you to use your own words to create a positive impact for yourself and others – whether it is for your patients, friends, or community.

Currently, I serve as a physician and an advocate. I lead telehealth and developed software that screens for suicide risk (with support of a digital health grant). I also joined friends to develop a by-clinician, for-clinician telemental health platform.

Outside of my Hippocratic Oath, my mission, at its core, was to destigmatize mental illness through cultivating thoughtful conversations. But I am also so much more; aren’t we all? I am a daughter, a sister, an aunt, a friend, and an American. I am working hard to create a life I love – the embodiment of the American Dream. If you meet me face to face, no curriculum vitae, no email, I’m Vietnamese. However, I am not the color of my skin or the shape of my eyes. I am no more defined by my lingering Vietnamese accent than I am by its Texan counterpart. Yet, throughout my life, my Vietnamese ethnicity has been a marker that others have used to define and objectify me.
 

Trauma emerges on national stage

I never thought it would happen to me, but as a resident physician, one of my most traumatic experiences of abusive power was when Donald Trump was running for president in 2016. He was using words and rhetoric that objectified women by classifying and quantifying their “attractiveness.” This culminated in a scandal surrounding a recording in which he said he would grab women by the $%&#@ ... and had been allowed to do so because he was a celebrity. That episode affected me profoundly, maybe more than most. As a child and adolescent psychiatrist, I knew the impact those words could have on future generations, and, as a woman and an aunt, I was appalled. But then, the effect turned to assault. Words matter.

I was living in New York City and as I made my nightly walk home on the Upper East Side, a man followed me. When I walked up the stairs to my building, he actually grabbed me ... by the $%&#@. He did this with the same casual manner that one might greet a coworker with a high-five. He then turned and walked away, laughing. I was overcome with shock; shocked that I could be so violated and yet thankful that he hadn’t taken any more aggressive liberties. He didn’t run away. He walked out as calmly as he had walked in, despite violating a most private piece of my femininity. And he laughed. As much as it jilted me, angered me, and made me feel demeaned and less-than, I know it’s a blessing that the story ended there; so often attacks against women end so much worse.

I questioned: “Why?” Why would this man do this to me? To anyone? I don’t know the answer, but I do know this: The things we normalize through the words we hear in the world, on the news, and at our dinner tables become action. It happened. This man didn’t skulk off into the alleyway. He didn’t hide. He laughed because he felt entitled. That’s because words matter.

My journey is paved with words that mattered. I was born in Vietnam; my family legally immigrated to the United States when I was 5 years old. Throughout grade school, I began to realize the power of spoken words, especially when I was frequently told to go back to where I came from. Questions flew at me like bullets, and whether innocent or borne of curiosity, were hurtful reminders that, through no choice of my own, I was an unwelcome foreigner. “Where are you from?” ... “No, where are you really, really from?” I felt eyes peering through me when my mother packed for me our culture’s traditional foods for lunch. “Ew, what’s that?” ... “That’s gross it smells.” How I longed for the cloak of a peanut butter and jelly sandwich and blonde hair.

As I approached high school, college, and postgraduate work, the “where are you from?” questions didn’t stop but took on a new connotation, as if I were some exotic pet that men had seen walking down the street. “Ooh, what is that?” While history is riddled with the objectification of women, rarely would any woman expect to have a stranger approach her and objectify her with a statement such as: “I only date girls with breast implants.” For Asian women, however, experiencing verbal objectification has become the norm. Each approach I faced was followed by a story about Asian girlfriends of their past and a request for my phone number that felt more like a demand.

What these men probably meant as flirtation, I internalized as inescapable concerns of whether or not they had true desire to get to know me as a person. I became used to unsolicited words and attention from men who objectified me as an exotic fetish. I tried to pretend it was okay, but why? Objectifying Asian women is racism. Their words remind me, and I still hear them, that America has a long history of hypersexualizing Asian women. These words – at their core – dehumanize Asian women, and as we have seen, lead to violence.

Over the past few weeks, there’s been discourse about the mass shooting in Atlanta. We need to pause and remember that the victims, like us, were human. These women killed in Atlanta had husbands, children, siblings, parents, and communities that they were taken away from, senselessly, based solely on their outward appearance. Whether or not this act was perpetrated by someone with a sexual addiction doesn’t matter. What happened is rooted in the systemic racism that has stereotyped Asian women as sexual objects. The perpetrator targeted a group of people because of the systemic racism ingrained in him, plain and simple.

Everybody, no matter how evolved one’s thinking, is influenced by words. You don’t have to have mental illness or malicious intent to fall for propaganda – that’s what makes it so scary, it works so well. Even among my own friends and family, some of the most compassionate people I know, I’ve heard disparaging remarks against Chinese people, from other Asians, repeating the same rhetoric they’ve seen in American newspapers and Asian media outlets, echoing the former president’s coronavirus references to the “Chinese virus.”

But what makes something systemic? What feeds this virus of hate and gives these practices their longevity? Pointing out problems doesn’t make them go away; we have to cultivate conversation based around solutions. And that’s our next step. What can we do to make a positive impact?

