Physician Mental Health During COVID-19: A Call to Action by Claire Zilber
(download from September 16, 2020 CPS COVID-19 Resource email) is the empowering newsletter article referenced in the CPS 2020 Winter Newsletter article Physician Burnout and Mental Health: “To Put Your Mask on First” By Kartiki Churi, MD February 2020Uneven Ground: Vaccination InequityBy Claire Zilber, MD, DFAPA
CPS President February 2021
Having saved all my vacation weeks in medical school for the very end, I was able to travel to Tibet and Nepal. I set out to climb Kala Patthar, an 18,514 foot pile of limestone and shale, from the top of which one has a clear view of Mt. Everest. Because our Sherpas threatened to mutiny so they could attend the Mani Rimdu festival scheduled for the same day as our summit, we shaved two acclimatization days off our ascent. Coming from sea level, I felt drained of energy and struggled for oxygen. I gave myself permission not to reach the summit, but talked myself into taking “just one more step.” The shale sometimes meant a step forward was really a slide back. Recently, I have been recalling that long-ago climb, applying its lessons to this point in the pandemic. We find ourselves at a precarious place on the pandemic’s path. We have one foot on solid limestone, our hope bolstered by effective vaccines that many healthcare providers and seniors have already received. Our other foot is slipping on the shale of a mutating virus whose new variants are more contagious (UK, Brazil, South Africa and California variants) and more virulent (UK variant), provoking fear of another surge before we have completely emerged from the last one. As we struggle to navigate this terrain, some of us are better equipped than others by virtue of our health status, our ethnicity, our wealth, and/or our privilege. Just as a well-equipped and experienced mountaineer would stop to assist one who may be struggling, it is incumbent upon us to help our more vulnerable neighbors, and especially our most at-risk patients. According to COVIDActNow, an excellent website with state and county statistics about infection rates, vaccination rates, ICU capacity and more, 9.2% of Coloradans have received their first dose of vaccine, and 3.4% have had both doses. One glaring problem is that these vaccines are disproportionately in the arms of well-off, white people. COVIDActNow doesn’t break down their data by race or ethnicity, but there is evidence of significant disparities in vaccination rates. This Colorado Sun story reports that less than 2% of Coloradans who have received the vaccine are Black, yet Black people represent 4% of the population. An even greater disparity exists in the state’s Hispanic/Latino population: they comprise 22% of Coloradans but only 4.3% of those who have been vaccinated. If anything, these groups should be vaccinated at a higher rate than the rest of the population because they are at more risk of infection, hospitalization and death from COVID. For example, this CDC Morbidity and Mortality Weekly Report reveals that in the first ten months of the pandemic in Denver, the majority of cases, hospitalizations and deaths were among Hispanics, although they represent only a quarter of the city’s population. This Colorado Public Radio report details why it is not accurate to suggest that most healthcare providers and seniors are white as an explanation for the vaccination rate disparity. This Kaiser Health News report further unravels the myth that the reason fewer Black people have received the vaccine is because most health care workers are white. In part, the lower vaccination rates of Black Americans may be due to vaccine hesitancy, as documented in this Pew Research Report, which shows that only 42% of Blacks express willingness to receive the vaccine, compared to 61% and 63% for Latinos and Whites, respectively. But that data doesn’t explain the low vaccination rates in the Latino population. It is our duty to find ways to overcome this vaccine avoidance by Blacks, not by bullying but by building trust and engagement. It is also our responsibility to understand and remedy the low vaccination rates in Latinos. The current web-based systems for obtaining vaccination appointments are part of the problem. The elderly and underprivileged may lack the web-connected devices and internet skills with which to make appointments online. To mitigate this problem, CDPHE has held two mass vaccination programs in the San Luis Valley and one on the west side of Denver to reach Latino/Hispanic residents. Many more efforts like this will be needed. Pop-up vaccination events at predominantly Black churches and barbershops, at Native American health and cultural centers, and other trusted sites in Black, Indigenous and People of Color (BIPOC) communities are necessary to ensure justice in the vaccination effort. Otherwise, we will continue to see reports, like this one, that those who live in wealthy, white neighborhoods are receiving the vaccine ahead of others. Equally appalling are the stories about wealthy citizens of other countries flying to Miami, Houston and San Diego for COVID vaccines. I have heard that some have flown to Denver, driven to a church outside of Vail, and received their vaccines there. Those vaccines were intended for low-income workers. I am disgusted. We don’t like to think that racism has infiltrated into healthcare, but it has been as deeply entrenched in medical settings as anywhere else. From the grossly unethical Tuskegee syphilis study, to the appropriation of Henrietta Lacks’ cervical cells for research without her consent, to the uneven distribution of medical resources and procedures in the US, to overt racism in clinical encounters, racism in healthcare is a profound problem that should concern and involve all of us. This recent NEJM Viewpoint, “One of Us”, about how racism affects Black healthcare providers, is especially poignant. I am inspired by stories like this one, about individual healthcare providers finding ways to fill the gaps in underserved neighborhoods. We need to amplify these efforts, to make them universal rather than dependent on a specific individual possessed of abundant initiative. The Colorado Vaccine Equity Task Force aims to provide accurate information, knowledgeable speakers, and vaccination events to BIPOC communities. Their goal is to see 80% of Colorado BIPOC adults immunized by autumn, 2021. As psychiatrists, we may be best situated to bring the vaccine to another population that experiences health disparities and reduced access to medical services: those with chronic mental illness (CMI). A recent study of COVID-19 mortality found that schizophrenia spectrum disorders conferred the second greatest risk, behind age, of COVID-19 mortality. Patients with schizophrenia spectrum disorders were 2.67 times more likely to die from COVID-19 within 45 days of testing positive than individuals with no mental illness. A pre-pandemic study of an intervention to address vaccination disparities for the CMI population demonstrated that creating a vaccination clinic in a community mental health center (CMHC) increased the vaccination rate from 18.75% to 83%. This remarkable success rate points to the potential for creating pop-up vaccination clinics at CMHCs to reach our most vulnerable patients. I hope that CPS and the APA will help advocate with CDPHE and the CDC, respectively, for this kind of innovation to reduce healthcare inequities among our patients, especially our CMI patients who are from BIPOC communities. In addition to advocating for and organizing vaccination events that are more geographically and culturally accessible to the full spectrum of humanity in Colorado, psychiatrists may also want to examine the ways in which we unwittingly continue to exercise our privilege at others’ expense. This NYT op-ed by a former ER doctor turned journalist discusses those who have “jumped the line.” She says, “Pity the rule followers: Many older Americans who are not tech-savvy or lack internet access have been unable to get [appointment] slots.” Neither of my parents has had a first dose yet despite the fact that they can navigate the internet. I admit that if they lived in Colorado, I might work my connections to find them a place in line (to which they are fully entitled anyway because of their age). But another part of me thinks that’s unjust. My parents have the privilege of wealth, excellent nutrition, and overall good health. I should really be helping seniors who have fewer resources, those who struggle to buy fresh produce, pay the utility bills, and afford their medications. Another important element of our response to the exercise of privilege in jumping the vaccination line is to educate the public and our patients about the ethics of vaccine distribution. They key point is the principle of justice in health care, which posits that resources should be allocated with systematic fairness. This viewpoint article from the NEJM offers a clear, nuanced ethical analysis of why politicians getting their vaccinations in advance of the elderly and those on the front line is an injustice. In his paper, What Will White Psychiatrists Sacrifice?, Dr. Keith Gallagher admits, “I have shrugged my shoulders at injustice as if I were powerless to influence it.” He asserts that we must make sacrifices to right the wrongs from which we have benefited, which involves recognizing and ceding our privilege. This may mean different things for each of us. For me, this includes not getting my vaccine ahead of the general public, while advocating consistently to help my senior and/or medically vulnerable patients get theirs. I continue to explore the other ways I can give up parts of my privilege to help raise up those who struggle more than I have ever needed to do. It will mean more than making financial contributions, although those are important. It will mean being willing not to reach the summit of this trail until the entire hiking party reaches it with me. We have been on this very steep trail for almost a year. We are exhausted. It looks like the trail may be leveling out up ahead. Don’t drink all your water and finish your trail mix yet! This is likely a false summit, and we may have miles and months ahead of us. I did make it to the top of Kala Patthar, but it wasn’t easy. I took “just one more step,” one step at a time, all the way up that heap of rocks. The view was spectacular. Much gratitude to Beth Cookson, MD, for sharing “One of Us” by Raymond Givens, MD, PhD. Colorado Psychiatric Society COVID-19 Resource List February 2021
The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials. February 3, 2021Colorado Psychiatric Society COVID-19 Vaccine Update
February 3, 2021
January 20, 2021Vaccines are on Everyone's Mind
