If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

In January, a teenager in suburban St. Louis informed his high school counselor that a classmate said he planned to kill himself later that day.

The 14-year-old classmate denied it, but his mother, Marie, tore through his room and found a suicide note in his nightstand. (She asked 麻豆女优 Health News to publish only her middle name because she does not want people to misjudge or label her son.)

His parents took him to Mercy Hospital St. Louis. According to his mother, providers told them they didn’t have beds available at their behavioral health center, so the teen spent three days in a room in a secured area of the emergency department and saw a doctor twice, one time virtually.

Joe Poelker, a Mercy hospital spokesperson, declined to answer questions from 麻豆女优 Health News. Leaders of Mercy and other local hospitals have described the shortage of beds for inpatient pediatric psychiatric care in the St. Louis area as for years.

Nationwide, psychiatric “boarding” 鈥� when a patient waits in the emergency room after providers decide to admit the person 鈥� has increased because of a rise in , among other mental health issues, and a shortage of inpatient psychiatric beds, according to a study of 40 hospitals in the . It found the number of cases in which children spent at least two days in pediatric hospitals before being transferred for psychiatric care also increased 66% from 2017 through 2023 to reach 16,962 instances.

St. Louis Children’s Hospital leaders aim to address that problem by opening a 77-bed pediatric mental health hospital in the suburb of Webster Groves. But as often happens with such proposals, neighbors objected. They worry it would worsen safety and lower .

Over the past decade, proposed psychiatric facilities for minors in , , , , and have also faced local resistance.

Behavioral health care advocates counter that such concerns are largely unfounded and rooted in stigma. Locating such facilities in remote areas 鈥� as neighbors sometimes suggest 鈥� reinforces the misconception that people with mental illness are dangerous and makes it harder to help them without their support system nearby, doctors say.

“We wouldn’t take children with cancer and say they need to be two hours away, where there is no one around them,” said Cynthia Rogers, a pediatric psychiatrist at St. Louis Children’s. “These are still children with illnesses, and they want to be in their home city, where their family can visit them.”

In the United States, the number of suicides among minors increased 62% from 2002 to 2022, according to a from the Centers for Disease Control and Prevention.

At St. Louis Children’s, the crisis has fueled more emergency room visits, Rogers said, with behavioral health visits nearly quadrupling from 2019 to 2023, jumping from 565 to 2,176. She attributes the increase to factors such as social media engagement, isolation caused by shutdowns during the covid-19 pandemic, and the political climate, which she said has been particularly hard on LGBTQ+ children.

“The pandemic seemed to throw gasoline on the fire,” Rogers said.

In the middle- and upper-class suburb of Webster Groves, St. Louis Children’s and KVC, a behavioral health provider, want to use a site that served as in the 19th century to create 65 inpatient beds for children needing care for about a week and 12 residential beds for people requiring longer stays. KVC now runs a who struggle in traditional classrooms and offers services to help children in foster care.

“Introducing a hospital into this historically significant residential area disrupts its stability by undermining” its character, one resident testified at a meeting.

Tim Conway, who has lived across from the site for three decades, told 麻豆女优 Health News that his opposition is primarily because the facility and its parking would take up more space than the existing structures.

The detailed security plans have not eased his concerns. “It makes me wonder why it needs to be that robust,” Conway said.

, a psychiatrist at the American Center for Psychiatry and Neurology in the United Arab Emirates, has impacts the locations of psychiatric facilities around the world and said people often don’t want the hospitals nearby because they associate them with violence or unpredictable behavior.

“The misconception of increased danger often stems from outdated stereotypes rather than factual evidence,” El Hayek said.

Little evidence suggests that people with mental illness are more likely to commit a crime or be violent than the general population, with the exception of people with a severe illness such as schizophrenia, who, while it’s still rare, to commit a violent act.

But residents near mental health hospitals have been rattled by encounters with patients who escaped or and about missing patients.

In Oklahoma City, Richard Scroggins in 2014 opposed the expansion of Cedar Ridge Behavioral Hospital, which then treated youths and adults, because of its security issues.

Scroggins, who raises horses and cattle on his property, at the time that he once found a stranger raking leaves in his yard. After determining the person was suffering from mental illness and harmless, Scroggins said, he called the police, who retrieved the person.

The Cedar Ridge provider ultimately dropped plans to expand the facility after community opposition.

Scroggins has since encountered other patients from the facility on his property but none in recent years, he told 麻豆女优 Health News in February. His perspective on the hospital has changed because its staff addressed his security concerns.

“Nobody wants it in their neighborhood, but it’s a necessity,” Scroggins said. “I’m a Christian, so we are supposed to reach out and help.”

Carrie Blumert, CEO of the , said psychiatric facilities make surrounding areas safer by providing medical care and “treating the root of people’s issues rather than just throwing them in a jail cell.”

In Marie’s case, her son was ultimately admitted to Mercy-affiliate Hyland Behavioral Health Center and spent a few days there until a physician told the family he probably just needed to speak with a counselor, she said. He was discharged.

A day later, she said, the teen said he still wanted to kill himself, so his parents took him to St. Louis Children’s, where he was admitted the same day. After a 15-minute visit, Marie said, a doctor pulled her aside and asked, “Have you ever thought that he might be on the autism spectrum?”

“鈥極h my gosh, you’re the first person to validate my feeling,’” Marie told the doctor.

Her son stayed two weeks at the hospital, during which providers diagnosed him with autism and prescribed antidepressants. He returned to the classroom and baseball field, Marie said, but learning he has autism upset him.

“He’s still trying to process that, and he’s very sensitive. And they are teenagers, so when kids are mean to him at school or make fun of him, he takes that to heart way more than a typical teenager would,” Marie said. “I have hope for him that he will be OK.”

And soon, she knows, kids like her son could have another option in St. Louis if they need acute psychiatric help.

Despite community pushback, the Webster Groves City Council the rezoning needed for the hospital in January. The officials described opponents’ concerns as legitimate but said the hospital would benefit children’s mental health and the surrounding community.

“This is by far and away one of the easiest votes I’ve ever had to take,” said Councilmember David Franklin, adding that the approval demonstrates that “Webster Groves cares not only about its own citizens but the citizens of this region.”

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He had lost a grandson to an overdose just hours before, but aiding stranded motorists was second nature to the 73-year-old retired school custodian, who remembered thousands of students’ names and regularly brought food pantry donations to a retirement community. “He always was there to help people,” said his son Bobby Herrick, who was in the car with him that night.

Just moments later, a truck driver trying to text his wife a picture of the hand sanitizer he had purchased swerved onto the shoulder and plowed into the vehicles, according to court and crash records. While the truck driver was not injured and the woman and Bobby Herrick recovered from their injuries, Max Herrick became one of at least 382 people who died in Missouri crashes involving a distracted driver from 2017 through 2021, according to the .

Despite such tragedies, Missouri is one of two states 鈥� the other is Montana 鈥� that do not prohibit all drivers from text messaging while operating vehicles. (Missouri has such a law for people 21 and under.)

Before this year, Missouri state lawmakers from both parties had proposed more than 80 bills since 2010 with varying levels of restrictions on cellphone use and driving. Similar legislation has been proposed in Montana, too. In both states, such bills have faltered, largely because Republican opponents say they don’t think the laws work and are just another infringement on people’s civil liberties.