Words have affected my life, and my words have given me power. I encourage others to engage in activities where they too can feel empowered. Since the beginning of the pandemic, I’ve leveraged my leadership position with the American Psychiatric Association’s Caucus of Asian American Psychiatrists and used my words to promote advocacy. I’ve also used my voice to raise national attention to the anti-Asian hate activities. Motivated by my own desire to seek a supportive space with others to reflect on our racial identities, I’ve also launched various free support groups for Asian American and Pacific Islanders (AAPI) professionals and health care providers. I want to feel a sense of connection with others who share my experiences, as I never underestimate the phenomenal force of comforting words from a healing community.

Clinicians need their own space for processing, too. It is vitally important for us to take care of ourselves, because our patients’ words can affect our own mental health. My colleagues are shocked by the amount of AAPI patients who are reaching out to them for care. Most of them have not worked with AAPI patients before, because so many people of AAPI descent do not often seek treatment. Many of our patients are dealing with anxiety surrounding their own health and wellness, coupled with financial uncertainties and social unrest. In particular, AAPI clinicians may start to experience bystander trauma, because, for the first time, they are thinking: “It could have been me.” AAPI clinicians are in a unique situation where they have the extra burden of providing a safe space for processing clients’ trauma while also processing their own. We may have experiences of discrimination or racially motivated assaults and can reexperience this trauma through our work. Before we can help others, we have to do a self-check and reflect on how we are doing and seek our own support.

If you are able to take care of yourself and feel empowered to make a difference, there are many ways to help fight against anti-Asian sentiment, both on a personal and more global scale.

We have to check our biases and those of our family, friends, and colleagues. Everyone, even mental health professionals, has biases and is affected by disinformation. We have to dig deep into our own unconscious biases, reflect on them, and commit to changing the biases around us. Do we, or our families, have unconscious biases against a particular minority group? If so, discuss it. No one is to blame. This is systemic, and no one is at fault. White men are not to be vilified. Conservative Republicans are not our enemy. Each of us is human, with our own flaws that can influence our own conscious and unconscious thoughts and actions. Let’s discuss racial issues with our family and friends. Whenever someone says something hateful or discriminatory toward another ethnic group or racial background, we have to call it out, and help them realize their biases and change them.

If you are able, use your words to write to your elected representatives. Send them a short email, no need to be fancy. For example, you can send a note of support for legislation that is similar to the COVID-19 Hate Crimes Act, which passed the Senate on Thursday, April 22, with 94:1 bipartisan support. This kind of legislation is a step in the right direction, but there is still more we must do to stop anti-Asian biases and hate. There is empowerment and healing through making your own voice heard. I hope that these tragic incidents will lead to impactful policy changes.

The next step in this journey of empowerment is speaking about your lived experiences publicly and promoting the voices of others. I dedicated a section of my social media platforms to amplifying Asian voices, sharing news, and updating my hashtags to support the #StopAsianHate movement. I made it a point to form relationships with other advocates, AAPI mental health professionals and those personally affected by anti-Asian hate. Speaking up and speaking out didn’t take away my worries, but it did remind me that I’m powerful and that I am not alone. I can take action and demand action. I do not have to hide in the shadows but can stand in the light, using my voice like a megaphone to call out injustice and intolerance.

I hope that, for AAPI clinicians who may be affected by these current events, this validates your experiences. You are not alone. This is a reminder to treat yourself with empathy as you would your patients. For others, I hope this helps you to learn the plight of many AAPI community members in this country. Together, we can use words to create better neighborhoods, a better country, and safe spaces for all communities, especially the marginalized. As we know, words matter.

Dr. Vo is a board-certified psychiatrist and is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is also a faculty member at the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of telemental health software, Orchid, that eliminates burdensome administrative tasks so that clinicians can focus on their patients and have time for their loved ones.
 

Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.

Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.

At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.

The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.

The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.

“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.

It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.

“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.

The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.

“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.

The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.

ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.

ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.

They also experienced greater bleeding and clotting events (P < .01).

Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.

The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.

Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.

These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.

“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.

“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.

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

Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.

Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.

At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.

The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.

The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.

“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.

It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.

“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.

The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.

“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.

The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.

ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.

ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.

They also experienced greater bleeding and clotting events (P < .01).

Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.

The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.

Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.

These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.

“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.

“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.

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

Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.

Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.

At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.

The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.

The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.

“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.

It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.

“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.

The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.

“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.

The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.

ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.

ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.

They also experienced greater bleeding and clotting events (P < .01).

Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.

The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.

Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.

These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.

“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.

“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.

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

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

A year into the COVID-19 pandemic, it is fair to say that children do transmit the virus, but at lower rates, Philip Zachariah, MD, of Columbia University, New York, said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

Supportive care remains a key element in treating children with COVID-19, Dr. Zachariah emphasized. His presentation on pediatric hot topics in COVID-19 addressed several issues including the importance of risk stratification, current therapeutic options, and the latest on multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
 

Recognize the high-risk patient

When it comes to identifying risk factors for COVID-19 in children, remember that the trajectory of disease is diverse, Dr. Zachariah said.

The presentations of COVID-19 in children include those who are older and/or have comorbidities and present with mainly respiratory issues, those who are younger with symptoms that might overlap with Kawasaki disease, and those who are older with symptoms of cardiac involvement and MIS-C.