By Claire Zilber, MD, DFAPACPS President We are at a difficult and dangerous phase of the pandemic. With vaccines available to some but not most, there is a risk that people will relax the stringency of their safety behaviors, wear masks less consistently, take more liberties with social exposure, and generally behave like the peril has passed. This letter will describe the state of Colorado’s vaccination effort, provide the most recent information about vaccine availability, discuss vaccine reluctance and how to work with people who have fears about its safety, and illuminate the human vulnerability to conspiracy theories that have tainted the vaccine effort. CMS held a Town Hall on vaccines on Wednesday, January 13, with presentations by Dr. Eric France (CMO of CDPHE), Dr. Mark Johnson (CMO of Jeffco Public Health) and Dr. Darlene Tad-y (VP of clinical affairs for Colorado Hospital Association). Colorado has 5.8 million residents, which represents 1.69% of the US population. We receive a proportionate number of vaccine doses from the US supply. Although we have the capacity to deliver more doses per week than are currently being administered, we don’t have more doses. We were told in the Town Hall that this would change this week or next, as the administration releases the vaccines that are being held in reserve for second doses. However, last Friday we learned that the federal government has no vaccines in reserve. As of last week, Colorado has received approximately 500,000 doses of the vaccine, and has immunized 209,000 people with one dose and 44,000 with two. At his press conference yesterday, Governor Polis announced that 5% of the state’s population will have received a first dose by the end of this week, including 20% of people over 70. The Town Hall addressed the somewhat disorganized process of moving from 1a to 1b categories (scroll down to chart of Phases) for vaccination, shifting from hospital-based to community-based vaccinations, which Dr. Tad-y framed as “building the plane after it’s already taken off.” It is reasonable to move away from hospitals as the primary location for vaccination, as hospitals are struggling to staff vaccination clinics while in the midst of a COVID surge. Furthermore, in rural counties there are practical geographic reasons to use pharmacies rather than hospitals for vaccination. The information about which sites are open for vaccination is changing weekly, sometimes daily, so practicing patience will help us contend with the resulting frustrations. Depending on the county in which a person resides, there are different places administering the vaccine. This webpage lists those places by county. For people who are unable or unwilling to go online, COHELP is a phone line that answers vaccine questions in multiple languages: 1-877-462-2911. A person may sign up through the patient portal of each system in their county and then wait for an invitation to schedule. There is an option to sign up by phone, but wait times can be as long as three hours. Anyone who gets a first dose is automatically scheduled for a second dose at the same location. Kaiser, UCHEALTH, Centura, and all the other major health systems are administering vaccines to 1a and the first half of the 1b list (above the dotted line on the chart) which includes seniors over 70, HCPs who work in person with patients who are not known to be COVID positive, firefighters, police, correctional workers and funeral workers. In addition, two major pharmacy chains that have outlets throughout the state (Safeway is one; the second may be King Soopers but they weren’t named at the time of this writing), will begin administering vaccines to people 70 and older. Counties are allocated doses of vaccine based on their population. It is disruptive to the fairness of the distribution process if a person with a second home in a different county gets their vaccine in the county of their second home. Please discourage this behavior. The state’s goal is to complete the vaccination of people aged 70+ by the end of February. Everyone appreciates that this vaccine is a precious resource and doses are not being wasted. If someone doesn’t show for their vaccine appointment, the remaining dose is put into someone else’s arm even if that person is not in the 1b category. Currently, the state is receiving the Pfizer/BioNTech and Moderna vaccines, both of which require two doses. Additional vaccines by Johnson&Johnson, AstraZenica and Novavax are in Stage 2-3 clinical trials. The first two will be single-dose vaccines, while the Novavax will likely require two doses. Although we are currently focused on getting the vaccine to people who desperately want it, we must also focus on those who are more reluctant, particularly people whose communities are most hard-hit by COVID. This study found that the proportion of adults who said they were somewhat or very likely to get the vaccine was 56% six weeks ago, down from 74% in early April. They also found that only 38% of Black individuals surveyed are likely to get the vaccine. We will need to vaccinate a higher proportion of the population to achieve herd immunity, but the exact number to target is elusive, as described in this excellent report from the Colorado Sun. Like me, you may have patients in your practice who are reluctant or completely unwilling to receive the vaccine. Dr. Joshua Morganstein, Chair of the APA Committee on Psychiatric Dimensions of Disasters, offers useful advice for discussing vaccination with reluctant patients. Although it is a public health goal to vaccinate the majority of the population, we must be prudent in our approach to this goal. Any heavy-handed policy is likely to backfire given the current political divisions in our country and risks further politicizing the vaccine. Although it is conceivable that eventually some workplaces, such as nursing homes or hospitals, may mandate vaccination for their employees, the legal and ethical implications of such mandates must be considered. Last week, the CDC announced that proof of a negative COVID test or recovery from COVID illness is required for international airline passengers arriving in the US. It is possible that airlines may require proof of vaccination, a so-called “vaccine passport” for air travel, but this is not necessarily going to occur and certainly not until the general public has had a chance to get vaccinated. One reason some people are refusing to consider the vaccine is the conspiracy theory that Bill Gates has inserted a microchip into the vaccine, which will be used to track the population. A YahooNews/YouGov poll from May 2020 found that 44% of Republicans believe this false claim. I was unable to find a more recent poll, but at least one of my patients continues to fear that this is true. This interview with a social science researcher offers useful advice about how to discuss misinformation with patients, including to not shame the patient either verbally or through your body language, to listen with humility to the patient’s concerns, and to consider this an ongoing conversation over several visits rather than a one-shot (no pun intended) effort to change someone’s mind. Although it may be tempting to silently or not-so-silently scoff at conspiracy theories, it is more beneficial for us to consider the human tendency to look for patterns or meaning where none exists. This article discusses the evolutionary advantage of slightly suspicious thinking, which both helps us anticipate real threats and makes us vulnerable to conspiracy theories. Finally, on the topic of vaccines and their funding, this paper describes the effort to create a fentanyl vaccine to protect against overdose. The fentanyl vaccine induces antifentanyl antibodies which bind to any fentanyl that might be used later and prevent it from getting out of the bloodstream and into the brain. The vaccines reduce brain fentanyl levels by 50% to 80%, depending on the dose of fentanyl taken. The fentanyl vaccine effort is funded at a fraction of that for COVID-19, a reflection of stigma by the pharmaceutical industry and the government about the value of investing to save the lives of people addicted to opiates. In the meantime, HHS has made it easier for physicians to prescribe buprenorphine, which isn’t as effective against fentanyl as it is for other opiates but is still saving lives. Any physician with a DEA license may prescribe buprenorphine to up to 30 patients without applying for a separate waiver. We have two innovative vaccines against COVID-19, and some of us have even received a dose or two, but we are not out of the woods. The more virulent new strain of COVID-19 is present in Colorado and at least 9 other states, and will be the predominant strain by March. I particularly appreciate the boxed comment at the end of this post by my favorite infectious disease blogger. There are many more months to go before it will be safe to relax our diligence. As they say in AA, take it one day at a time. Stay healthy, Claire Colorado Psychiatric Society COVID-19 Resource List January 20, 2021
The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials. Thank you to our Platinum Partner for their support ![]() December 23, 2020Our Balancing Act
By Claire Zilber, MD, DFAPACPS President When I was a child, I was drawn to all manner of activities that involved exercising my balance. One of my favorites was standing on the exact center of a see-saw, one leg on either side of the central pivot point, attempting to keep the see-saw perfectly parallel to the ground. This is the image I hold now as I work to find equilibrium between despair at the ongoing deaths from COVID (320,000 in the US and 4,432 in Colorado as of December 22) plus concern about the long-term neuropsychiatric sequelae of infection, and excited optimism that the Moderna and Pfizer vaccines herald an end to the pandemic. The neurologic manifestations of COVID are common, varied, and persistent. A small German study found post-mortem evidence that SARS-CoV-2 enters the brain by crossing the neural–mucosal interface in olfactory mucosa. A study of hospitalized COVID-19 patients found that one in seven had neurologic complications, which the study authors believed to be the result of hypoxia. An older study notes cases of encephalitis and Guillain-Barré syndrome, while this recent Spanish case report describes the successful treatment of a 39-year-old man with SARS-CoV-2 encephalitis with interferon and tocilizumab. A study of 29 patients who had recovered from COVID-19 revealed persistent cognitive dysfunction, hypothesized to be due to the inflammatory process. A large analysis of the medical records of 62,354 recovered COVID patients in the US showed that 18% had a psychiatric diagnosis within 90 days of recovery, most often for an anxiety disorder, insomnia or dementia. Of equal concern are the reports of lingering “brain fog.” This NYT story includes reporting on a nurse practitioner who admits that she’s working in an impaired state. What if she inadvertently harms a patient? What if her licensing board sees this confession? The brain fog is one of the most confusing symptoms among so-called “long-haulers,” those who experience lingering disabilities long after their acute illness has abated. We have all been counting on this nightmare ending, but what about those who develop a chronic illness that persists beyond the pandemic, whose nightmare has no conclusion? Fortunately, a way out of our collective nightmare has opened up this month with the approval and early distribution of two extremely effective vaccines, and others are on the way. Each state has developed its own vaccine priority protocol, and Colorado’s can be found here. Because most psychiatrists are working via telehealth, we are not considered frontline workers eligible for the earliest doses of the vaccine; however, those who must evaluate patients in person, including psychiatrists in inpatient units and prisons, and addiction psychiatrists who administer injections, are in the 1B category and may be vaccinated this winter. Here is the state’s information for health care professionals, which will include details about how to access vaccination if you aren’t able to obtain it through your employer. Both CPS and the APA are advocating to ensure our members have access to the vaccines. CPS is in contact with CDPHE and other organizations and is actively monitoring information on the logistics of vaccinations for psychiatrists not directly employed by a hospital or affiliated with a facility. As soon as there is specific guidance on how providers in category 1B who need to have direct patient contact can get a vaccine, we will notify members. Additional information is available at https://covid19.colorado.gov/vaccine. This Colorado Sun article suggests that the line between 1A and 1B categories is somewhat fluid.
Because I can see my patients via telehealth, I feel it is more ethical to prioritize those who need the vaccine more than I do. Rather than focusing on when we get our own vaccinations, which will happen when they happen, let us turn instead to our capacity as public health professionals. Psychiatrists play a vital role in educating our patients and dispelling their anxieties. Patients with chronic mental illness have a lower influenza vaccine uptake rate than the general population, and by virtue of their economic status and chronic health conditions are at higher risk for severe COVID-19 illness. Psychiatrists are central to helping these vulnerable patients access the vaccine. We are also well positioned to help our patients and the public deal with vaccine hesitancy through motivational interviewing, as discussed in this article from CU Anschutz’s Department of Psychiatry. Another article offers five strategies to help overcome vaccine hesitancy, including making vaccination free and easily accessible, making admission to valued settings (schools, workplaces, cultural institutions, our offices) contingent upon vaccination, and using endorsements from trusted leaders to increase uptake. It is crucial to include leaders from diverse community settings, such as local religious and civic leaders, if we are to reach the communities most at risk for COVID and least trusting of health authorities.