Nevertheless, Missouri Republicans and Democrats introduced at least seven bills this session concerning hand-held phone use while driving 鈥� and road safety advocates think such legislation has a better chance of passing this year. Montana, meanwhile, has a bill seeking to block localities’ distracted driving laws.

“I’m from the party that wants to minimize the amount of laws 鈥� and I agree 鈥� but you got to be smart about it,” said , a Republican and former Missouri state representative who proposed legislation three times to limit hand-held cellphone use. “There are actually laws that are needed to try to provide awareness and save unnecessary deaths.”

Supporters of hands-free driving laws concede that distracted driving restrictions are not a panacea for all traffic fatalities. And even if Missouri passes additional restrictions on cellphone use, small nuances in wording could influence whether such a law is effective.

Nationwide, about 3,000 people typically die in distracted driving crashes each year, , though researchers suggest that’s an undercount. While hands-free options are now standard for new vehicles, the number of distracted driving deaths has stayed relatively steady. They represented at least 1 in 12 traffic fatalities in 2020.

Distracted driving laws reduce fatalities 鈥� if, like the ones established in , they ban all hand-held cellphone use rather than banning only a specific activity such as texting, according to the Governors Highway Safety Association and a in the journal Epidemiology. Banning texting alone does not make a difference, those researchers found.

Oregon and Washington saw significant reductions in the rates of monthly rear-end crashes when they broadened their laws to prohibit “holding” a cellphone as compared with states that banned only texting, from the Insurance Institute for Highway Safety. Those two states also prohibited holding a phone when stopped temporarily 鈥� say, at a red light.

“If you tell a driver that they are breaking the law just by holding the phone in their hand, a police officer who is trying to enforce that law doesn’t have to decide whether or not the driver is texting,” said Ian Reagan, a senior research scientist at the Insurance Institute.

By contrast, California broadened its texting bans to prohibit “holding and using” a phone but did not specify whether that ban applied to a driver stopped temporarily. It did not see a significant reduction in rear-end crashes, which the researchers said are a more telling metric than the often-underreported crashes attributed to distracted driving.

Whatever the cause, traffic fatalities since the pandemic began. Among the 10 states with the highest rates of deaths from fatal motor vehicle crashes in 2020, according to the Insurance Institute, only one, Tennessee, had a ban on hand-held phone use for all drivers at the time. Among the 10 states with the lowest rates of such fatalities, all but Utah had a hand-held ban for all drivers.

Montana ranked fifth-highest, and Missouri came in at No. 12.

Adrienne Siddens lost her husband, Randall, who was working at a Columbia, Missouri, triathlon in 2019, because a woman using her cellphone to video chat was driving 18 mph over the speed limit and not paying attention to cars stopped at a red light. The driver swerved and entered a lane that was closed for the race, according to court records.

The woman , including Randall, who flew more than 127 feet. He spent most of the next six months on life support before dying.

“I now have to raise our three beautiful babies alone,” Adrienne Siddens, who was pregnant with their third child when the crash occurred, testified in a March 2022 hearing on Porter’s bill. “With your help, passing this legislation and enforcing a hands-free policy, so many other families will not have to experience this grief.”

Republicans referred the legislation to the state House’s Downsizing State Government Committee. The bill died.

State Rep. , a Republican who served on the committee, told KHN he’s concerned that either law enforcement could use a ban to stop people randomly or they would have difficulty enforcing it.

“I’m very hesitant to adopt a prohibition on a particular kind of distraction, as opposed to simply enforcing the traffic laws and making sure that people aren’t weaving in and out of lanes,” said Lovasco.

In Montana, Republicans such as state not only don’t support a statewide ban, but they also want to overrule Missoula and the 14 other Montana cities, towns, and tribal governments that on hand-held cellphone use while driving.

“These laws are going to make the roads more dangerous because people are just going to hide it and put the phone lower in their car instead of keeping their phone up and their eyes up,” said Trebas, who that would prevent local governments from enacting such ordinances. Trebas described his evidence to support that assertion as “mostly anecdotal.”

John MacDonald, a former lobbyist for Missoula, opposed a similar bill by Trebas that failed in 2017. MacDonald ascribed resistance to a statewide ban to the same forces that made Montana the last state to establish a numerical speed limit; its limit was “reasonable and prudent” .

“It’s something ingrained in Montana that our vehicle is sort of an extension of our home, and the government should not be dictating to us how we can behave in that vehicle,” said MacDonald.

A law like Trebas’ proposal already exists in Missouri: Even if a Missouri municipality establishes a ban on texting and driving, as the St. Louis suburb , it’s not enforceable because the its law supersedes local ordinances.

Angela Nelson, AAA Missouri’s vice president of public affairs and government relations, said her group’s past education on the perils of distracted driving has helped position new statewide proposals to pass this year. The group, part of a coalition that aims to curb distracted driving accidents, from two Republicans that restricts holding an electronic communication device, as well as using one, while driving. Other Republican legislators introduced a measure to just expand the texting ban to all drivers, regardless of age. AAA has not taken a position on that one.

Lovasco, though, said it was too early to predict whether any will pass.

Siddens, who has advocated for such bills since she lost her husband, remains optimistic that Missouri lawmakers will pass a tougher law after hearing about the tragedies for so many years. “At some point, they will do something about it,” she said. “They will have to.”

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What was unusual was seeing a bar owner 鈥� in this case, Pop’s Blue Moon’s Joshua Grigaitis 鈥� grab cans of the drink and give them to customers without looking over his shoulder in a state where , for now. Missouri voters will decide whether to liberalize the law in the Nov. 8 election.

“Contains 10mg of the good stuff, which equals less than .3% by volume. This means it can be sold almost anywhere!” Grigaitis posted on Facebook last month when he announced the new products from his cannabis-infused drink company: hemp-derived delta-9 THC seltzer in “cherry blossom” or “heady lemon” flavors.

Grigaitis thinks he is on solid legal footing in selling the seltzer because it comes from hemp, not marijuana, two plants from the same Cannabis genus. Still, he labels the cans with the percentage of THC by volume, which refers to a federal limit allowed for hemp, anticipating scrutiny of his product.

Rather than offer his drink in the crowded market for medical and adult-use marijuana 鈥� which remains illegal at the federal level and faces costly taxes and regulations where legal at the state level 鈥� Grigaitis thinks a loophole in a federal law concerning hemp allows him to sell a product that offers the same sort of buzz at his bar, online, and just about everywhere else.

As such, he said, hemp-derived delta-9 tetrahydrocannabinol products have the “potential to flip the entire cannabis industry upside down.”

Grigaitis is not the only one who senses an opportunity. Some 120 brands are selling hemp-derived delta-9 products online, according to an by CBD Oracle, which reports on the industry.

But others in the cannabis industry are concerned about the loophole and are seeking federal legislation to prevent people from selling intoxicating hemp products outside of dispensaries. They say some of the products aren’t safe because minors could access them more easily than products from dispensaries. And they generally aren’t subject to oversight from state regulatory systems. The critics also claim that the products subvert the intent of a 2018 federal law that removed hemp from the federal controlled substances list.

“The medical marijuana and recreational marijuana industries are very regulated to the point where identification, passports, driver’s licenses are all held very tightly at these dispensaries,” said Eric Wang, vice president of sustainability for the , a Kentucky-based trade group.