The overall hospitalization rate for children with COVID-19 is approximately 5%, but once hospitalized, the rates of ICU admission are approximately 30% and reflect rates seen in adult patients, Dr. Zachariah noted.

In general, data show that underlying conditions are more common in acute COVID-19 cases, and laboratory anomalies are more pronounced in patients with MIS-C, he said.

Based on the most recent studies, independent risk factors for acute COVID-19 in children include extremes of age (infancy or adolescence), minority populations, obesity, medical complexity, immune compromise, and asthma.

However, data are limited on specific issues of medical complexity, and risk depends on the level and type of immunosuppression, as morbidity and mortality have been relatively low in transplant patients, Dr. Zachariah noted.

Another dilemma lies in recognizing MIS-C in a febrile child, Dr. Zachariah noted. A complex question, “but persistent high fever in the setting of known recent COVID-19 infections (within 3 to 6 weeks) seems key,” he said. “If given the chance to do one blood test, I would suggest doing a CRP [C-reactive protein] as a screening test,” Dr. Zachariah said. The best laboratory prognosticators appear to be lymphopenia and brain natriuretic peptide (BNP) he added.

A final risk factor is innate immune defects that might predispose previously healthy children to severe acute COVID-19, such as differences in cytokine expression, said Dr. Zachariah.

“For example, autoantibodies against type 1 interferon production may dispose to severe disease,” he noted. Patients with MIS-C have shown patterns of T-cell activation similar to those seen in severely ill adults, and activation of vascular patrolling CX3CR1+ CD8 + T cells appears as a distinguishing feature in MIS-C, he explained.
 

Prevention plans with monoclonal antibodies

Another hot topic in pediatric COVID-19 is the prevention of severe disease and hospitalization using the currently available therapies, Dr. Zachariah said. However, when interpreting efficacy data, clinicians are almost always extrapolating relative risk to absolute risk in children, he noted.

“Convalescent plasma was promising, but the data on efficacy are increasingly negative,” he noted. Instead, a more exciting development is the use of monoclonal antibodies, which, ideally, “will deliver protection to ‘high risk’ populations in the very early stages of infection,” he said.

Bamlanivimab/etesevimab is “a neutralizing IgG1 monoclonal antibody that binds to overlapping domains of the receptor binding domain of the spike protein of SARS-CoV-2,” said Dr. Zachariah. In a study of 1,035 patients with a median age of 56 years, a single intravenous infusion of bamlanivimab plus etesevimab within 3 days of a positive COVID-19 test showed a 70% reduction in risk of COVID-19 hospitalizations or death.

For children, the current Food and Drug Administration Emergency Use Authorization for monoclonal antibody use covers patients aged 12-17 years, who weigh 40 kg or more, and meet any of several other criteria: a body mass index at the 85th percentile or higher, sickle cell disease, congenital or acquired heart disease, neurodevelopmental disorders such as cerebral palsy, chronic respiratory disease requiring daily control, diabetes, or chronic kidney disease, Dr. Zachariah said.

In addition, pediatric patients aged 12-17 years could be considered for monoclonal antibody treatment in consultation with a pediatric infectious disease specialist if they are symptomatic with COVID-19, weigh at least 40 kg, are not hospitalized for COVID-19 symptoms, and have no new oxygen requirements, he said.
 

More on MIS-C

Currently, IVIG is the most common treatment for MIS-C in the United States, Dr. Zachariah said. In addition, a study published in JAMA Feb. 1, 2021, showed that IVIG in combination with methylprednisolone was associated with a lower risk of treatment failure compared to IVIG alone in 111 children with a median age of 8.6 years.

Although comparative effectiveness data are lacking, in long-term follow-up, all the patients seemed to be doing fine, Dr. Zachariah said. Potential second-line therapies for atypical MIS-C include anakinra and tocilizumab, he added.

Dr. Zachariah concluded by emphasizing the potential of COVID-19 vaccines, with studies underway for both Moderna and Pfizer vaccines in children younger than 16 years.

Dr. Zachariah had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

rfranki@mdedge.com

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

rfranki@mdedge.com

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

rfranki@mdedge.com

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

The Food and Drug Administration could expand the use of the Pfizer COVID-19 vaccine to teens early next week, The New York Times and CNN reported, both citing unnamed officials familiar with the agency’s plans.

In late March, Pfizer submitted data to the FDA showing its mRNA vaccine was 100% effective at preventing COVID-19 infection in children ages 12 to 15. Their vaccine  is already authorized for use teens and adults ages 16 and older.

The move would make about 17 million more Americans eligible for vaccination and would be a major step toward getting both adolescents and teens back into classrooms full time by next fall.

“Across the globe, we are longing for a normal life. This is especially true for our children. The initial results we have seen in the adolescent studies suggest that children are particularly well protected by vaccination, which is very encouraging given the trends we have seen in recent weeks regarding the spread of the B.1.1.7 U.K. variant,” Ugur Sahin, CEO and co-founder of Pfizer partner BioNTech, said in a March 31 press release.

Getting schools fully reopened for in-person learning has been a goal of both the Trump and Biden administrations, but it has been tricky to pull off, as some parents and teachers have been reluctant to return to classrooms with so much uncertainty about the risk and the role of children in spreading the virus.