It’s possible that even before we’ve all been vaccinated, we’ll have access to at-home testing to ensure it’s safe to go to work, to school, or on a social visit. The first at-home, 20-minute Coronavirus test received FDA approval last week, and the developer anticipates the availability of three million tests in January 2021. Of course, we’ll need a hundred times that monthly number if we’re going to use frequent testing to open up society before we have all been vaccinated, but more tests are on the way. Which brings me to another important duty of psychiatrists at this crucial time in the pandemic: we must find ways to fortify our patients’ (and families’ and neighbors’) commitment to pandemic safety while we wait for herd immunity. That workers in ERs and ICUs will be vaccinated by next month protects our healthcare workforce, but doesn’t resolve the problem of maskless people in public. To get people to follow COVID guidelines, it may be helpful to appeal to their care for others. This Harvard study from early in the pandemic found that public health messages focused on protecting others were more likely to inspire compliance with health guidelines than messages focused on the need to protect oneself. If you want to read more about prosocial behaviors, go to The Top 10 Insights from the Science of a Meaningful Life. I have found nothing motivates my compliance with regulations more than the stories I hear from patients, friends, and the media about the intense suffering of people dying in ICUs, healthcare workers crumbling from exhaustion, families agonizing that they cannot be with their loved ones at the end. Hearing this testimony, I cannot harbor the possibility that my behavior might transmit the virus and disrupt or end another’s life. This JAMA article should be mandatory reading for everyone not on the frontlines. We have included it in our COVID-19 Resources for the Public this week, so feel free to direct people there if they are expressing reluctance to maintain safe behaviors. Compliance with public health regulations doesn’t mean we are doomed to a gloomy Christmas and New Year devoid of celebrations and diversions. I hope each one of you has a few extra days off in the next couple of weeks, time to slow down the stressful pace, reboot your exercise regimen, connect meaningfully with people you love, and find some frivolous fun. Do you have a Christmas movie tradition? You can watch the latest blockbuster movies from home. My mother’s childhood family holiday tradition was to travel to New York City to catch a Broadway theatre performance. You can too! Here are some free ones; and here are a collection of Broadway Christmas plays, ballets and concerts. Those of us from the West Coast have other traditions: check out the Christmas concerts and sing-alongs from San Francisco’s Grace Cathedral. Unless you were wealthy enough to fly on the Concorde, never before have you been able to take in a show in New York and join a concert in San Francisco on the same day! A pandemic silver lining, for sure. If playing games with the clan after opening gifts was your family tradition, that’s still possible. Here are six classic games you can share on Zoom, and another 21 collected here. In case you didn’t know, that activity is called a “covideo party.” Satisfy your word nerd urge with other novel coronavirus neologisms in this amusing article. Go play! We must remain steadfast in our mask wearing and social distancing until the CDC signals that enough of the population has been vaccinated for us all to be safe. We must balance our optimism and excitement with caution and diligence. Which reminds me of another lesson I have learned from a variety of physical activities. Whether shooting a basketball, serving at tennis, swinging a golf club, or holding an arabesque, the same principle applies: you must maintain your focus and follow through with the physical gesture all the way to the end of the motion in order to achieve success. Stay healthy, Claire Zilber, MD, DFAPA Colorado Psychiatric Society COVID-19 Resource List December 23, 2020
The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
December 9, 2020Lighting the Candles of ResilienceBy Claire Zilber, MD, DFAPA Chanukah begins Thursday at sundown, celebrating a miracle. A vial of sacred oil, only enough to keep the everlasting light illuminated for one night, lasted eight nights, long enough for the community to acquire a fresh supply. This year, that story feels particularly relevant. We know relief in the form of a vaccine is on its way to us, but we are not the first in line for it, and it will be a while before our communities are safe. As we witnessed over Thanksgiving, many people are so exhausted by the pandemic restrictions, so in need of connection, that they threw caution to the wind. The case rates reflect the result, yet the anticipated spike from Thanksgiving gatherings won’t show up until later this week. We must double down on safety over the winter holidays, or we will have a nightmarish January. What oil can we find to sustain our hope and renew our diligence? After reviewing some information about the exhaustion and depletion that are real for all of us, I’ll bring you some good news and suggestions. Holidays are hard in a pandemic, especially in the tenth month of social restrictions. Our colleague and former CPS President Peter Mayerson coined the term “sequesteritis.” I want to see my friends’ unmasked smiles. I yearn to give them hugs. I long to visit my mother. I’m only one of 7.8 billion people on this planet who share these feelings. Our Brains Explain the Season’s Sadness reports on why we all are so depleted. According to the neuroscientist interviewed for the story, our prefrontal cortex is working overtime to keep an eye out for all the threats we face. Remaining vigilant about the coronavirus, civil unrest, political turmoil, job insecurity, the wellbeing and education of our children, wildfires, hurricanes, and separation from family takes a lot of energy. Add to that the extra focus required to work and socialize on a screen, or to work in PPE, and you’ve got one very tired brain. Although the phrase “deaths of despair” predates the pandemic, it is especially fitting now as preliminary data suggests deaths from drug overdoses have doubled. Like a lotus emerging from mud, there are glimmers of good news arising from the nightmare of the pandemic. Researchers observe a decline in youth vaping in the pandemic, and this commentary includes suggestions for ways to intervene to maintain this trend after pandemic restrictions are lifted. Since youth vaping is linked to marijuana use, a reduction in the former may have a significant impact on the pathway to addiction. Another measure of good news oil is that the pandemic has increased our access to online material that we can use in our work. Take, for example, this stigma-busting video discussion between two women in the publishing industry, one with dyslexia and the other with bipolar disorder. It includes reflection on how the pandemic has added further complexity to managing their neurodiversities, as well as valuable information about combatting shame, and advice to managers who supervise people with neurodiverse qualities. We have dropped this into the COVID-19 Resources for the Public page on the CPS website, so you can share it with your patients. One of the conversation starters at CPS' Monday evening cranberry-margarita-infused Winter Party was to identify a way each of us has grown during the pandemic. Albert Einstein wrote that “Adversity introduces a man to himself.” The pandemic provides an opportunity to dig more deeply into ourselves for the strength to endure; we will be changed. As psychiatrists, we have the privilege to help others who might otherwise break under this pressure, help them find their resilience and emerge from the storm. In my work these last few months, I find that empathetic humor is especially helpful in those moments when someone is describing their latest personal calamity piled upon this collective disaster. Something about the release of laughter eases the tension on the soul, and we find we can bend a little further after all. In that spirit, I was delighted to read JAMA’s best of 2020 Graphic Medicine. If you don’t have time to click on all the links inside that review, here are two highlights. This comic by Gemma Correll, Creativity in Captivity, pokes fun at what she plans to do during the shelter-in-place order vs. what she actually does. Another gem in the JAMA review was the revelation that there’s an annual conference on graphic medicine, and that they have created a free, monthly virtual meet-up during the pandemic called Drawing Together. Free art therapy for us! Good news, humor and art therapy are some of the extra oil we need to keep our lanterns lit, to help us find the will to stay safe for a few more months as we wait our turn for the vaccine and then wait a little longer for enough of the population to be immunized so that we all can be safe. The CDC’s recent revision of quarantine guidelines applies a scientific lens to choosing a length of quarantine based on risk. I find the graph especially helpful in illuminating the difference between 7, 10 and 14 days of quarantine, and the table below it clarifies how adding a negative PCR or antigen test may increase confidence about reducing quarantine from 14 to 10 days. I also was reassured to see what precautions epidemiologists are taking in their personal lives; apparently, that I do not place my mail in quarantine does not make me a daredevil. Whew! When a physician friend told me that he is only doing the top four activities on the chart, I felt a competitive zing because I’m only doing the top three. Hey, if friendly competition is what it takes to keep me safe, I’m all in. In the end, I’d rather have sequesteritis than coronavirus. Although I didn’t set out to include eight positive links in this letter, to correspond to the eight nights of Chanukah, it worked out that way. There is your oil. Now light your candles and those of your patients so that we all retain the fortitude to manage our behavior, reduce our risk of acquiring and transmitting the virus, and further develop our capacities for endurance and resilience. Stay healthy, Claire Colorado Psychiatric Society COVID-19 Resource ListDecember 9, 2020
November 25, 2020
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Interested in learning about the outcomes of the Governor’s Behavioral Health Task Force and potential legislation in the 2021 session? The event features CPS members C. Neill Epperson, MD and Elizabeth Lowdermilk, MD, along with CDHS Executive Director Michelle Barnes and others. This activity has been approved for AMA PRA Category 1 Credit NOTE: You do NOT need to be a CMS member to attend this event. if you do not have a CMS member number or do not know your CMS member number, you can write n/a or enter any number when requested in the registration form |
November 25, 2020
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Register for all 4 upcoming CPS events - The pandemic may hinder us from gathering in person, but CPS is here to ensure you have ample opportunity to stay connected to friends and colleagues. Event details at https://www.coloradopsychiatric.org/events. |
NYT - How to Have a Fully Remote Family Thanksgiving - Skipping travel this year to stop the spread of Covid-19? Here’s how to digitally reimagine the holiday, from meal prep to after-dinner activities (11-18-20) |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
By Claire Zilber, MD, DFAPA
CPS President
For many of us, our first exposure to the field of psychiatry was as a student on an inpatient ward. In college, a course on Abnormal Psychology included a field trip to the Philadelphia State Hospital where each student was paired with a patient. I was assigned to a man with Tourette’s syndrome, who shouted obscenities while pacing the halls and gesticulating. I imagine how dangerous life would have been for him in public, where people would misunderstand his illness as aggression; however, at the time, he alarmed me so much I could barely conduct the interview. An inpatient unit is simultaneously a safe haven and a scary place, and the pandemic has amplified this dichotomy. This week I’ve explored the risks particular to inpatient psychiatric settings, the guidance issued to help mitigate those risks, some ethical quandaries that have emerged, and several creative solutions.