By contrast, he said, a 12- or 13-year-old child can buy a hemp-derived product legally.

When a bipartisan group of lawmakers passed the 2018 Farm Bill, the advertised aim was to help struggling farmers by allowing them to grow industrial hemp. The law also meant people could sell CBD across state lines. CBD has since become a multibillion-dollar industry.

At the time, then-Senate Majority Leader , a Republican from Kentucky who sponsored the legislation, said of hemp that “everybody has figured it out that this isn’t the other plant.”

The primary difference between marijuana and hemp is that hemp contains very small amounts of THC. The states that it can contain no more than 0.3% delta-9 THC on a dry-weight basis.

Grigaitis argues that his hemp-derived delta-9 beverage is legal because the amount of THC in the beverage is less than 0.3% of the weight of the liquid.

“That is supported by my lawyers, my test labs, my insurance, my bank 鈥� everyone,” said Grigaitis, whose Mighty Kind drinks appear in the recent Kevin Smith movie “Clerks III.”

His hemp-derived delta-9 is made from one of two methods: extracting the cannabinoid from the hemp plant itself or through a chemical conversion in which CBD from the hemp is dissolved in a solvent, Grigaitis said. The company is exploring both methods to determine the pros and cons of each, he said.

Because the source is hemp rather than marijuana, he sees a clear path to selling his product beyond dispensaries, which come with extensive regulations and taxes and thus narrow profit margins. Why would he sell in a dispensary, he asked, “when you could go next door into a CBD shop or a vape shop or a grocery store or a bar and sell your stuff?”

But some in the industry disagree with Grigaitis’ interpretation of the federal law. The proportion of the dry weight refers to the amount in the plant, not a beverage, said Jonathan Miller, general counsel for the Hemp Roundtable.

Rep. (D-Maine) has that would amend the 2018 law with additional restrictions on hemp-derived products. Pingree spokesperson Victoria Bonney said the congresswoman was not available for an interview.

In the meantime, at least a dozen states have passed laws limiting sales of another hemp-derived substance, delta-8, which is also intoxicating but not as strong as delta-9. But states have been slow to catch up with these new drug products.

Miller hopes parts of Pingree’s legislation will be included in the 2023 Farm Bill, given the 2018 bill expires next year. The roundtable seeks regulations to limit the amount of THC in finished products rather than in the plant alone and to restrict the sale of intoxicating hemp products to the adult-use marketplace, such as at a pot dispensary, Miller said. Alternatively, the group wants it regulated like alcohol.

The organization includes board members from some of the biggest companies in the adult-use marijuana marketplace, including its president, Pete Meachum. He is a lobbyist employed by , a Canadian cannabis company whose largest shareholder is Altria, maker of Marlboro cigarettes and an investor in Juul. Meachum declined an interview request.

“Anything that threatens the exclusivity of the regulated market is going to be of concern to those that have their time and money invested in it,” Grigaitis said.

But Miller said that with new federal regulations, hemp-derived products “would be available in the same locations where you can buy marijuana products, so there would be an even playing field.”

Other industry groups and the have also called for the FDA to regulate hemp-derived products.

In the meantime, the Pop’s Blue Moon patrons didn’t seem worried about the lack of regulation and were happy to try Grigaitis’ new seltzer. Harper Britz, a 21-year-old who works in the music industry, said she got a pleasant buzz from the seltzer. She liked that she could taste the cannabis.

“It gets that aroma on the nose, just like when you’re smelling wine,” said Britz, who lives in St. Louis and said she regularly uses cannabis. “I’d probably drink this every day if I could.”

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Hours after enjoying the tasty drink and the silliness that reminded Kennedy of a high from weed, she said, she started to feel “really shaky and faint” before collapsing in her friend’s arms. Kennedy regained consciousness and recovered, but her distaste for delta-8 remains, even though the substance is legal at the federal level, unlike marijuana.

“I’m not one to really tell people what to do,” said Kennedy, 35, who lives in Milwaukee and works in software sales. But if a friend tried to order a delta-8 drink, “I would tell them, 鈥楢bsolutely not. You’re not putting that in your body.’”

The FDA and some marijuana industry experts share Kennedy’s concerns. At least a dozen states have banned the hemp-derived drug, including Colorado, Montana, New York, and Oregon, which have legalized marijuana. But delta-8 manufacturers call the concerns unfounded and say they’re driven by marijuana businesses trying to protect their market share.

So what is the difference? The flower of the marijuana plant, oil derived from it, and edibles made from those contain delta-9 tetrahydrocannabinol, the substance that produces the drug’s high, and can be legally sold only at dispensaries in states that have legalized marijuana. Similar products that contain delta-8 THC are sold online and at bars and retailers across much of the U.S., including some places where pot remains illegal. That’s because a 2018 federal law legalized hemp, a variety of the cannabis plant. Hemp isn’t allowed to contain more than 0.3% of the psychotropic delta-9 THC found in marijuana.

The concerns about delta-8 are largely focused on how it’s made. Delta-8 is typically produced by dissolving CBD 鈥� a compound found in cannabis plants 鈥� in solvents, such as toluene that is often found in paint thinner. Some people in the marijuana industry say that process leaves potentially harmful residue. A in the journal Chemical Research in Toxicology last year found lead, mercury, and silicon in delta-8 electronic cigarettes.

The FDA has about the “serious health risks” of delta-8, citing concerns about the conversion process, and has received more than 100 reports of people hallucinating, vomiting, and losing consciousness, among other issues, after consuming it. From January 2021 through this February, national poison control centers received more than 2,300 delta-8 cases, 70% of which required the users to be evaluated at health care facilities, according to the FDA.

Delta-8 is “just the obvious solution to people who want to have access to cannabis but live in a state where it’s illegal,” said Dr. , a primary care physician at Massachusetts General Hospital and a longtime medical cannabis provider. “You can either get in a lot of trouble buying cannabis, or you can get delta-8.”

Grinspoon described delta-8 as about half as potent as marijuana. But because of the lack of research into delta-8’s possible benefits and the absence of regulation, he would not recommend his patients use it. If it were regulated like Massachusetts’ medical and recreational marijuana programs, he said, harmful contaminants could be flagged or removed.

, chief scientific officer at ProVerde Laboratories, a Massachusetts marijuana and hemp testing company, said he has examined thousands of delta-8 products and all contained contaminants that could be harmful to consumers’ health.

Delta-8 has “incredible potential as a therapeutic” because it has many of the same benefits as marijuana, minus some of the intoxication, said Hudalla. “But delta-8, like unicorns, doesn’t exist. What does exist in the market is synthetic mixtures of unknown garbage.”

Justin Journay, owner of the delta-8 brand 3Chi, is skeptical of the concerns about the products. He started the company in 2018 after hemp oil provided relief for his shoulder pain. He soon started wondering what other cannabinoids in hemp could do. “鈥楾here’s got to be some gold in those hills,’” Journay recalled thinking. He said his Indiana-based company now has more than 300 employees and sponsors a NASCAR team.

When asked about the FDA’s reports of bad reactions, Journay said: “There are risks with THC. There absolutely are. There are risks with cheeseburgers.”

He attributes the side effects to taking too much. “We say, 鈥楽tart low.’ You can always take more,” Journay said.