A recent study of roughly 150,000 school-aged children in Israel found that while kids under age 10 were unlikely to catch or spread the virus as they reentered classrooms. Older children, though, were a different story. The study found that children ages 10-19 had risks of catching the virus that were as high as adults ages 20-60.

The risk for severe illness and death from COVID-19 rises with age.

Children and teens are at relatively low risk from severe outcomes after a COVID-19 infection compared to adults, but they can catch it and some will get really sick with it, especially if they have an underlying health condition, like obesity or asthma that makes them more vulnerable.

Beyond the initial infection, children can get a rare late complication called MIS-C, that while treatable, can be severe and requires hospitalization. Emerging reports also suggest there are some kids that become long haulers in much the same way adults do, dealing with lingering problems for months after they first get sick.

As new variants of the coronavirus circulate in the United States, some states have seen big increases in the number of children and teens with COVID. In Michigan, for example, which recently dealt with a spring surge of cases dominated by the B.1.1.7 variant, cases in children and teens quadrupled in April compared to February.

Beyond individual protection, vaccinating children and teens has been seen as important to achieving strong community protection, or herd immunity, against the new coronavirus.

If the FDA expands the authorization for the Pfizer vaccine, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices will likely meet to review data on the safety and efficacy of the vaccine. The committee may then vote on new recommendations for use of the vaccine in the United States.

Not everyone agrees with the idea that American adolescents, who are at relatively low risk of bad outcomes, could get access to COVID vaccines ahead of vulnerable essential workers and seniors in other parts of the world that are still fighting the pandemic with little access to vaccines.

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

The Food and Drug Administration could expand the use of the Pfizer COVID-19 vaccine to teens early next week, The New York Times and CNN reported, both citing unnamed officials familiar with the agency’s plans.

In late March, Pfizer submitted data to the FDA showing its mRNA vaccine was 100% effective at preventing COVID-19 infection in children ages 12 to 15. Their vaccine  is already authorized for use teens and adults ages 16 and older.

The move would make about 17 million more Americans eligible for vaccination and would be a major step toward getting both adolescents and teens back into classrooms full time by next fall.

“Across the globe, we are longing for a normal life. This is especially true for our children. The initial results we have seen in the adolescent studies suggest that children are particularly well protected by vaccination, which is very encouraging given the trends we have seen in recent weeks regarding the spread of the B.1.1.7 U.K. variant,” Ugur Sahin, CEO and co-founder of Pfizer partner BioNTech, said in a March 31 press release.

Getting schools fully reopened for in-person learning has been a goal of both the Trump and Biden administrations, but it has been tricky to pull off, as some parents and teachers have been reluctant to return to classrooms with so much uncertainty about the risk and the role of children in spreading the virus.

A recent study of roughly 150,000 school-aged children in Israel found that while kids under age 10 were unlikely to catch or spread the virus as they reentered classrooms. Older children, though, were a different story. The study found that children ages 10-19 had risks of catching the virus that were as high as adults ages 20-60.

The risk for severe illness and death from COVID-19 rises with age.

Children and teens are at relatively low risk from severe outcomes after a COVID-19 infection compared to adults, but they can catch it and some will get really sick with it, especially if they have an underlying health condition, like obesity or asthma that makes them more vulnerable.

Beyond the initial infection, children can get a rare late complication called MIS-C, that while treatable, can be severe and requires hospitalization. Emerging reports also suggest there are some kids that become long haulers in much the same way adults do, dealing with lingering problems for months after they first get sick.

As new variants of the coronavirus circulate in the United States, some states have seen big increases in the number of children and teens with COVID. In Michigan, for example, which recently dealt with a spring surge of cases dominated by the B.1.1.7 variant, cases in children and teens quadrupled in April compared to February.

Beyond individual protection, vaccinating children and teens has been seen as important to achieving strong community protection, or herd immunity, against the new coronavirus.

If the FDA expands the authorization for the Pfizer vaccine, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices will likely meet to review data on the safety and efficacy of the vaccine. The committee may then vote on new recommendations for use of the vaccine in the United States.

Not everyone agrees with the idea that American adolescents, who are at relatively low risk of bad outcomes, could get access to COVID vaccines ahead of vulnerable essential workers and seniors in other parts of the world that are still fighting the pandemic with little access to vaccines.

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

The Food and Drug Administration could expand the use of the Pfizer COVID-19 vaccine to teens early next week, The New York Times and CNN reported, both citing unnamed officials familiar with the agency’s plans.

In late March, Pfizer submitted data to the FDA showing its mRNA vaccine was 100% effective at preventing COVID-19 infection in children ages 12 to 15. Their vaccine  is already authorized for use teens and adults ages 16 and older.

The move would make about 17 million more Americans eligible for vaccination and would be a major step toward getting both adolescents and teens back into classrooms full time by next fall.

“Across the globe, we are longing for a normal life. This is especially true for our children. The initial results we have seen in the adolescent studies suggest that children are particularly well protected by vaccination, which is very encouraging given the trends we have seen in recent weeks regarding the spread of the B.1.1.7 U.K. variant,” Ugur Sahin, CEO and co-founder of Pfizer partner BioNTech, said in a March 31 press release.