As if obstacles to inpatient admission weren’t already extensive, including insurance barriers, bed shortages, stigma, and past traumatic experiences with treatment, now patients may fear presenting to the hospital because of COVID. Indeed, this report from February about an outbreak in a psychiatric hospital in South Korea, which led to over 100 infected patients and 17 deaths, reinforces beliefs that the hospital is unsafe. Lest we think such carelessness couldn’t happen here, this September 29 article from The Gazette reports on the closing of a psychiatric hospital in Johnstown (just east of Loveland) because of inadequate pandemic precautions as well as allegations of patient abuse.
Unlike medical and surgical units, psychiatric units are organized around the therapeutic milieu, based on the concept that interactions among patients as well as with staff have therapeutic value. How can we maintain a group milieu while isolating potentially infectious patients? Some direction has been provided by our government. For example, this SAMHSA guidance, issued in May, considers ways to reduce morbidity and mortality by mitigating risks for patients and staff while preserving the functioning of the healthcare system. Updated October 13, here is the link to the APA’s practice guide for COVID-19. Scroll down to the heading on inpatient psychiatry. These resources relate to a March 18 guidance issued by CMS (Centers for Medicare & Medicaid Services) about tiers of care, which triggered APA’s statement that ECT should be considered an essential procedure, not an elective procedure that could be postponed during a lockdown.
More substantial guidelines have been offered by our colleagues. This July 2020 literature review about psychiatric care in the US during the pandemic addresses all locations of psychiatric treatment (ie: outpatient, emergency rooms, C/L, and inpatient). Scroll down to section 3.3 to read their findings about inpatient psychiatry, and then move on to section 4, which includes a consideration of the ethical implications of admitting patients to an inpatient unit, which some have compared to a nursing home in terms of exposure risk. Informed consent about this risk is necessary, but may be difficult to obtain from a psychotic patient. This excellent double case report highlights ethical and logistical considerations when caring for older adults on inpatient psychiatric units. This paper from the Journal of Medical Ethics also uses a case study to elucidate ethical dilemmas and policy recommendations for when patients refuse COVID-19 testing and won’t comply with quarantine or social distancing on psychiatric inpatient units.
A variety of adaptations have been adopted across the country. The University of Rochester created a COVID-19-positive psychiatric unit so that inpatients can benefit from the milieu and group support while also receiving expert medical care. In Colorado, the predominant model (based on information from Denver Health and Porter Hospital) is to hospitalize COVID-positive psychiatric patients on the medical service and support those patients with telepsychiatry from the C/L team.
Telepsychiatry is not being used on the inpatient service at Denver Health. Patients are tested prior to admission, and only those who test negative are admitted to the psychiatry unit. Staff and patients are screened for symptoms daily, social distancing is enforced as much as possible, mask wearing is encouraged, and the unit is frequently sanitized. Groups and other therapeutic programs are being continued. Initially quiet, the inpatient units at Denver Health have been busy since September, which likely reflects the “mental health wave” of the epidemic we’ve been anticipating. Staff have remained healthy, with only four positive tests among the inpatient and ER teams, all of whom recovered quickly. Staff burnout is a big concern, as is how to manage patients who refuse COVID testing (go back to the Journal of Medical Ethics case study to read the discussion about balancing a patient’s right to auonomy against the public health imperative to not place other patients and an entire staff at risk).Staff burnout and maintaining inadequate staffing are real problems. The compelling part of this article addresses how longstanding problems with understaffing and inadequate inpatient beds, which leads to long stays in non-therapeutic emergency departments, has been exacerbated by the pandemic. One psychiatrist has accelerated his pre-pandemic project to create truly therapeutic spaces for psychotic or suicidal patients in emergency departments, with the goal of being able to send 75-80% of patients home without inpatient admission. Similarly, this report from a London hospital asserts that the kinds of adaptations we see happening now may lead to positive changes in inpatient units that will persist beyond the pandemic. For example, they instituted point-of-care testing for clozapine levels, which expedited dose titration; enhanced videoconferencing connections with community agencies to facilitate a smooth and efficient discharge plan; and even used telehealth to meet with patients’ family members during rounds.
Inpatient psychiatric services are a crucial component of mental health treatment, and will continue to be necessary throughout the pandemic and its aftermath. While the challenges COVID-19 has brought to inpatient psychiatry are formidable, the solutions emerging from this crisis reveal the creativity and adaptability of our colleagues. We don’t have all the answers, but at least we’re identifying important questions to help respond to the needs of acutely psychotic or suicidal patients while containing the risk of infection as much as possible.
I am grateful to Drs. Steve Mayes, Beth Cookson and Christian Thurstone for their valuable contributions.
November 11, 2020
Updates |
9News - Here are the Colorado counties that are moving to tighter COVID-19 restrictions - A list of Colorado counties that have recently tightened restrictions due to an uptick in COVID-19 cases. Includes information on Denver’s Home by 10 curfew (updated 11-9-20). Also see the Colorado County COVID-19 dial dashboard (updated daily) |
CO HCPF - Register for the Telemedicine Stakeholders Engagement Meeting - Thursday, November 12, 2020 4:00 PM MST - 5:00 PM MST - The Department of Health Care Policy and Financing is continuing its consideration of telemedicine policies and their effects on access, quality of care, budget, and provider and member experiences. Their goal is to ensure that members have access to quality telemedicine services while managing their fiscal responsibilities. They have been assessing and developing policy around telemedicine. Proposed policy will be shared and feedback requested. |
APA - Register for the APA Town Hall on Structural Racism, Part 3: The Trauma of Structural Racism and its Transmission Across Generations - Monday, November 16 | 6-7:30 MT (8:00 - 9:30 p.m. ET) - Disparities in mental health for people of color remain pervasive and persist across generations. There is a growing consensus that structural and interpersonal racial discrimination fundamentally impact mental health in communities of color. The persistent stress of experiencing discrimination has an impact across generations, and the degree to which the health consequences of racism and bigotry can be passed down from one generation to the next is an important avenue of exploration. This town hall will delve into this issue. Have a question you would like the panel to address? Submit your question at this link. |
APA - Register Here for an Update on 2021 Changes to Billing and Documentation for Outpatient E/M Services - Tuesday, November 17, 6pm MT (8 pm ET) - Join this webinar to learn about the changes to billing and documentation for Outpatient E/M services that will take effect on January 1, 2021. The webinar will include how to select the appropriate CPT code based on medical decision making or time, a review of the necessary documentation, and a Q&A portion with APA’s CPT coding and documentation experts. Also see Bump in Medicare Values for E/M Codes Could Increase Psychiatrist Payment (8-31-20) and AMA - E/M office-visit changes on track for 2021: What doctors must know (8-5-20) |
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
All but one of my patients on Monday was dispirited about making it through this winter. Worn down by almost eight months of health anxiety, social restrictions, inability to visit far-flung relatives, and political angst, the frigid conditions early in the week seemed to knock the wind out of almost everyone. The alarming surge in cases in Colorado, with over 2100 new cases reported on Sunday and a new case rate of 24.3 per 100K residents, is a great concern, dwarfed only by the reality that every single one of our neighboring states is faring even worse, according to Johns Hopkins University. In this letter, I offer an update about psychiatric sequelae of COVID-19 infection itself, managing chronic mental illness during this pandemic, and coping with depression. Lest this leave you hollowed out in despair, I promise levity at the end.
Psychiatric Conditions Associated with COVID-19
There appear to be several different biological pathways to psychiatric syndromes as a result of COVID infection. Acute syndromes include delirium, and symptoms related to acute stroke caused by the vascular manifestations of infection. Later psychiatric symptoms may be the result of immunologic responses to infection, and perhaps from the ongoing presence of the virus within the CNS (within endothelial cells, macrophages or monocytes). There is so much more to learn about this virus. To the extent that the CNS may serve as a reservoir for infection, as it does for HIV, we may find long-term psychiatric sequelae emerging months or years after initial infection. For now, we must content ourselves with hypotheses about mechanisms of illness, and small studies, which were recently reviewed in this paper. The reviewers found only two studies of psychiatric conditions in patients with COVID-19, which showed high rates of PTSD and depression in those patients. The remaining studies examined the indirect effect of the pandemic on wellbeing among patients with chronical mental illness (CMI), the general public, and the healthcare workforce.
Coping with CMI in the Pandemic
For patients with CMI, the pandemic has added new burdens to an already overburdened and under-resourced population. With most outpatient clinics operating via telemedicine, patients without reliable access to the internet or whose paranoia interferes with their willingness to use telehealth are less able to engage in treatment. As discussed in this Kaiser Health News article, acute treatment settings like ERs, inpatient units, detox centers, and residential treatment facilities are now even more difficult to get into than usual because beds have been reduced to keep patients and staff safe during the pandemic. Furthermore, patients with CMI have more medical comorbidities than the average person, yet they have less access to medical care, a problem likely to be exacerbated in the pandemic. The Canadian authors of this article suggest mitigation strategies that are equally applicable in the US, such as increasing access to low-cost technology so that patients can access telehealth regardless of their economic means, as well as bolstering resources to support collaboration between primary care and psychiatry. Another unique intersection between COVID-19 and patients with psychosis is highlighted by this case report of a patient on clozapine who was hospitalized for COVID-19 in the UK. The patient developed toxic levels of clozapine, presumably because cytokine release associated with COVID-19 infection downregulates CYP 1A2, thereby slowing the metabolism of clozapine.