Journay said that he understands concerns about contaminants in delta-8 products and that his company was conducting tests to identify the tiny portion of substances that remain unknown, which he asserts are cannabinoids from the plant.

An conducted by Hudalla’s firm last year and posted on 3Chi’s website found multiple unidentified compounds that “do not occur naturally” and thus “would not be recommended for human consumption.” Delta-8 oil is still sold on 3Chi’s site.

Journay said the analysis found that only 0.4% of the oil contained unknown compounds. “How can they then definitively say that compound isn’t natural when they don’t even know what it is?” he said in an email.

“The vast majority of negative information out there and the push to make delta-8 illegal is coming from the marijuana industries,” Journay said. “It’s cutting into their profit margins, which is funny that the marijuana guys would all of a sudden be for prohibition.”

Delta-8 products do appear to be significantly cheaper than weed. For example, Curaleaf, one of the world’s , offers packages of gummies that contain 100 milligrams of delta-9 THC for $25, plus sales tax, at a . At 3Chi, , with no tax.

Journay’s criticism of the marijuana industry holds some truth, said Chris Lindsey, government relations director for the , which advocates for legalization of marijuana for adults. “We see this happen in every single adult-use legalization state,” said Lindsey. “Their established medical cannabis industry will sometimes be your loudest opponents, and that’s a business thing. That’s not a marijuana thing.”

Still, the bans might not be working fully. In New York, which banned delta-8 in 2021, Lindsey said, it’s available at any bodega.

In July, Minnesota implemented a law that limits the amount of THC, including delta-8, allowed in hemp products outside of its medical marijuana program. said the law would wipe out delta-8. But the state cannot “control what’s being sold over the internet outside of Minnesota and shipped in,” said Maren Schroeder, policy director for , which aims to legalize recreational cannabis for adults.

Max Barber, a writer and editor in Minneapolis, remains interested in delta-8 despite his state’s restrictions. Even though he could likely obtain a medical marijuana prescription because he has an anxiety disorder and chronic sleep problems, he hasn’t pursued it because pot made his anxiety worse. He used CBD oil but found the effects inconsistent. In March 2021, he tried a 10-milligram delta-8 gummy.

“It got me pretty high, which I don’t enjoy,” he said.

Then he found what he considers the right dosage for him: one-third of a gummy, which he takes in the evening. He said he now gets between six and eight hours of sleep each night, has less anxiety, and is better able to focus. “I have become kind of an evangelist for delta-8 for everyone I know who has sleep problems,” said Barber, who bought enough gummies to last for months after the new law went into effect.

To address concerns about delta-8, the federal government should regulate it and make accessing cannabis easier for consumers, said Paul Armentano, deputy director of the .

He pointed in the International Journal of Drug Policy showing that the number of Google searches for delta-8 in the U.S. soared in 2021 and that interest was especially high in states that restricted cannabis use. “In an environment where whole-plant cannabis is legally available, there would be little to no demand for these alternative products,” said Armentano.

Lindsey, of the Marijuana Policy Project, isn’t so sure that would matter. When he first learned of delta-8’s growing popularity in 2021, he thought it would go the way of drugs like K2 or Spice that he said fall between the regulatory rules long enough to get on shelves before eventually getting shut down.

“That didn’t materialize,” said Lindsey. “The more that we understand about that plant, the more of these different cannabinoids are going to come out.” And that, he said, will in turn spur interest from consumers and businesses.

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Then a fellow patient at a Denver neurologist’s office mentioned something that gave Taylor hope: a CBD oil called Charlotte’s Web. The person told her the oil helped people with uncontrolled epilepsy. However, the doctor would discuss it only “off the record” because CBD was illegal under federal law, and he worried about his hospital losing funding, Taylor said.

The federal government has since legalized CBD, and it has become a . The FDA also has approved one cannabis-derived prescription drug, Epidiolex, for three rare seizure disorders.

But not much has changed for people with other forms of epilepsy like Taylor who want advice from their doctors about CBD. Dr. , a Florida neurologist who specializes in epilepsy, said all of his patients now ask about it. Despite the buzz around it, he and other physicians say they are reluctant to advise patients on over-the-counter CBD because they don’t know what’s in the bottles.

The FDA does little to regulate CBD, so trade groups admit that the marketplace includes potentially harmful products and that quality varies widely. They say pending bipartisan federal legislation would protect those who use CBD. But some consumer advocacy groups say the bills would have the opposite effect.

Caught in the middle are Taylor and other patients desperate to stop losing consciousness and having convulsions, among . They must navigate the sometimes-murky CBD market without the benefit of regulations, guidance from doctors, or coverage from health insurers. In short, they are “at the mercy and the trust of the grower,” said Sirven, who practices at the Mayo Clinic in Jacksonville.

While the CBD industry is new territory for the FDA, people have used cannabis to treat epilepsy for centuries, according to a report co-authored by Sirven in the journal .

More than 180 years ago, an Irish physician administered drops from a hemp tincture to an infant experiencing severe convulsions. “The child is now in the enjoyment of robust health, and has regained her natural plump and happy appearance,” Dr. William Brooke O’Shaughnessy wrote at the time.

Much of the recent interest in CBD stemmed from the which featured Charlotte Figi, then 5, who had hundreds of seizures each week. With the use of CBD oil, her seizures suddenly stopped, CNN reported. After that, hundreds of families with children like Charlotte migrated to Colorado, which had legalized marijuana in 2012. Then in 2018, the federal government removed hemp from the controlled substances list, which allowed companies to ship CBD across state lines and meant families no longer needed to relocate.

The companies from marketing CBD products as dietary supplements and making claims about their benefits for conditions such as epilepsy.

The agency is gathering “research, data and other safety and public health input to inform our approach and to address consumer access in a way that protects public health and maintains incentives for cannabis drug development through established regulatory pathways,” Dr. Janet Woodcock, then the FDA’s acting commissioner, said in 2021, according to a .

“The FDA has really done little to protect consumers from an unregulated marketplace that they have created,” said , general counsel for the Council for Responsible Nutrition, a different dietary supplements trade group.

A recent study in Epilepsy & Behavior on 11 oils found that three contained less CBD than claimed, while four contained more. Charlotte’s Web contained 28% more CBD than advertised, according to the report. The study also that the problems “mirror concerns” raised for , which the FDA does regulate.

“I’m not anti-CBD,” said , a professor of pharmacy and neurology at the University of Wisconsin-Madison who co-authored the study and for the Epidiolex manufacturer. “There needs to be oversight so that patients know what they are getting.”

Some states, such as Michigan, have cannabis regulatory agencies. As such, Dr. , a neurologist at Henry Ford Hospital in Detroit, thinks that when a person shops at one of the state’s dispensaries, “you have a pretty good idea of what you’re getting.” Barkley regularly reviews his patients’ CBD products and discusses how many milligrams they take to help control their epilepsy.

But Barkley said CBD has inherent variability because it comes from a plant.

“It’s no different than saying, 鈥業’m going to treat you with a Honeycrisp apple for an ailment.’ Every apple is a little bit different,” said Barkley. “The lack of standardization makes it difficult.”

About five years ago, Trina Ferringo of Turnersville, New Jersey, asked a pediatric neurologist about giving CBD to her teenage son, Luke, because his prescription drugs were causing severe side effects yet not preventing his epileptic seizures. The doctor was “adamantly opposed to it” because of the lack of FDA oversight and concerns it might contain THC, the chemical in marijuana that produces a high, Ferringo recalled.