Getting schools fully reopened for in-person learning has been a goal of both the Trump and Biden administrations, but it has been tricky to pull off, as some parents and teachers have been reluctant to return to classrooms with so much uncertainty about the risk and the role of children in spreading the virus.

A recent study of roughly 150,000 school-aged children in Israel found that while kids under age 10 were unlikely to catch or spread the virus as they reentered classrooms. Older children, though, were a different story. The study found that children ages 10-19 had risks of catching the virus that were as high as adults ages 20-60.

The risk for severe illness and death from COVID-19 rises with age.

Children and teens are at relatively low risk from severe outcomes after a COVID-19 infection compared to adults, but they can catch it and some will get really sick with it, especially if they have an underlying health condition, like obesity or asthma that makes them more vulnerable.

Beyond the initial infection, children can get a rare late complication called MIS-C, that while treatable, can be severe and requires hospitalization. Emerging reports also suggest there are some kids that become long haulers in much the same way adults do, dealing with lingering problems for months after they first get sick.

As new variants of the coronavirus circulate in the United States, some states have seen big increases in the number of children and teens with COVID. In Michigan, for example, which recently dealt with a spring surge of cases dominated by the B.1.1.7 variant, cases in children and teens quadrupled in April compared to February.

Beyond individual protection, vaccinating children and teens has been seen as important to achieving strong community protection, or herd immunity, against the new coronavirus.

If the FDA expands the authorization for the Pfizer vaccine, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices will likely meet to review data on the safety and efficacy of the vaccine. The committee may then vote on new recommendations for use of the vaccine in the United States.

Not everyone agrees with the idea that American adolescents, who are at relatively low risk of bad outcomes, could get access to COVID vaccines ahead of vulnerable essential workers and seniors in other parts of the world that are still fighting the pandemic with little access to vaccines.

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

Concern and anxiety around COVID-19 remains high among Americans, with more people reporting mental health effects from the pandemic this year than last, and parents concerned about the mental health of their children, results of a new poll by the American Psychiatric Association show. Although the overall level of anxiety has decreased from last year’s APA poll, “the degree to which anxiety still reigns is concerning,” APA President Jeffrey Geller, MD, MPH, told this news organization.

The results of the latest poll were presented at the American Psychiatric Association 2021 annual meeting and based on an online survey conducted March 26 to April 5 among a sample of 1,000 adults aged 18 years or older.

Serious mental health hit

In the new poll, about 4 in 10 Americans (41%) report they are more anxious than last year, down from just over 60%.

Young adults aged 18-29 years (49%) and Hispanic/Latinos (50%) are more likely to report being more anxious now than a year ago. Those 65 or older (30%) are less apt to say they feel more anxious than last year.

The latest poll also shows that Americans are more anxious about family and loved ones getting COVID-19 (64%) than about catching the virus themselves (49%). 

Concern about family and loved ones contracting COVID-19 has increased since last year’s poll (conducted September 2020), rising from 56% then to 64% now. Hispanic/Latinx individuals (73%) and African American/Black individuals (76%) are more anxious about COVID-19 than White people (59%).

In the new poll, 43% of adults report the pandemic has had a serious impact on their mental health, up from 37% in 2020. Younger adults are more apt than older adults to report serious mental health effects.

Slightly fewer Americans report the pandemic is affecting their day-to-day life now as compared to a year ago, in ways such as problems sleeping (19% down from 22%), difficulty concentrating (18% down from 20%), and fighting more with loved ones (16% down from 17%).

The percentage of adults consuming more alcohol or other substances/drugs than normal increased slightly since last year (14%-17%). Additionally, 33% of adults (40% of women) report gaining weight during the pandemic.

Call to action

More than half of adults (53%) with children report they are concerned about the mental state of their children and almost half (48%) report the pandemic has caused mental health problems for one or more of their children, including minor problems for 29% and major problems for 19%.

More than a quarter (26%) of parents have sought professional mental health help for their children because of the pandemic.

Nearly half (49%) of parents of children younger than 18 years say their child received help from a mental health professional since the start of the pandemic; 23% received help from a primary care professional, 18% from a psychiatrist, 15% from a psychologist, 13% from a therapist, 10% from a social worker, and 10% from a school counselor or school psychologist.

More than 1 in 5 parents reported difficulty scheduling appointments for their child with a mental health professional.

“This poll shows that, even as vaccines become more widespread, Americans are still worried about the mental state of their children,” Dr. Geller said in a news release.

“This is a call to action for policymakers, who need to remember that, in our COVID-19 recovery, there’s no health without mental health,” he added.

Just over three-quarters (76%) of those surveyed say they have been or intend to get vaccinated; 22% say they don’t intend to get vaccinated; and 2% didn’t know.

For those who do not intend to get vaccinated, the primary concern (53%) is about side effects of the vaccine. Other reasons for not getting vaccinated include believing the vaccine is not effective (31%), believing the makers of the vaccine aren’t being honest about what’s in it (27%), and fear/anxiety about needles (12%).