Coping with Depression in the Pandemic
By now, it has been well documented that rates of depression have soared as a result of pandemic related stresses including grief over the deaths of loved ones, hardship because of loss of employment, job/food/housing insecurity, isolation because of physical distancing restrictions, and a surge in domestic violence. Because the pandemic has required massive adaptation for almost all of us, any form of psychotherapy focused on navigating the many changes and stressors in our environments is key to effective treatment. Some authors advocate specifically for Interpersonal Psychotherapy for patients and families, while others recommend Cognitive Behavior Therapy for frontline workers. The impact of grief on family members of COVID-19 victims and healthcare professionals on the frontlines who are experiencing multiple deaths on their watch is of particular concern. We know from previous research that sudden and traumatic loss, as well as multiple sequential losses, are more likely to result in prolonged grief disorder. This article addresses the potential scope of grief as a result of the pandemic, and offers a public health/community strategy for managing a grieving population, including more training for primary care providers and referral to mental health for the more complicated cases, such as those involving psychosis or suicidal ideation. In this PsychNews story on suicide prevention strategies for the pandemic, I followed the link to a free training on CALM: Counseling on Access to Lethal Means. It takes around two hours to complete the training. While much of the information is familiar to psychiatrists, this may be an important time for us to refresh our suicide prevention counseling skills. There are additional articles in this week’s Resources for Providers about depression and suicide in the pandemic.
Enough Tricks, Time for Treats
I admit to my own trepidation last weekend: how will I be able to help all my patients keep their heads above water if I don’t stay well myself? I was bolstered by this NYT story on What Scandinavians Can Teach Us About Embracing Winter. We include this in our Resources for the Public page, so please remember to direct your patients and others to that page. It helped me reframe my dread by reminding me of all the treats that come with cold weather: hot beverages, cozy sweaters, improved sleep on crisp nights, opportunities to invent new favorite soups, “owning the park” when I walk my dog on mornings too cold for others to venture out, snowshoe day-trips with friends, and so much more. In addition to leaning on old favorites, I intend to create new traditions. For example, with the Blue Moon on Halloween, I plan to drink a Blue Moon beer, listen to all the different covers of Rodgers and Hart’s Blue Moon, and gaze at our beautiful satellite. For those of you adapting the holiday for children, I appreciate the tips at the end of the CDC’s Guidance for Halloween, especially the inspiration to hold a treasure hunt at home in lieu of trick-or-treating in the neighborhood. I love treasure hunts! If all else fails, and the winter doldrums suck the life out of you, try Yoga for When You Feel Dead Inside.
October 28, 2020
Updates |
COVID-19 Exposure Notifications have started in Colorado! You can now activate this service to protect your community while maintaining your privacy. CO Exposure Notifications can quickly and anonymously notify you if you’ve likely been exposed, allowing you to reduce risk for your loved ones, seek timely medical attention, and stay home. Find out more at addyourphone.com. |
Mayor Michael Hancock announced two additional public health orders in Denver. Also see yesterday’s update - State Moves Denver Back to Level 3 Restrictions - CDPHE has moved the City and County of Denver, among other counties, to the more restrictive Safer at Home Dial Level 3 (10-27-20) |
CPR - New Health Order Limits Personal Gatherings To 10 People From No More Than 2 Households In Most Counties (10-23-20). Also see amendment to the health order (download) (10-23-20) |
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
The pandemic has prompted unprecedented changes in healthcare, including psychiatric practice. Telemedicine is suddenly mainstream and is changing norms before we can consider their ethical implications. Discussions about rationing care, a very taboo notion in the US, were widespread in the spring when hospital beds and ventilators were scarce in Italy, Spain, England, New York, and other hotspots. Decision-making algorithms for access to ICU beds and ventilators and for administration of vaccines are covered in the medical literature and lay media. Concerns about the ethical implications of rushing a vaccine through the regulatory process have become a touchy political issue, and medical editors are issuing political opinions in advance of the presidential election. This is more fodder for ethical analysis than can be managed in this space, so I will focus on three areas most relevant to psychiatrists: boundaries within telehealth, C/L psychiatry and COVID-19 ethics, and an ethical approach to public health policy.
In May 2020, the APA conducted a member survey about their use of telehealth before and after the public health emergency caused by SARS CoV-2. Whereas before the pandemic 64% of respondents used no telehealth in any of their patient encounters, a mere two months later 85% were using telehealth for 76-100% of their clinical work. Initially, we were mostly focused on getting the technology to work for us and our patients, paying attention to only the most obvious ethical issues, like privacy and confidentiality in clinician and patient environments. The APA’s Best Practices in Videoconferencing-Based Telemental Health states, “During a telemental health session, both locations shall be considered a patient examination room regardless of a room’s intended use.” We fretted about how to ensure the patient’s room is private if we can’t see the entire space. Eventually, other concerns surfaced, like hidden obstacles to confidentiality in the form of eavesdropping or recording devices. If the psychiatrist or the patient has an Alexa or Echo device within earshot, might it start recording or even speaking in response to what it hears? Might the patient intentionally record the session without the psychiatrist’s knowledge or consent? Might the psychiatrist do so without the patient’s consent?
Telepsychiatry has provoked a loosening of boundaries. A previous article on boundaries written in April feels quaint six months later. Then, it felt awkward that patients could see one wall of my home. Now, many of them ask to see my dog if they hear him bark or squeak a toy. To deny that request would seem cruelly withholding. Only recently have I considered that my dog could be in a different room when I have patient appointments, reducing the temptation to cross this boundary. This opinion piece by Lori Gottlieb, author of Maybe You Should Talk to Someone, reveals several ways in which the loosening of boundaries because of seeing patients in their homes (or cars, backyards, front porches, sidewalks… ) enhances the therapy. On the other hand, I’m disconcerted that she admits to downgrading her wardrobe. I believe it is more professional and respectful to dress as we would if we were in our offices.
Just as outpatient psychiatrists are faced with a variety of new ethical dilemmas, C/L psychiatrists are encountering new challenges, too. When should they see a patient in person, using up precious PPE, and when is it better to do an evaluation via telehealth? Is the decision to use telehealth a convenient rationalization for reducing personal risk of exposure, or a sound policy? This article from UCLA strongly argues the latter, not just for psychiatrists but for all medical personnel who don’t absolutely need to touch the patient. In addition to adapting their consultations to include telehealth when appropriate, C/L psychiatrists may encounter new kinds of consult requests, such as evaluating whether a patient has capacity to request to leave the hospital AMA during the pandemic, or assessing the patient who wants to change their status to DNR in order to conserve resources for others. Johns Hopkins has published an excellent resource, Capacity Assessments During the COVID-19 Pandemic, to help clinicians navigate these unique situations.
In addition to new ethical dilemmas for outpatient and C/L psychiatrists, we may also focus on the ethics of public policy decisions during the pandemic. We are experts on cognition and communication, and can help shift the conversation about personal responsibility for public health (ie: wearing masks and conforming to physical distancing guidelines) when we notice and correct bias in messaging. This paper, Cognitive Bias and Public Health Policy During the Pandemic, identifies four types of bias evident in the public narrative that compromise public safety. Another article focuses on the virtues of compassion, solidarity and justice as important guides to public policy in the pandemic. When we incorporate these themes into our discussions with reluctant patients, workplace administrators, and policy makers, we advance the conversation along ethical lines.
Perhaps the most distressing ethical problem highlighted by the pandemic is the absence of justice (equal access to treatment for all) in US healthcare. While the President is able to receive an experimental monoclonal antibody in Phase II trials, 44 million Americans are without health insurance. Much has been written about disparities in health outcomes during the pandemic; this summary from SAMHSA is a good place to start if you want to delve more deeply into the intersections between race, behavioral health and COVID-19.
In closing, this letter identifies several ethical dilemmas uncovered by or created by our responses to the pandemic. There are many more. I will devote a future letter to inpatient psychiatry during the pandemic, including ethical issues encountered in that setting. If you have other pandemic-specific ethical questions, please contact me through [email protected] and I will endeavor to address them in later letters.
Stay healthy,
Claire
Claire Zilber, MD, DFAPA
CPS President
October 14, 2020
Updates |
Application can be made here: Provider Relief Fund Application and Attestation Portal. Deadline: November 6, 2020 |
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Claire Zilber, MD, DFAPA
September 30, 2020
“Hope is being able to see that there is light despite all of the darkness.” Desmond Tutu
As the Jewish New Year starts and the secular year crosses the threshold into its last quarter, the world feels desolate. We’re ten months into a global pandemic with no end in sight, which has sickened more than 33 million and killed over one million people globally, with over 7 million cases in the US and 205,676 deaths (from Johns Hopkins). Conspiracy theories complicate responses to the pandemic, as personal participation in precautions and attitudes towards accepting a vaccine vary depending on one’s beliefs. Police killings disproportionately affect people of color, provoking months of protests, which in turn have sometimes led to violent clashes with counter-protesters. Economic distress because of pandemic shutdowns has led to food and housing insecurity for millions of Americans. Wildfires have scorched over five million acres across the West, a fairly abstract number that this article attempts to contextualize. Ruth Bader Ginsberg’s death has unleashed political shenanigans which are deepening our national strife, and the upcoming election has everyone on edge regardless of their political affiliation. This is a lot to hold as we go about our work, trying to help people regain and sustain mental health. I have labored in the last two weeks to reframe my despair so I can be useful to others. I look both to the past and the future to bolster my hope, and eventually end up in the present.
On the Sunday evening following Ruth Bader Ginsberg’s death, a conversation with my father-in-law planted the seed of perspective. He reminded me that things looked grim throughout much of World War II until Hitler’s army encountered the Russian winter. An unforeseen ally in the war, it turned the tide. I have been trying to imagine the thoughts and feelings of the inhabitants of France, Poland, Greece, England, and other European countries that were either occupied or imperiled by fascist forces. However menacing we feel our situation may be, the circumstances in WWII were even more dire. Yet, in the end the Allies prevailed, Europe was rebuilt, and the European Union eventually emerged, joining former enemies as partners.
Karl Menninger’s 1959 lecture to the APA Assembly addresses hope in the context of healing. He, too, goes back to WWII, to the Buchenwald concentration camp, to find an example of hope against all odds being marshalled by the physicians who were also prisoners to sustain themselves and help their fellow inmates. This eloquent lecture places hope squarely at the center of psychiatric education and practice.