Instead, in 2018, the doctor prescribed Epidiolex. Luke went from having several seizures each week to a couple per month. Ferringo is pleased with the outcome but now often fights with her insurance company because Epidiolex, which has a list price of $32,500 per year, isn’t approved for her son’s form of epilepsy.

Charlotte’s Web typically costs between $100 and $400 each month, depending on how much someone takes. Unlike Epidiolex, insurance never covers it.

Beyond the cost difference, it’s unclear whether a highly purified CBD product such as Epidiolex is more effective than products like Charlotte’s Web that contain CBD and other plant compounds, creating what scientists describe as a beneficial “entourage effect.”

A of CBD studies in the journal Frontiers in Neurology, authored by scientists in the cannabis industry, found 71% of patients with treatment-resistant epilepsy reported a reduction in seizures after taking the CBD-rich products, but among patients taking purified CBD, the share was only 46%.

Patients taking CBD-rich products rather than purified CBD also reported taking lower daily doses and experiencing fewer side effects.

“Every cannabinoid when individually tested has a degree of anticonvulsant properties so that if you give a blend of various cannabinoids, they will have some additive effect,” Barkley said.

pending in Congress would designate CBD as a dietary supplement or food. The Senate version would allow the federal government to “take additional enforcement actions” against such products.

Jonathan Miller, general counsel to the , a coalition of hemp companies, said the legislation would protect consumers and allow CBD manufacturers to sell their products in stores as dietary supplements.

However, , counsel for the Center for Science in the Public Interest, said such legislation would actually make consumers less safe. The FDA does not have the for safety and effectiveness before they are marketed and does not routinely analyze their ingredients.

“If a CBD company right now is doing something questionable or potentially unsafe, the FDA can easily remove the product simply for being illegally marketed as a drug,” said Jose. If the legislation passes, he said, the FDA could not do that.

Instead, Jose said, Congress should provide the FDA with more authority to regulate CBD and dietary supplements and more funding to hire inspectors.

The FDA does not comment on pending legislation, spokesperson Courtney Rhodes said.

Patients like Taylor, the Colorado woman with epilepsy, aren’t waiting for the federal government. After the doctor’s visit, she borrowed money from family members and purchased a bottle of Charlotte’s Web.

“The effects were night and day,” she said. “I was able to get out of bed.”

She befriended a grower and spends about $50 per month on CBD powder, gummies, and oil. She now takes only one prescription medication for seizures rather than four. She has about one seizure per month, which means she can’t drive. Her medical providers still don’t seem open to discussing CBD, she said, but that doesn’t bother her much.

“After being on it for this many years and seeing the evidence 鈥� the 180-degree turnaround that my life made 鈥� it’s a choice I’m going to make whether they are with it or they are against it,” she said. “It’s working for me.”

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That’s even though she has not been vaccinated against covid-19.

But leaders of the nursing home, where 22 residents died from covid before vaccines were available, likely won’t be able to employ unvaccinated people like Smith for much longer. The U.S. Supreme Court on Jan. 13 upheld a requiring health care workers at facilities that receive Medicaid or Medicare funding to be fully vaccinated. If all staffers 鈥� excluding those with approved religious or medical exemptions 鈥� aren’t fully vaccinated, the facility will lose that money.

Health care sites in Missouri and other states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated, according to the Centers for Medicare & Medicaid Services, while facilities in states that didn’t sue to block the mandate have a Feb. 28 deadline.

That poses a challenge for Frontier and its residents because the nursing home already doesn’t have enough staffers. And it is in the state with the lowest rate of fully vaccinated nursing home health care workers, 67% as of Jan. 9, according to CMS data. Frontier’s reported staff vaccination rate was just 30% at the start of the year.

That compares with a national rate of 81%, according to the federal data.

Although the mandate ensures that unvaccinated staff members are not caring for some of the people most vulnerable to the virus, not enough workers are willing to take the low-paying, challenging jobs. If they quit to avoid getting shots or are fired because they won’t get them, nursing home residents might not be any safer 鈥� because of lack of care.

“Obviously we need good staff members to take care of residents, but the residents need to be safe as well,” said Marjorie Moore, who supports the mandate and is executive director of Voyce, a St. Louis nonprofit that advocates for nursing home residents and their families.

“A person who lives in their own home has the chance to say, 鈥業 don’t want somebody in my home who isn’t vaccinated,’” she added. “In a nursing home, they don’t have the opportunity to say, 鈥業 don’t want somebody who is unvaccinated coming up and feeding me.’”

The problem of inadequate staffing at nursing homes predates the pandemic, and it’s gotten worse.

In March 2020, 3.3 million people were employed at U.S. nursing homes and residential care facilities, according to the Bureau of Labor Statistics. In December 2021, that number had dropped to 2.9 million, a loss of 400,000 workers.

Nursing home operators can’t find enough staffers because they often don’t pay much. The mean hourly wage for nursing assistants in Missouri was $13.33 in 2020, according to the statistics bureau. And the homes require employees to take on a slew of responsibilities, including feeding residents, changing adult diapers, and caring for residents who have dementia and may become combative.

Nursing assistants “can typically find a job with better pay that is less physically and emotionally demanding,” said , a University of Rochester professor who studies long-term care. “Somebody’s life and dignity is in your hands, and it’s a huge responsibility, and you are not getting paid commensurate with that responsibility.”

Those downsides of the job often lead to significant turnover. In 2017-18, among nursing home employees in Missouri was 138%, the fourth-highest in the country, according to a . Frontier had a rate of more than 300%, according to Huizi Yu, one of the study’s authors.

The nursing home’s management declined to comment.

Smith, the nurse who works for a health care staffing agency, said she has not been vaccinated against covid because she had a rare cancer in 2017 and is “very particular about what I put in my body.”

She said, “I’m not sure if I would be able to get it just to keep a job.”

But, she noted in a text message, “I still practice safely.”

And, indeed, no Frontier residents have died from covid since the outbreak at the start of the pandemic, according to the federal data. But the center reported having seven new confirmed cases among its residents and 10 new cases among its staff as of Jan. 9. At the beginning of the year, 89% of residents were fully vaccinated against covid.

Low vaccination levels among staffers place residents at greater risk, according to a in The New England Journal of Medicine. Facilities in high-covid counties with an average staff vaccination rate of approximately 30% had nearly three times as many covid deaths among residents as facilities where about 82% of employees were vaccinated, the analysis found.

“An unvaccinated or low-vaccinated staff, I think, pretty clearly puts residents at risk 鈥� even if they are vaccinated,” said McGarry, one of the analysis’s authors.

The vaccination rate has increased from fewer than half of Missouri nursing home staff members when President Joe Biden announced the mandate for nursing homes Aug. 18 to about two-thirds of staffers now, according to the federal data.

Like Frontier, Northview Village does not have enough staffers, and most people who work there have not been vaccinated. The facility 鈥� a nursing home in a predominantly Black, low-income north St. Louis neighborhood 鈥� held a vaccination drive in December to increase its roughly 20% staff vaccination rate, but the numbers did not rise, according to the federal data. And only half of residents were fully vaccinated.

The Northview management declined to comment.