Resiliency a finite resource

Reached for comment, Samoon Ahmad, MD, professor in the department of psychiatry, New York University, said it’s not surprising that Americans are still suffering more anxiety than normal.

“The Census Bureau’s Household Pulse Survey has shown that anxiety and depression levels have remained higher than normal since the pandemic began. That 43% of adults now say that the pandemic has had a serious impact on their mental health seems in line with what that survey has been reporting for over a year,” Dr. Ahmad, who serves as unit chief of inpatient psychiatry at Bellevue Hospital Center in New York, said in an interview.

He believes there are several reasons why anxiety levels remain high. One reason is something he’s noticed among his patients for years. “Most people struggle with anxiety especially at night when the noise and distractions of contemporary life fade away. This is the time of introspection,” he explained.

“Quarantine has been kind of like a protracted night because the distractions that are common in the so-called ‘rat race’ have been relatively muted for the past 14 months. I believe this has caused what you might call ‘forced introspection,’ and that this is giving rise to feelings of anxiety as people use their time alone to reassess their careers and their social lives and really begin to fret about some of the decisions that have led them to this point in their lives,” said Dr. Ahmad.

The other finding in the APA survey – that people are more concerned about their loved ones catching the virus than they were a year ago – is also not surprising, Dr. Ahmad said.

“Even though we seem to have turned a corner in the United States and the worst of the pandemic is behind us, the surge that went from roughly November through March of this year was more wide-reaching geographically than previous waves, and I think this made the severity of the virus far more real to people who lived in communities that had been spared severe outbreaks during the surges that we saw in the spring and summer of 2020,” Dr. Ahmad told this news organization.

“There’s also heightened concern over variants and the efficacy of the vaccine in treating these variants. Those who have families in other countries where the virus is surging, such as India or parts of Latin America, are likely experiencing additional stress and anxiety too,” he noted.

While the new APA poll findings are not surprising, they still are “deeply concerning,” Dr. Ahmad said.

“Resiliency is a finite resource, and people can only take so much stress before their mental health begins to suffer. For most people, this is not going to lead to some kind of overdramatic nervous breakdown. Instead, one may notice that they are more irritable than they once were, that they’re not sleeping particularly well, or that they have a nagging sense of discomfort and stress when doing activities that they used to think of as normal,” like taking a trip to the grocery store, meeting up with friends, or going to work, Dr. Ahmad said.

“Overcoming this kind of anxiety and reacclimating ourselves to social situations is going to take more time for some people than others, and that is perfectly natural,” said Dr. Ahmad, founder of the Integrative Center for Wellness in New York.

“I don’t think it’s wise to try to put a limit on what constitutes a normal amount of time to readjust, and I think everyone in the field of mental health needs to avoid pathologizing any lingering sense of unease. No one needs to be medicated or diagnosed with a mental illness because they are nervous about going into public spaces in the immediate aftermath of a pandemic. We need to show a lot of patience and encourage people to readjust at their own pace for the foreseeable future,” Dr. Ahmad said.

Dr. Geller and Dr. Ahmad have disclosed no relevant financial relationships.

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

Concern and anxiety around COVID-19 remains high among Americans, with more people reporting mental health effects from the pandemic this year than last, and parents concerned about the mental health of their children, results of a new poll by the American Psychiatric Association show. Although the overall level of anxiety has decreased from last year’s APA poll, “the degree to which anxiety still reigns is concerning,” APA President Jeffrey Geller, MD, MPH, told this news organization.

The results of the latest poll were presented at the American Psychiatric Association 2021 annual meeting and based on an online survey conducted March 26 to April 5 among a sample of 1,000 adults aged 18 years or older.

Serious mental health hit

In the new poll, about 4 in 10 Americans (41%) report they are more anxious than last year, down from just over 60%.

Young adults aged 18-29 years (49%) and Hispanic/Latinos (50%) are more likely to report being more anxious now than a year ago. Those 65 or older (30%) are less apt to say they feel more anxious than last year.

The latest poll also shows that Americans are more anxious about family and loved ones getting COVID-19 (64%) than about catching the virus themselves (49%). 

Concern about family and loved ones contracting COVID-19 has increased since last year’s poll (conducted September 2020), rising from 56% then to 64% now. Hispanic/Latinx individuals (73%) and African American/Black individuals (76%) are more anxious about COVID-19 than White people (59%).

In the new poll, 43% of adults report the pandemic has had a serious impact on their mental health, up from 37% in 2020. Younger adults are more apt than older adults to report serious mental health effects.

Slightly fewer Americans report the pandemic is affecting their day-to-day life now as compared to a year ago, in ways such as problems sleeping (19% down from 22%), difficulty concentrating (18% down from 20%), and fighting more with loved ones (16% down from 17%).

The percentage of adults consuming more alcohol or other substances/drugs than normal increased slightly since last year (14%-17%). Additionally, 33% of adults (40% of women) report gaining weight during the pandemic.

Call to action

More than half of adults (53%) with children report they are concerned about the mental state of their children and almost half (48%) report the pandemic has caused mental health problems for one or more of their children, including minor problems for 29% and major problems for 19%.

More than a quarter (26%) of parents have sought professional mental health help for their children because of the pandemic.