Just as the world didn’t know what would happen next in the waning months of 1942, we don’t know what will happen as 2020 winds down and hands over this turmoil to 2021. Cringing, we may ask, “Can it get any worse?” I do my best to avoid that thought path, which can lead to apocalyptic fears. Instead, I focus on the signs pointing toward hope. Let’s begin with Anthony Fauci, who offered two reasons for hope earlier this month. He noted that there is a significant response in infection rates when communities choose to adhere to public health recommendations, indicating that we can control the pandemic through our collective action. He also noted that three vaccines are in phase three trials. It’s worth clicking on this link just to see Dr. Fauci’s smile, which reliably triggers a small relaxation response in my nervous system.
Additional reasons for optimism include a spate of recent papers demonstrating the efficacy of corticosteroids in critically ill patients with COVID-19. There is now enough evidence of utility for this readily available, inexpensive medication for it to be a first line treatment for severely ill patients. This JAMA editorial offers a nice mini-review of the literature. Even better news is that two saliva tests for SARS-CoV2 received FDA approval last month. They need to be scaled up, but eventually we could end up where Dr. Paul Sax, my favorite Infectious Disease blogger, suggested we go way back in July, with at-home rapid testing. Even without a vaccine, we could be back in the office face-to-face with our patients if everyone was doing daily home testing. Finally, the Chief of the World Health Organization expresses optimism that the pandemic will end in less than two years, which will make it shorter in duration than the 1918 influenza pandemic. He says our advanced technology will allow us to respond more quickly and effectively than a century ago.
Another reason we may progress quickly is the fact that so many of the world’s scientists are all working on the same problem at the same time. This spurs innovation. For example, a research team at UC San Diego is adapting nanosponge technology, originally developed to treat bacterial pneumonia, to protect pulmonary tissue from the coronavirus. This delightfully optimistic editorial from the Canadian Family Physician projects that, having worked collaboratively to address the pandemic, the world’s scientists will learn how to come together to address other global crises such as climate change and poverty.
In addition to scientific advances in response to the current swirl of crises, we may see changes at the individual level. This military psychologist writes about post-traumatic growth, a phenomenon seen in combat-exposed soldiers. He describes a potential for many of us to go beyond resilience to personal improvement, and says that skills to foster a positive outlook, spirituality, active coping, self-efficacy, meaning-making, and acceptance of limits and circumstances can all be taught. Psychiatrists are in a prime position to teach these skills to our patients. There is a wealth of articles about adaptation and staying positive, such as this one. Indeed, you will find many others on the CPS webpage of resources for the public.
The current state of affairs is beyond stressful. Our lives are disrupted and we feel uneasy. Yet these are the very conditions that can bring about innovations and cause transformations in individuals, communities, and societies. Who would have imagined that we would transition so quickly to telehealth? This is a change in healthcare practice that will not disappear after the pandemic ends. Who would have predicted that TaNehisi Coates’ Between the World and Me would be on the NYT Bestseller list for over 100 weeks? This reflects a society-wide interest in understanding and resolving racism that will not revert. Seven months ago, I would never have believed that some of my more reluctant patients would be doubling down on their self-care practices, but they have demonstrated to themselves that meditation, exercise, gratitude lists, or whatever works for them is actually worth the effort. They cannot unlearn these skills. We have been changed, as a society, as a profession, and as individuals.
September 30, 2020
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
I imagine that all healthcare professionals (HCPs) are experiencing a surge in stress during the COVID-19 pandemic. We all need resources to take care of ourselves so we can perform well in our care of patients. Physicians as a group are self-sacrificing, dedicated to helping others, and loathe to ask for help or show signs of weakness. Medical training amplifies all these characteristics. It is a painful irony that, at this time of surging HCP distress, the peer assistance organization to which we have turned for 34 years for confidential assessment and treatment monitoring is under serious threat. In this letter I will discuss HCP distress during the pandemic, consider how moral injury has been amplified by the pandemic, introduce the threat to CPHP as a unique cause of moral injury to Colorado physicians and physician assistants, and present potential solutions.
As early as March of this year we were seeing reports about mental health outcomes among health care workers in Wuhan. In June, the published results of a survey of HCPs in New York demonstrated that psychological symptoms were common, with 57% of respondents reporting acute stress, 48% endorsing depressive symptoms, and 33% acknowledging anxiety symptoms. Lack of control, fear of transmitting COVID-19 to family, and fear for the health of family and friends were the most upsetting stressors, each endorsed by over 70% of respondents. The survey found that, while physical exercise was the most common coping strategy (59%), the majority of participants (51%) expressed interest in one or more proposed mental health wellness activities, especially online self-guided counseling with access to an individual therapist (33%) and individual counseling (28%). Some medical centers have responded by creating innovative pandemic wellness programs for their workforce, such as this one from Rush University in Chicago. They describe Wellness Rounds, a Wellness Consult Service, onsite confidential counseling, and a crisis response algorithm.
Most reports of HCP distress highlight the difficulties of working with critically ill and dying patients who are isolated from the support of their families, the fear of becoming ill or transmitting the virus to loved ones, concerns about access to PPE, and a sense of lack of control or uncertainty. An additional concern has been moral injury, which comprises the feelings of anxiety, helplessness or outrage that occur when HCPs feel unable to surmount inequities or deficiencies in the health care system, such as when shortages of PPE or other resources force HCPs to make decisions that are contrary to their commitment to healing, and awareness of how deeply rooted structural racism has made people of color especially vulnerable to the pandemic. This pre-pandemic video from Dr. Z, who is best known for his satirical raps about health care, is a profoundly serious six-minute lesson that defines moral injury and its roots in a broken health care system. The problems discussed in the video have been amplified during the pandemic. This interview looks at the effect of “moral stress” on individual HCPs and explores lessons from the pandemic about our health care system. This APA guidance document on moral injury in the pandemic is a must-read for physicians, administrators and other leaders. It asserts that, “Moral injury is associated with strong feelings of shame and guilt and with intense self-condemnation and a shattered core sense of self.” It highlights the circumstances in the current crisis that may lead to moral injury and introduces three tiers of interventions that health care systems may implement to reduce risk for such injury.
Although the literature on moral injury is primarily focused on situations in which HCPs must make decisions about treatment that are counter to their moral commitments to providing the best possible care to patients, it is showing up in a unique way right now in Colorado health care. The Department of Regulatory Agencies (DORA), the state entity that oversees all the licensing boards including the medical board, has awarded the peer health contract to Peer Assistance Services (PAS) instead of the Colorado Physician Health Program (CPHP). For background about CPHP and the importance of a confidential peer health program for physicians, physician assistants and medical trainees, please read my summer 2019 newsletter article, “Safe Haven Is Integral to Physician Wellness.” At the time of this writing, CPHP has appealed DORA’s decision and is simultaneously encouraging a public education campaign about the vital importance of confidential treatment of physicians by other physicians in order to keep the medical workforce healthy and our patients safe.
To learn more about CPHP’s campaign, check out www.PatientSafetyColorado.com, a website that outlines key issues and calls us to action. CPS’ Executive Council voted unanimously to include CPS as a supporter of confidentiality for physician treatment. On the website you will find a copy of former State Senator Irene Aguilar’s Denver Post Guest Commentary, “Doctors in crisis deserve privacy as they seek treatment” (September 2, 2020). The website also contains examples of other letters to the editor written by physicians. CPS has submitted letters to the editor as well as a longer letter to the DORA Director who oversees the Procurement and Contracts Department, the Executive Director of DORA, Governor Polis and other leaders asserting our concerns about the change in the peer assistance contract.
If you feel moved to write a letter to the editor of The Denver Post, The Boulder Daily Camera, The Colorado Springs Gazette, or your local paper, please do so. Especially if you have experience of any kind with CPHP, whether as a client, a clinician to whom they refer their clients, or a medical director who refers employees for evaluations, consider sharing your perspective about the value to the public of allowing physicians to have confidential assessment and treatment by highly vetted physicians and other clinicians. If a 150 word letter to the editor isn’t your style, please consider a Tweet: https://twitter.com/PatientSafetyCO.
In addition to this activism, there are other ways we can work to improve the mental health of our healthcare workforce during the pandemic. This thoughtful opinion piece offers strategies for maintaining resilience and optimism during this crisis. This inspiring article proposes steps forward to humanize the health care system to address the pre-pandemic problems that lead to HCP burnout. Please also check out the last two articles in the Resources for Providers list below, one on global spikes in physician burnout during the pandemic, the other on effective wellness coaching of physicians.
As psychiatrists, we are in the best position to attend to the mental health of our health care colleagues. Whether through leadership in our institutions, through our clinical activities, or through activism, we are the definitive spokespeople for the power of prevention and treatment of emotional distress. I hope each of you will join me in standing up to advocate for what we know is right, and to identify and eradicate moral injury in all its manifestations.
Stay healthy,
Claire
Claire Zilber, MD, DFAPA
CPS President
September 16, 2020
Updates |
THANK YOU to all the CPS members (and others) who have sent in resources, written articles or reached out to us about these emails! We love hearing from you! |
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
Have you noticed the anger? I feel it rise in me when an unmasked stranger infringes on my personal space. I see it rise in others when I step off the sidewalk to avoid them, and they yell at me for being unfriendly. I see it everywhere in the news about protesters and counter-protesters, in political speeches, in accelerating statistics about child abuse and homicide. My topic this week is pandemic rage, which I believe flows from our collective reduced capacity to manage mounting stress, and which may be connected to increases in general hostility, domestic violence and gun violence.
There have been many descriptions of mounting anger during the pandemic. From a blog about “mom rage” to an international analysis of Twitter word clouds, which found that emotions have evolved from fear to anger as the pandemic has progressed, to an essay in Vice about pandemic-fueled hate that is just too fun a read to skip, we see many expressions of difficulty managing anger in the popular media. The scientific literature on pandemic rage so far includes a research report about increased stress and anger among youth since the pandemic began, and a Brazilian Journal of Psychiatry editorial that connects the anger to underlying fear. This interview of a Harvard psychologist also explores pandemic-related anger as a secondary manifestation of fear.