Kimberly Watkins, a technician who works to keep Northview residents active, was reluctant to get any of the shots, in part because she heard the conspiracy theory that they contained a tracking chip. But she said she decided to go ahead and get vaccinated because she has asthma and high blood pressure. Co-workers told her their doctors said that they didn’t need the vaccine or that they may be allergic to it.

Now with the mandate taking effect, Moore, of the nonprofit Voyce, thinks most local nursing home staffers will comply.

She highlighted Mary, Queen and Mother Center, a Catholic nonprofit nursing home in St. Louis County, that announced its own mandate in August. Before its Sept. 30 deadline, the nursing home saw its staff vaccination rate increase from 67% to 92%, with the remainder being those with a medical or religious exemption, according to the organization. The facility retained almost all its staff.

Not everyone is worried about nursing home staffers being vaccinated, in part reflecting the community around them. Just are fully vaccinated.

“I’m not into forcing stuff on people,” said Antuan Diltz, a St. Louis firefighter whose mother is a 64-year-old retired nurse with dementia and diabetes living at Frontier. She received the vaccine; Diltz had not.

But others, like Bill Talton, who have family at Frontier hope more staffers will get the shots. Talton, a 77-year-old retired computer programmer, said he is happy with the care his younger brother, who has dementia, has received, although he sometimes couldn’t visit him during covid-related lockdowns.

“It’s kind of late in the game,” said Talton, who is fully vaccinated and received a booster. “They’ll get it done 鈥� I hope.”

KHN data editor Holly K. Hacker contributed to this report.

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For example, 30-year-old fan Lazarus Pittman had planned to see Wilco and co-headliner Sleater-Kinney in August 2020 at the open-air venue in this suburb west of St. Louis. Then the show was postponed because of the covid-19 pandemic. Pittman got sick with the coronavirus. He quit his job as a traffic engineer in Connecticut to relocate to St. Louis for his girlfriend 鈥� only to have her break up with him before he moved.

But he still trekked from New England to Missouri in a converted minivan for the rescheduled outdoor show. “Covid’s been rough, and I’m glad things are opening up again,” he said.

Yet hours before Pittman planned to cross off the concert from his bucket list, he learned the latest wrinkle: He needed proof of vaccination or a negative covid test from the previous 48 hours to enter the concert.

The bands announced the requirements just two days earlier, sending some fans . It was the latest pivot by the concert industry, this time amid an increase in delta variant infections and lingering concerns about the recent Lollapalooza music festival in Chicago being a superspreader event.

After more than a year without live music, promoters, bands and fans are eager to keep the concerts going, but uncertainty remains over whether the vaccine or negative-test requirements actually make large concerts safe even if held outdoors.

“Absolutely not,” said Dr. , a specialist in pediatric infectious diseases at Northwestern University. “There is just too much covid that is circulating everywhere in the U.S.”

During the first months of summer, large outdoor venues such as Red Rocks Amphitheatre in Colorado and Ruoff Music Center in Indiana again hosted bands such as the String Cheese Incident and Phish, with sellout crowds of mostly maskless people inhaling marijuana or whatever other particles were possibly around.

Then the delta variant surge in July prompted renewed concerns about large gatherings, even at such outdoor venues.

Tan, and other doctors, that Lollapalooza, with an estimated 385,000 attendees from July 29 to Aug. 1, was a “recipe for disaster” even though organizers instituted a vaccine or negative-test requirement.

It turned out that Lollapalooza was not a superspreader event, at least according to Chicago Department of Public Health Commissioner Dr. Allison Arwady, who that only 203 attendees were diagnosed with covid.

Tan said she is skeptical of those numbers.

“We know that contact tracing on a good day is difficult, so think about a venue where you have hundreds of thousands of people,” Tan said. “That just makes contact tracing that much more difficult, and there always is a reluctance for people to say where they have been.”

But , an infectious disease expert at the University of Arizona, said she sees the Lollapalooza data as “a really good sign.” Still, an outdoor concert with the new entrance rules is not without risk, she said, particularly in states such as Missouri, where the delta variant has thrived.聽

“If you are considering an event in an area that has high or substantial transmission, it’s probably not a great time for a large gathering,” Popescu said.

Recently, two of the country’s largest live music promoters, AEG Presents and Live Nation Entertainment, announced they would begin requiring vaccination cards or negative covid tests where permitted by law starting in October. But not all bands and venues are instituting such measures. And some simply are postponing shows yet again. For the second straight year, organizers canceled the annual New Orleans Jazz & Heritage Festival slated for October.

Theresa Fuesting, 55, wasn’t planning on coming to her first Wilco show, even though she had four tickets, until the bands announced the new rules.

“I still think it’s a threat even though I am vaccinated,” said Fuesting, who lives just over the river from St. Louis in Illinois.

For promoters, ensuring that people like Fuesting feel safe enough to use their tickets affects their bottom line, said Patrick Hagin, who promoted the Wilco concert and serves as a managing partner of The Pageant and Delmar Hall music venues in St. Louis. Even if the tickets are already purchased, bar and merchandise sales at the venue suffer if fans are no-shows.

“Also you worry: Is this person who purchased a ticket going to even come in the future?” said Hagin.

In non-covid times, more than 90% of ticket buyers ultimately attend, Hagin said. During the pandemic, that number has been as low as 60%.

Hagin said he is offering refunds for shows at his venues. St. Louis Music Park did not offer for the Wilco concert and that it was instituting the requirements “based on what each show wants.” The venue operators did not answer questions for this story.

Jason Green, unable to get a refund for the Aug. 13 show, sold his two sixth-row tickets for $66 鈥� which was $116 less than he paid for the pair in March 2020. He was concerned the venue’s new requirements weren’t enough.

“You want to wait and see if that’s a legit thing that is keeping things from being spread,” said Green, 42, who lives in St. Louis and is fully vaccinated against covid.

He skipped the concert even though he and friends in a comic book collective liked Wilco enough to name a recent comic after the band’s album “A Ghost Is Born.” The band enjoys a loyal local following: Tweedy is from Belleville, Illinois, just across the Mississippi River, and the band played its debut in 1994 in St. Louis.

Fuesting and Pittman took their chances.

This was many fans’ first visit to the new venue, an open-air beneath a curved roof. It was supposed to open last year but was delayed because of the pandemic.

Fans passed through metal detectors and quickly showed their vaccine cards or test results to people sitting at tables. Out of about 2,500 attendees, the venue had to turn only four people away; one of them left, got a test and then returned, Hagin said.

“I was very encouraged just by how positive the compliance was,” he said.

Fortunately, Pittman had a photo of his vaccine card on his phone, which organizers accepted.

“It was so much fun,” said Fuesting, who wore a mask for the whole show. “I just liked the energy of the crowd. They were all just such super fans and singing along to every song.”

The band encored with their classic tune “Casino Queen,” the name of a riverboat casino in East St. Louis, Illinois.

“Casino Queen,” Tweedy sang, “my lord, you’re mean.”

So is covid. But for Pittman, who didn’t wear a mask, the show was worth the gamble. He said he was so into the music, he could push the coronavirus from his mind, at least for a bit.

“They just played all of my favorite songs, one after another,” Pittman said. “I wasn’t even thinking about it.”

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The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.

He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started “doctor-shopping” at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose.

If the state had had a monitoring program, doctors might have detected Mullane’s addiction and, Arbini thinks, her son might still be alive. She said it’s been embarrassing that it’s taken Missouri so long to agree to add one.