Nearly half (49%) of parents of children younger than 18 years say their child received help from a mental health professional since the start of the pandemic; 23% received help from a primary care professional, 18% from a psychiatrist, 15% from a psychologist, 13% from a therapist, 10% from a social worker, and 10% from a school counselor or school psychologist.

More than 1 in 5 parents reported difficulty scheduling appointments for their child with a mental health professional.

“This poll shows that, even as vaccines become more widespread, Americans are still worried about the mental state of their children,” Dr. Geller said in a news release.

“This is a call to action for policymakers, who need to remember that, in our COVID-19 recovery, there’s no health without mental health,” he added.

Just over three-quarters (76%) of those surveyed say they have been or intend to get vaccinated; 22% say they don’t intend to get vaccinated; and 2% didn’t know.

For those who do not intend to get vaccinated, the primary concern (53%) is about side effects of the vaccine. Other reasons for not getting vaccinated include believing the vaccine is not effective (31%), believing the makers of the vaccine aren’t being honest about what’s in it (27%), and fear/anxiety about needles (12%).

Resiliency a finite resource

Reached for comment, Samoon Ahmad, MD, professor in the department of psychiatry, New York University, said it’s not surprising that Americans are still suffering more anxiety than normal.

“The Census Bureau’s Household Pulse Survey has shown that anxiety and depression levels have remained higher than normal since the pandemic began. That 43% of adults now say that the pandemic has had a serious impact on their mental health seems in line with what that survey has been reporting for over a year,” Dr. Ahmad, who serves as unit chief of inpatient psychiatry at Bellevue Hospital Center in New York, said in an interview.

He believes there are several reasons why anxiety levels remain high. One reason is something he’s noticed among his patients for years. “Most people struggle with anxiety especially at night when the noise and distractions of contemporary life fade away. This is the time of introspection,” he explained.

“Quarantine has been kind of like a protracted night because the distractions that are common in the so-called ‘rat race’ have been relatively muted for the past 14 months. I believe this has caused what you might call ‘forced introspection,’ and that this is giving rise to feelings of anxiety as people use their time alone to reassess their careers and their social lives and really begin to fret about some of the decisions that have led them to this point in their lives,” said Dr. Ahmad.

The other finding in the APA survey – that people are more concerned about their loved ones catching the virus than they were a year ago – is also not surprising, Dr. Ahmad said.

“Even though we seem to have turned a corner in the United States and the worst of the pandemic is behind us, the surge that went from roughly November through March of this year was more wide-reaching geographically than previous waves, and I think this made the severity of the virus far more real to people who lived in communities that had been spared severe outbreaks during the surges that we saw in the spring and summer of 2020,” Dr. Ahmad told this news organization.

“There’s also heightened concern over variants and the efficacy of the vaccine in treating these variants. Those who have families in other countries where the virus is surging, such as India or parts of Latin America, are likely experiencing additional stress and anxiety too,” he noted.

While the new APA poll findings are not surprising, they still are “deeply concerning,” Dr. Ahmad said.

“Resiliency is a finite resource, and people can only take so much stress before their mental health begins to suffer. For most people, this is not going to lead to some kind of overdramatic nervous breakdown. Instead, one may notice that they are more irritable than they once were, that they’re not sleeping particularly well, or that they have a nagging sense of discomfort and stress when doing activities that they used to think of as normal,” like taking a trip to the grocery store, meeting up with friends, or going to work, Dr. Ahmad said.

“Overcoming this kind of anxiety and reacclimating ourselves to social situations is going to take more time for some people than others, and that is perfectly natural,” said Dr. Ahmad, founder of the Integrative Center for Wellness in New York.

“I don’t think it’s wise to try to put a limit on what constitutes a normal amount of time to readjust, and I think everyone in the field of mental health needs to avoid pathologizing any lingering sense of unease. No one needs to be medicated or diagnosed with a mental illness because they are nervous about going into public spaces in the immediate aftermath of a pandemic. We need to show a lot of patience and encourage people to readjust at their own pace for the foreseeable future,” Dr. Ahmad said.

Dr. Geller and Dr. Ahmad have disclosed no relevant financial relationships.

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

Concern and anxiety around COVID-19 remains high among Americans, with more people reporting mental health effects from the pandemic this year than last, and parents concerned about the mental health of their children, results of a new poll by the American Psychiatric Association show. Although the overall level of anxiety has decreased from last year’s APA poll, “the degree to which anxiety still reigns is concerning,” APA President Jeffrey Geller, MD, MPH, told this news organization.

The results of the latest poll were presented at the American Psychiatric Association 2021 annual meeting and based on an online survey conducted March 26 to April 5 among a sample of 1,000 adults aged 18 years or older.

Serious mental health hit

In the new poll, about 4 in 10 Americans (41%) report they are more anxious than last year, down from just over 60%.

Young adults aged 18-29 years (49%) and Hispanic/Latinos (50%) are more likely to report being more anxious now than a year ago. Those 65 or older (30%) are less apt to say they feel more anxious than last year.

The latest poll also shows that Americans are more anxious about family and loved ones getting COVID-19 (64%) than about catching the virus themselves (49%). 