There is a lot to fear in a pandemic, and one fear that has been prominent among public health officials, mental health professionals, and advocates for women and children is a rise in domestic abuse and violence since the lockdowns began. This emergency medicine article, published in late April, describes increased reports of intimate partner violence from Wuhan, France, Cyprus and Singapore, and provides data about domestic violence reports and arrests in several US cities during the first month of lock-down. This news story describes a surge in domestic violence, including murders of women and children in the UK since March.
This trauma psychology commentary considers the surge in domestic violence during this pandemic within the context of other disasters, and suggests measures we should take, including increased funding to shelters and hotlines, heightened public and clinician recognition of domestic violence, and improved planning for women’s and children’s safety in future disasters. Those suggestions are elaborated further in this thoughtful paper about the role of psychiatry in addressing pandemic-related domestic violence. Here is an example of how a health system can directly educate the public about the intersection between domestic violence and COVID-19, including pragmatic steps a woman may take to ensure her and others’ safety. It includes a link to an app called MyPlan that offers safety plans for a variety of intimate partner violence situations, and provides assistance in assessing risks and locating resources.
It is impossible to talk about pandemic rage without also discussing firearms, which increase the lethality of all angry encounters including those in domestic violence. According to Guns Down, an American woman is fatally shot by a current or former intimate partner every 16 hours. This heart-wrenching report from the University of Pennsylvania notes that March 2020 was the worst month for gun violence in Philadelphia in the last five years, and describes the impact from the perspective of surgeons responding to gunshot wounds in the midst of a pandemic. This paper differentiates the gun buying surges this year in March and June from other such surges. An additional three million guns were sold from March through June compared to previous years. In 2020, the gun buying frenzy has been in response to the pandemic and the George Floyd (and related) protests; prior surges have been responses to uncertainty about changing gun policy.
Pandemic-fueled fear drove thousands of Coloradans to purchase guns. From March through June of this year, the Colorado Bureau of Investigations conducted over 188,000 background checks for firearm transfers, an increase of 71% over the same period last year. Ceasefire Colorado reports that between January 1st and July 31st, there have been 142 firearms homicides in Colorado, up 29% from the same period in 2019 (data from Gun Violence Archive). As of August 5th, three Colorado children died as a result of “an accidental shooting.” Two of these children were only three years old.
Widespread increases in anxiety, fear, grief, economic strain, disruptions to daily routines, and racial and economic inequities have frayed all our nerves. Friction at home, on the sidewalks, in stores, and at the workplace is higher. Physical distancing regulations, including reduced access to school, childcare and extended family members, leaves partners and parents little chance to deescalate and reset. Adding a firearm to this tinderbox increases the risk of tragedy.
What can psychiatrists do for the public, our patients and ourselves? We can continue to offer policy guidance to public officials to increase social support to families, fund mental health treatment, and enact gun reforms. We can repeat the suggestion by our pediatrician colleagues to end active shooter drills in schools during the pandemic so as not to further traumatize children. We can treat our patients with compassion for their anger, and remember to assess their risks for being the perpetrator or recipient of violence. We can check in about our own mental wellbeing, including our own degree of anger, frustration, and fear.
Those of you who know me may feel a bit incredulous that I’m ending this letter with a Christian stay-at-home-moms’ blog. The author tapped into my own truth when she wrote, “There’s something no one tells you about anger: It’s the juice. Anger has energy and power in it. You shouldn’t let it hijack you, yes. But properly directed, anger catalyzes change.” I choose the vicissitude of my pandemic rage: sublimation. Let’s use the energy of our anger, but not the venom, to fuel our responses now.
Stay healthy,
Claire Zilber, MD, DFAPA
CPS President
September 2, 2020
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
Two of my patients delivered babies in the last month, and my niece is due in a few weeks. All three women, two of them health care professionals, have had very different pregnancy and delivery experiences than they had anticipated when they first learned they were pregnant, pre-pandemic. Fortunately, all have remained physically and emotionally healthy, although two of the three have had to contend with more worry than usual. This is in contrast to the stories of three other Colorado women, each of whom had COVID-19 during their pregnancy or delivery. In this letter, I’ll summarize the known medical risks to women and babies posed by COVID-19, and then delve into the experience of pregnancy and the post-partum, including what we know so far about mental health outcomes during the pandemic.
We know that pregnancy causes changes in a woman’s immune system to reduce the likelihood of her body rejecting the fetus. This immunosuppression may increase a woman’s susceptibility to the novel coronavirus. Data from the CDC released in late June suggest that pregnant women may be more susceptible to COVID-19, and that Black and Hispanic women are disproportionately affected. Among 91,412 women of reproductive age with coronavirus infections in the first five months of 2020, the 8207 who were pregnant were 50% more likely to end up in intensive care units (ICUs) than their nonpregnant peers. Pregnant women were also 70% more likely to need ventilators, although they were no more likely to die. However, a much smaller study from Sweden cited in this article found that women with COVID-19 were nearly six times as likely to be admitted to an ICU than their nonpregnant, COVID-19-infected peers. The latter article elaborates on several possible mechanisms through which pregnant women are more susceptible to the effects of the virus.
So far, there are reassuring reports about fetal health despite the mother’s COVID-19 infection. Most babies are born uninfected and without evidence of placental infection, although there have been reports of both of those occurrences. However, because the pandemic is relatively new, we have limited data about the consequences of first trimester exposure.
Because of concern about exposing pregnant women to health care settings during the pandemic, they may have fewer in-person prenatal visits. One of my patients who had second trimester spotting struggled with the decision about whether to go in to the clinic to be checked, or stay home to protect herself and her baby from coronavirus. Reassuringly, this Mass General study found no meaningful association between the number of obstetrical visits and novel coronavirus infection.
We know that attentive prenatal care improves outcomes for women and their infants, and is one of many healthcare disparities for women from minority populations. This news story and interview discusses the pandemic’s effects on Black mothers, including their experiences of implicit bias in healthcare settings.
The pandemic has drastically changed the delivery experience as well. As outlined in this article, hospitals vary in their labor and delivery (L&D) policies depending on the status of the pandemic in their community and other factors. If a laboring woman tests positive or has symptoms suggestive of COVID, she may be allowed only one companion. Women who are not infected may be allowed more companions, but everyone must remain masked the entire time. The Colorado Department of Public Health and the Environment (CDPHE) released helpful guidance for L&D practices and breastfeeding. Earlier in the pandemic, the American Academy of Pediatrics (AAP) advised separation of potentially infected mothers from their newborns. In late July, AAP changed their recommendations to reflect recognition of the importance of breastfeeding and bonding, and the additional knowledge gained over time about the relative safety of newborns even when their mothers have COVID-19.
This article proposes areas for future research, and emphasizes the need for “mega-studies” to gather meaningful data about true incidence of maternal coronavirus infection, mother-to-child transmission, breastfeeding recommendations, long-term effects on fetal and child development, and long-term health service delivery changes. One way to gather large cohorts is through international registries, and there is now an International Registry of Coronavirus Exposure in Pregnancy.
From a medical standpoint, we now know that pregnant women are at greater risk from the coronavirus, but that their newborns are relatively safe. From a mental health perspective, the experience of pregnancy during the pandemic is complex and the issues are not yet well defined. A Canadian study found doubled rates of depression and anxiety in pregnant women in April 2020. Here is a link to the abstract, from which you may download a PDF of the entire study. Alternatively, you may prefer the news story associated with the study, which summarizes the results and suggests that social distancing may be the cause of this phenomenon, although I would add that heightened anxieties about health and the delivery could also play a role.
Becoming a new mother during a pandemic also entails disappointing changes from one’s expectations of this usually joyous time of life. This article dubs this phenomenon “social pressure shift” and offers an empathetic view of how a mother’s experience may differ from her expectations, from not having a regular baby shower, to not having parents from out of town present for the delivery, to steeply curtailed social visits after the birth. Furthermore, lactation consultants, essential resources for new moms or mothers of babies with problems latching on, are no longer as accessible. This article makes connections between the support of a lactation consultant, successful breastfeeding, infant health, and post-partum depression. I would add that frustration or failure in breastfeeding may also impact mother-infant bonding, with potential long-lasting relational impacts.
Increased stress and decreased social support may explain the rise in observed post-partum depression and anxiety since the pandemic began. Although there is no firm data yet, this news story quotes an external relations officer for a maternal mental health clinic in New York who says call volume has increased three-fold. This article by a researcher offers a sneak peek at results from a global survey of pregnant women in the pandemic. In the survey, over 70% of women reported clinically significant depression or anxiety, and over 40% screened positive for post-traumatic stress disorder (PTSD).
Psychiatrists know that maternal mental health has profound implications for child development and the mental health of subsequent generations. It is imperative that we meet maternal mental health needs during this pandemic. This article offers pragmatic suggestions for obstetricians and mental health providers, including ensuring that our patients are not being excessively strict in their physical distancing precautions to the point of isolating at home, and being proactive in our surveillance for and treatment of antenatal and postpartum psychiatric disorders. We may also guide our pregnant patients toward new resources, such as this site designed to help women identify doulas, lactation consultants and other supports in their area.
In conclusion, we are still learning about the medical and mental health implications of the COVID pandemic, but what we know so far suggests that obstetricians, pediatricians and psychiatrists must team up to bolster the safety and wellbeing of pregnant women, new mothers, and babies. We need more research, but we must not wait for the research to take action now. I am meeting more often with my pregnant and post-partum patients, emphasizing self-care and social support, helping them manage excessive anxiety, and judiciously adjusting medication when needed.
This is both a challenging and gratifying time to be a psychiatrist. Keep up your own well-being so you remain available for our important work.
My sincere gratitude goes to Kartiki Churi, MD, for assistance gathering resources for this letter.