“As a parent, you would stand in front of a train; you would protect your child forever 鈥� and if this helps, it helps,” said Arbini, 61. “It can’t kill more people, I don’t think.”

But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates. Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention compiled by 麻豆女优.

Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri’s new toll could cause more people to overdose and leave the state with buyer’s remorse.

“If we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others’ mistakes and not repeat them,” said Rachel Winograd, a psychologist who leads , a state program aimed at reducing harm from opioid misuse.

Before Missouri’s monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills.

State Sen. , a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. , a family physician and fellow Republican who expressed and .

In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the , concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed.

The new does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.

Dr. , an epidemiologist at Columbia University who has studied monitoring programs, said it’s important to mandate that prescribers review a patient’s information in the database. “We know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis,” she said.

But , a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.

He and his colleagues in the intensive care unit at Carney Hospital in Boston don’t use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted.

“Rather than pulling out a piece of paper and being accusatory, I find it’s much better to present myself as a caring provider and sit down and have an honest discussion,” Wood said.

When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state .

But the number of opioid overdose deaths 鈥� with the exception of a slight dip in 2018 and 2019 鈥� has since consistently ticked upward, according to a of CDC data. In 2020, Kentucky was estimated to have had the nation’s second-largest in drug overdose deaths.

When efforts to establish Missouri’s statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, to the county health department. The county now plans to move its program into the state one, which is scheduled to launch in 2023.

Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has “saved lives across the state.” Opioid prescriptions decreased dramatically once the county established the monitoring program. In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people; in 2019, it was down to 58.3 prescriptions, to the CDC.

The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020.

Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can’t obtain them and instead buy street drugs that are more potent and contain impurities.

But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said.

“We absolutely are not prepared for that in Missouri,” said Winograd, of NoMODeaths. “Substance use treatment providers will frequently tell you that they are at max capacity.”

Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to , a St. Louis-based nonprofit that aims to reduce harm from alcohol and drug use.

For example, the waiting list for residential treatment at the clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri.

Tipton, who has worked at the clinic for 17 years, said that before the covid-19 pandemic, people struggling with opioid addiction mainly used prescription pills; now it’s mostly heroin and fentanyl, because they are cheaper. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, to the National Institute on Drug Abuse.

Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help.

Inez Davis, diversion program manager for the Drug Enforcement Administration’s St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because “doctor shoppers and those who commit prescription fraud now have one less avenue.”

Winograd said it’s possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate. “I don’t think that’s the answer,” she said. “We need to move in the direction of decriminalization and a regulated drug supply.” Specifically, she’d rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe.

State Rep. , a Republican from St. Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri’s opioid problem any worse than many other states’. He also worries the monitoring program will lead to an increase in overdose deaths.

“I would love the people that passed this bill to stand by the numbers,” Hill said. “And if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board.”

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When two St. Louis Blues hockey players were sidelined because of covid-19 just days before this year’s NHL playoffs, the team said young defenseman Jake Walman had been vaccinated against the deadly illness. But it was mum about the vaccination status of a more well-known player: star forward David Perron.

It wasn’t until 10 days later 鈥� and after the Colorado Avalanche buried the team, without Perron touching the ice in any of the series’ four games 鈥� that he begrudgingly acknowledged he had been vaccinated.

“I don’t want to talk about that anymore,” Perron, the team’s leading scorer, said at a press conference.

While fans often know intricate details about athletes’ knee joints and concussions, covid vaccinations are another story. Reticence is common among professional athletes. Vaccination status is also a point of secrecy among some Republican lawmakers, other public figures and even many regular people.

Public health leaders say that people in the limelight do not have an obligation to announce or answer media questions about their vaccination status, but many add that they hoped more well-known names would become role models for getting the vaccines.

Instead, they say, the politicization of the shots, misinformation and flawed public messaging from the federal government have made the vaccines controversial and something some public figures are reluctant to endorse, which then ripples across society.

President Joe Biden is trying to get at least 70% of the nation’s adults vaccinated by July 4. So far, according to the Centers for Disease Control and Prevention, have received at least one dose.

“I continue to be hopeful that celebrities will share their vaccination status and use their platform to encourage people to get vaccinated,” said , a sociologist and the dean of the School of Public Health and Tropical Medicine at Tulane University. “But I haven’t seen a lot of celebrities really embrace that role.”

LaVeist and others in public health hoped someone would step up as Elvis Presley did in 1956 to help increase the low rate of polio vaccinations. He received his shot on “The Ed Sullivan Show.”

But that occurred years after the polio vaccine was developed, whereas the covid vaccines became available less than a year after the onset of the pandemic.

“We still have not done a good enough job of explaining to people how and why it is that we were able to have a vaccine developed so quickly, and a lot of people have questions about whether corners were cut,” said LaVeist, who criticized the Trump administration’s decision to call its vaccine development program Operation Warp Speed.

Former President Donald Trump also hurt vaccination efforts among Republicans when he received his vaccine rather than in a public setting like Biden and other former presidents, said , a behavioral scientist who studies vaccination at Indiana University School of Medicine.

When CNN conducted a of congressional lawmakers in May, 95 of the 212 Republican House members said they had received the vaccines and 112 Republican offices did not respond at all. (All congressional Democrats said they had received the vaccines.)

“For some individuals, particularly if their social circle is very anti-vaccine or skeptical of the vaccine, it can feel very uncomfortable to come out and say, 鈥業 got vaccinated,’” Zimet said.

Sports stars, who are often asked about their health, could change public perceptions of the vaccines, said , a bioethicist at the Hastings Center, a research institute in Garrison, New York.

“In the worst days of HIV-AIDS, the fact that Magic Johnson was willing to talk about being HIV-positive changed public conversation in this country,” Berlinger said. “Not everyone is able to step into that role.”

Basketball king LeBron James, when asked if he planned to get a covid vaccine, , “That’s a conversation that my family and I will have. Pretty much keep that to a private thing.”

, a sociologist at the University of Colorado-Denver who has studied vaccine hesitancy, thinks that James and other NBA stars could be reluctant to promote the vaccines because of the way athletes have been castigated in recent years for taking stands on hot-button issues.

But James has expressed support for the Black Lives Matter movement and called for the prosecution of police officers who shot and killed Breonna Taylor, a Black medical worker, in her Kentucky apartment.

“It’s not like he is someone who has been a shrinking violet and has not stepped into the public arena to make very strong statements about inequities and problems in our society,” Zimet said. “So, it’s a little hypocritical that he would now say, 鈥楾his is a private issue.’”

Not everyone in public health is convinced, though, that what James, Perron and other celebrities say is crucial to vaccination efforts.

, a professor of family science at University of Maryland, the role of communication in vaccine acceptance during events such as the 2009 H1N1 pandemic. She found that while public figures’ disclosures can make a difference, they are not as important as endorsements from “people we care about and people who care about us,” she said.

“If Beyoncé came out with a vaccine video, would people watch it? Yes,” Quinn said. “Is it entertainment? Yes. Does it move somebody? Not necessarily, because her life is so dramatically different” than that of an ordinary person.

But , a law professor at the University of Alberta and the author of a on vaccine myths, believes celebrities can make a big difference, pointing to actor Jenny McCarthy’s role in the anti-vaccine movement.