Concern about family and loved ones contracting COVID-19 has increased since last year’s poll (conducted September 2020), rising from 56% then to 64% now. Hispanic/Latinx individuals (73%) and African American/Black individuals (76%) are more anxious about COVID-19 than White people (59%).

In the new poll, 43% of adults report the pandemic has had a serious impact on their mental health, up from 37% in 2020. Younger adults are more apt than older adults to report serious mental health effects.

Slightly fewer Americans report the pandemic is affecting their day-to-day life now as compared to a year ago, in ways such as problems sleeping (19% down from 22%), difficulty concentrating (18% down from 20%), and fighting more with loved ones (16% down from 17%).

The percentage of adults consuming more alcohol or other substances/drugs than normal increased slightly since last year (14%-17%). Additionally, 33% of adults (40% of women) report gaining weight during the pandemic.

Call to action

More than half of adults (53%) with children report they are concerned about the mental state of their children and almost half (48%) report the pandemic has caused mental health problems for one or more of their children, including minor problems for 29% and major problems for 19%.

More than a quarter (26%) of parents have sought professional mental health help for their children because of the pandemic.

Nearly half (49%) of parents of children younger than 18 years say their child received help from a mental health professional since the start of the pandemic; 23% received help from a primary care professional, 18% from a psychiatrist, 15% from a psychologist, 13% from a therapist, 10% from a social worker, and 10% from a school counselor or school psychologist.

More than 1 in 5 parents reported difficulty scheduling appointments for their child with a mental health professional.

“This poll shows that, even as vaccines become more widespread, Americans are still worried about the mental state of their children,” Dr. Geller said in a news release.

“This is a call to action for policymakers, who need to remember that, in our COVID-19 recovery, there’s no health without mental health,” he added.

Just over three-quarters (76%) of those surveyed say they have been or intend to get vaccinated; 22% say they don’t intend to get vaccinated; and 2% didn’t know.

For those who do not intend to get vaccinated, the primary concern (53%) is about side effects of the vaccine. Other reasons for not getting vaccinated include believing the vaccine is not effective (31%), believing the makers of the vaccine aren’t being honest about what’s in it (27%), and fear/anxiety about needles (12%).

Resiliency a finite resource

Reached for comment, Samoon Ahmad, MD, professor in the department of psychiatry, New York University, said it’s not surprising that Americans are still suffering more anxiety than normal.

“The Census Bureau’s Household Pulse Survey has shown that anxiety and depression levels have remained higher than normal since the pandemic began. That 43% of adults now say that the pandemic has had a serious impact on their mental health seems in line with what that survey has been reporting for over a year,” Dr. Ahmad, who serves as unit chief of inpatient psychiatry at Bellevue Hospital Center in New York, said in an interview.

He believes there are several reasons why anxiety levels remain high. One reason is something he’s noticed among his patients for years. “Most people struggle with anxiety especially at night when the noise and distractions of contemporary life fade away. This is the time of introspection,” he explained.

“Quarantine has been kind of like a protracted night because the distractions that are common in the so-called ‘rat race’ have been relatively muted for the past 14 months. I believe this has caused what you might call ‘forced introspection,’ and that this is giving rise to feelings of anxiety as people use their time alone to reassess their careers and their social lives and really begin to fret about some of the decisions that have led them to this point in their lives,” said Dr. Ahmad.

The other finding in the APA survey – that people are more concerned about their loved ones catching the virus than they were a year ago – is also not surprising, Dr. Ahmad said.

“Even though we seem to have turned a corner in the United States and the worst of the pandemic is behind us, the surge that went from roughly November through March of this year was more wide-reaching geographically than previous waves, and I think this made the severity of the virus far more real to people who lived in communities that had been spared severe outbreaks during the surges that we saw in the spring and summer of 2020,” Dr. Ahmad told this news organization.

“There’s also heightened concern over variants and the efficacy of the vaccine in treating these variants. Those who have families in other countries where the virus is surging, such as India or parts of Latin America, are likely experiencing additional stress and anxiety too,” he noted.

While the new APA poll findings are not surprising, they still are “deeply concerning,” Dr. Ahmad said.

“Resiliency is a finite resource, and people can only take so much stress before their mental health begins to suffer. For most people, this is not going to lead to some kind of overdramatic nervous breakdown. Instead, one may notice that they are more irritable than they once were, that they’re not sleeping particularly well, or that they have a nagging sense of discomfort and stress when doing activities that they used to think of as normal,” like taking a trip to the grocery store, meeting up with friends, or going to work, Dr. Ahmad said.

“Overcoming this kind of anxiety and reacclimating ourselves to social situations is going to take more time for some people than others, and that is perfectly natural,” said Dr. Ahmad, founder of the Integrative Center for Wellness in New York.

“I don’t think it’s wise to try to put a limit on what constitutes a normal amount of time to readjust, and I think everyone in the field of mental health needs to avoid pathologizing any lingering sense of unease. No one needs to be medicated or diagnosed with a mental illness because they are nervous about going into public spaces in the immediate aftermath of a pandemic. We need to show a lot of patience and encourage people to readjust at their own pace for the foreseeable future,” Dr. Ahmad said.

Dr. Geller and Dr. Ahmad have disclosed no relevant financial relationships.

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