“The role that pop culture can play in normalization is a constructive role,” Caulfield said. “We are getting close to that hesitancy hurdle in jurisdictions where you are getting 60-65% of people vaccinated, so this messaging may seem trivial, but it matters when you are talking about trying to get another 2% or 3% of the population vaccinated.”

During the time when Perron was quiet during the playoff series, sportswriters and fans speculated about his vaccination status. At the press conference where he revealed his vaccination after being questioned about it, Perron said, “I don’t know why it’s a big deal.” He pointed out that he and two other players had gotten covid despite being vaccinated.

“It’s unfortunate and shows that it’s not perfect,” he said, adding that, among his teammates, “I can tell you that we support each individual to make their own decision.”

Even if Perron had declined a vaccine or not revealed his status, some fans would likely not have held it against him.

Thomas Welch, who hosts a hockey , “Locked On Blues,” quickly decided to get vaccinated because his father and brother have Crohn’s disease, which means they could face a greater risk from the coronavirus. But Welch said he understands that for some people the vaccines might not make sense for various reasons.

“As much as we love talking about these players and breaking down the analytics of the sport, at the end of the day, each of these players are people,” said Welch, who lives in Jefferson County, outside St. Louis. “We lose sight of that a lot.”

[Correction:聽This article was revised at 10 a.m. ET on June 21, 2021, to correct an editing error that failed to specify President Joe Biden’s vaccination goal set for July 4 was for 70% of adults to have received at least one shot, not the overall population.]

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That had long been a problem in mental health care. Some outpatient programs previously had no-show rates as high as 60%, to several .

Only 9% of psychiatrists reported that all patients kept their appointments before the pandemic, according to an American Psychiatric Association report. Once providers switched to telepsychiatry, that number increased to 32%.

Not only that, but providers and patients say teletherapy has largely been an effective lifeline for people struggling with anxiety, depression and other psychological issues during an extraordinarily difficult time, even though it created a new set of challenges.

Many providers say they plan to continue offering teletherapy after the pandemic. Some states are making permanent the temporary pandemic rules that allow providers to be reimbursed at the same rates as for in-person visits, which is welcome news to practitioners who take patients’ insurance.

“We are in a mental health crisis right now, so more people are struggling and may be more open to accessing services,” said psychologist , associate professor at University of Colorado School of Medicine in Aurora. “It’s much easier to connect from your living room.”

The problem for patients who didn’t show up was often as simple as a canceled ride, said Jody Long, a clinical social worker who studied the 60% rate of no-shows or late cancellations at the University of Tennessee Health Science Center psychiatric clinic.

But sometimes it was the health problem itself. Long remembers seeing a first-time patient drive around the parking lot and then exit. The patient later called and told Long, “I just could not get out of the car; please forgive me and reschedule me.”

Long, now an assistant professor at Jacksonville State University in Alabama, said that incident changed his perspective. “I realized when you’re having panic attacks or anxiety attacks or suffering from major depressive disorder, it’s hard,” he said. “It’s like you have built up these walls for protection and then all of a sudden you’re having to let these walls down.”

Absences strain providers whose bosses set billing and productivity expectations and those in private practice who lose billable hours, said Dempsey, who directs a program to provide mental health care for families of babies with serious medical complications. Psychotherapists often overbooked patients with the expectation that some would not show up, she said.

Now Dempsey and her colleagues no longer need to overbook. When patients don’t show up, staffers can sometimes contact a patient right away and hold the session. Other times, they can reschedule them for later that day or a different day.

And telepsychiatry performs as well as, if not better than, face-to-face delivery of mental health services, according to a World Journal of Psychiatry of 452 studies.

Virtual visits can also save patients money, because they might not need to travel, take time off work or pay for child care, said Dr. , chairperson of the American Psychiatric Association’s telepsychiatry committee and a psychiatrist at the University of Colorado medical school.

Shore started examining the potential of video conferencing to reach rural patients in the late ’90s and concluded that patients and providers can virtually build rapport, which he said is fundamental for effective therapy and medicine management.

But before the pandemic, almost 64% of psychiatrists had never used telehealth, according to the psychiatric association. Amid widespread skepticism, providers then had to do “10 years of implementations in 10 days,” said Shore, who has consulted with Dempsey and other providers.

Dempsey and her colleagues faced a steep learning curve. She said she recently held a video therapy session with a mother who “seemed very out of it” before disappearing from the screen while her baby was crying.

She wondered if the patient’s exit was related to the stress of new motherhood or “something more concerning,” like addiction, she said. She thinks she might have better understood the woman’s condition had they been in the same room. The patient called Dempsey’s team that night and told them she had relapsed into drug use and been taken to the emergency room. The mental health providers directed her to a treatment program, Dempsey said.

“We spent a lot of time reviewing what happened with that case and thinking about what we need to do differently,” Dempsey said.

Providers now routinely ask for the name of someone to call if they lose a connection and can no longer reach the patient.

In another session, Dempsey noticed that a patient seemed guarded and saw her partner hovering in the background. She said she worried about the possibility of domestic violence or “some other form of controlling behavior.”

In such cases, Dempsey called after the appointments or sent the patients secure messages to their online health portal. She asked if they felt safe and suggested they talk in person.

Such inability to maintain privacy remains a concern.

In a Walmart parking lot recently, Western Illinois University psychologist heard a patient talking with her therapist from her car. Keefe said she wondered if the patient “had no other safe place to go to.”

To avoid that scenario, Keefe does 30-minute consultations with patients before their first telehealth appointment. She asks if they have space to talk where no one can overhear them and makes sure they have sufficient internet access and know how to use video conferencing.

To ensure that she, too, was prepared, Keefe upgraded her Wi-Fi router, purchased two white noise machines to drown out her conversations and placed a stop sign on her door during appointments so her 5-year-old son knew she was seeing patients.

Keefe concluded that audio alone sometimes works better than video, which often lags. Over the phone, she and her psychology students “got really sensitive to tone fluctuations” in a patient’s voice and were better able to “pick up the emotion” than with video conferencing, she said.

With those telehealth visits, her 20% no-show rate evaporated.

Kate Barnes, a 29-year-old middle school teacher in Fayetteville, Arkansas, who struggles with anxiety and depression, also has found visits easier by phone than by Zoom, because she doesn’t feel like a spotlight is on her.

“I can focus more on what I want to say,” she said.

In one of Keefe’s video sessions, though, a patient reached out, touched the camera and started to cry as she said how appreciative she was that someone was there, Keefe recalled.

“I am so very thankful that they had something in this terrible time of loss and trauma and isolation,” said Keefe.

Demand for mental health services will likely continue even after the lifting of all covid restrictions. About 41% of adults were suffering from anxiety or depression in January, compared with about 11% two years before, to data from the U.S. Census Bureau and the National Health Interview Survey.

“That is not going to go away with snapping our fingers,” Dempsey said.

After the pandemic, Shore said, providers should review data from the past year and determine when virtual care or in-person care is more effective. He also said the health care industry needs to work to bridge the digital divide that exists because of lack of access to devices and broadband internet.

Even though Barnes, the teacher, said she did not see teletherapy as less effective than in-person therapy, she would like to return to seeing her therapist in person.

“When you are in person with someone, you can pick up on their body language better,” she said. “It’s a lot harder over a video call to do that.”

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