Stay healthy,
Claire Zilber, MD, DFAPA
CPS President
August 19, 2020
Updates |
CPS -REGISTER for PsychSummit: Psychiatry in an Evolving World - THIS SUNDAY, August 23rd from 4:30pm – 7:15pm (MST) 2.25 AMA PRA Category 1 Credits - APA Members: $20; Residents and Med Students: Free thanks to APA, Inc - Psychiatrists from across the country will come together for a three-session event on “Psychiatry in 2020”. We will begin with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will address the biggest events of 2020 head on with a live panel conversation tackling the challenges of COVID-19 and structural racism. |
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
The Pandemic Time Warp
Claire Zilber, MD, DFAPA
CPS President
“That really drives you insane,
Let’s do the Time Warp again.”
(The Time Warp, from Rocky Horror Picture Show)
During the first weeks of the novel coronavirus pandemic, every day seemed interminable. What I had accomplished in the morning, by evening felt like it had occurred days ago. A whole week seemed grindingly long, and the weekends fleetingly short. More accustomed now to the flow of the days and weeks, there remains a distortion about the duration of our altered lifestyle. Working from home, avoiding the gym, going grocery shopping once every two weeks, and drastically curtailing my social life seems to have been the norm almost forever, yet it’s only been five months. What’s going on?
A disconnect between objective time, measured by clocks and calendars, and subjective time, measured by our internal perceptions, has been amplified by the pandemic. Changed routines and uncertainty about the future contribute to our distorted experience of the passage of time. This article describes this phenomenon in more detail (note - the author uses the f-word once) and suggests some common-sense ways to help combat the distortion: set up a regular schedule (social rhythm therapy), change the focus of your thoughts when you find yourself ruminating (cognitive therapy), and introduce some fun (behavior therapy).
In addition to the loss of normal time flow benchmarks, the trauma of the pandemic further contributes to distorted perception of time. This article describes the psychological literature on time perception and trauma. Essentially, trauma interrupts the normal flow of time, forcing us to be hyper-focused on the present moment. “Interrupting the flow of time creates perceptual distortions such as feeling like time has stopped or that everything is in slow motion, experiencing a sense of timelessness, confusing the order of time and days, and perceiving a foreshortened future.” The authors propose specific areas of research related to the effects of distorted time perceptions in the pandemic.
Pre-pandemic research about passage of time judgements has demonstrated that positive affect and high arousal are associated with time passing more quickly than normal, whereas negative affect and low arousal are associated with time passing more slowly than normal. “Time flies when you’re having fun” is subjectively true. A British study of time perception before and after lockdown found that more than eighty percent of participants experienced changes in how quickly they perceived time passing during lockdown compared to pre-lockdown. Subjects who were older or less satisfied with their current levels of social interaction were more likely to experience slower passage of time over the course of a day or week. Higher stress and a lower task load were also associated with slower passage of time over the course of a day. The paper includes an excellent review of the psychology of time experience. If you don’t want to read the whole paper, here is its press release, which succinctly summarizes the findings.
We need additional research about the pandemic time warp. Simon Grondin, a professor of psychology at Université Laval in Québec City, and author of The Perception of Time, is conducting a study of how physical distancing may distort time perception. If you are interested in participating in the study, follow the link within this announcement.
What we know so far from psychological research is that disruption of routines, uncertainty about the future, trauma, stress, task load, age, and perhaps physical distancing all contribute to our pandemic time warp experiences. Although less scientific, this article introduces an important additional perspective to the discussion about our collective experience of distorted time during the pandemic. Optimistically, I propose that this and other lighthearted ways of viewing the pandemic will reduce stress, ease trauma, increase a feeling of social affiliation, and thereby restore more accurate perception of the passage of time.
August 5, 2020
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HHS - COVID-19 Public Health Emergency Extended - Declaration of Public Health Emergency for COVID-19 was extended for an additional 90 days. This renewal keeps important regulatory changes and waivers relevant to psychiatrists in effect for 90 more days (7-23-20) |
CPS - REGISTER for PsychSummit: Psychiatry in an Evolving World - August 23rd from 4:30pm – 7:15pm (MST) The APA has designated this live activity for a maximum of 2.25 AMA PRA Category 1 Credits (TM) - APA Members: $20; Residents and Med Students: Free thanks to APA Inc - Psychiatrists from across the country will come together for a three-session event on “Psychiatry in 2020”. We will begin with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will address the biggest events of 2020 head on with a live panel conversation tackling the challenges of COVID-19 and structural racism. |
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
Dear Colleagues,
So many opinions, so few data points. The news is full of conflicting recommendations from the Administration, health care organizations, teachers, parents and pundits. In this letter you will find scientific data about SARS-CoV-2 transmission in pediatric populations, as well as clarification of the position statements of various healthcare organizations. This may assist you in conversations with your patients or their parents to help them determine the most appropriate solution as they consider their options.
One concern about allowing children back to school is that they will bring the virus home to more vulnerable members of the household. As explored in this Kaiser Family Foundation report, 6% of US seniors live in homes with school-aged children. Initial data from China and this more recent report from Switzerland suggest that most children have mild or asymptomatic illness, and that transmission within family clusters is much more likely to be from adult to child than the other way around. In only 8% of households did children develop symptoms before others in the home. That reassuring news is offset by a Korean study that suggests that older children (ages 10-19) may spread the virus to household members more readily than adults do. They followed nearly 60,000 contacts of 5700 COVID-19 index patients for roughly 10 days. Their findings included that 12% of household contacts were infected, versus 2% of non-household contacts. When the index patient was aged 10–19 years, 19% of household contacts were infected. In contrast, when the index patient was aged 30–49, 12% of household members were infected, and when the index patient was aged 0–9 years, just 5% of household contacts were infected. The authors acknowledge that they "could not determine direction of transmission."
A second concern is that a small number of children who are infected with the virus develop an inflammatory multisystem syndrome with presentations ranging from fever and inflammation to myocardial injury, shock, and development of coronary artery aneurysms. Of course, no parent wants to risk such a serious outcome for their child, but we must remember that this is an exceedingly rare occurrence. This JAMA editorial, Should Coronavirus Disease 2019–Associated Inflammatory Syndromes in Children Affect Social Reintegration?, argues that we should not allow fear of a condition that may affect hundreds be a basis for restricting millions of children from school. This public health approach is rational but may be difficult to apply when dealing with parents’ emotional, protective instincts.
More convincing may be data about the pandemic effects on kids’ social and emotional health. This report from China, Behavioral and Emotional Disorders in Children During the COVID-19 Pandemic, describes a preliminary study of children’s responses during the lockdown phase of the pandemic response. They found high rates of clinginess, fear of infection, inattention, irritability, sleep disorders, nightmares and other symptoms indicative of stress. As psychiatrists, we are already aware of the importance of daily routines, social bonds with classmates, and mentorship from teachers and coaches. These experiences, all provided by school, help children develop self-regulation and self-esteem. We know that when these processes are interrupted by abuse, neglect or serious medical illness, the child’s developmental trajectory is thrown off course. What we don’t know is what happens when an entire population of children experience massive stressful disruption all at the same time. From this perspective, a return to school feels like it could be protective, but that is conjecture, not data.
Another argument for returning to school is concern about the impact of remote learning on academic “health,” especially for students with home environments that aren’t able to provide access to technology or to the calm and structure that promotes learning. This NYT article describes several studies of academic progress during springtime lockdowns that showed loss of academic skills, particularly among students from less privileged zip codes. Can our society afford to allow disparities in education to get larger than they already are, especially now that we are more acutely aware of the history and consequences of these disparities?
The question about whether and under what conditions schools should reopen has become a political hot button recently as the White House and the CDC have publicly disagreed, as seen for example in this CNN report. The CDC, whose mission is to prevent the spread of disease, takes the position that remote learning is safest, but they also offer pages of guidance to parents, teachers and school administrators about how to be safer while in school.
In contrast, The American Academy of Pediatrics (AAP) has recommended that schools reopen in August so that students can be “physically present in school” as much as possible. AAP’s recommendation to reopen schools is based on concern that continuing remote learning is likely to result in severe learning loss, an increase in mental health symptoms, an increase in both physical and sexual child abuse, an increase in adolescent substance use, and an increase in suicide. AAP reports that they have already seen some of these outcomes in children and adolescents between March and May 2020 when school was remote.
This interview with Dr. Sean O’Leary, a pediatrician at CU Anschutz, a father of two teens, a survivor of COVID-19, and one of the authors of the AAP position statement, illuminates the balance pediatricians are trying to strike between emerging knowledge about the impact of distance learning and the risk of COVID-19 transmission by children.
As a result of this recommendation by the AAP, Denver Public Schools was considering reopening in August, with precautions. However, after meeting with health officials from Denver Health, they announced that they will delay in-person learning. The first day of school will be August 24, but it will be in a remote learning format. They will consider a gradual return to in-person learning starting September 8.
The APA and AACAP (American Academy of Child and Adolescent Psychiatry) issued a joint statement supporting the reopening of schools if possible, and highlighting the importance of social interactions for healthy development, the need for adaptive techniques for some students to learn remotely, and the role of mental wellbeing for students, teachers and parents.
The two largest organizations representing teachers, the American Federation of Teachers (AFT is the teachers’ union) and the Association of American Educators (AAE is non-union), have websites rich with COVID-19 related resources. The AFT website includes a plan for reopening schools. The AAE website has an interesting report on results of their springtime teacher survey about COVID-19. One striking finding is that 84% of responding teachers agreed with school closure.
Teachers do more than educate. One of their roles is to monitor the health of children in the classroom, including for signs of child abuse and neglect. Ordinarily, 20% of abuse and neglect reports come from teachers. This paper highlights concerns about increased child abuse and neglect during the pandemic, combined with less reporting of such abuse because children are not in school.
Schools do more than educate. They provide a safe space, a daily meal (sometimes two, if breakfast is provided), opportunities to form friendships with peers, interaction with caring adults, and access to school nurses and mental health counselors. This thoughtful interview with psychologist Elena Hontoria Tuerk about supporting children’s development during the pandemic addresses many of these important functions of schools, as well as the importance to parents of having a break from their children.
One group of students about which I am especially concerned are LGBTQ youth. Many of these kids aren’t safe coming out to their parents and they rely on peers for crucial support. These children are at higher risk than others for physical abuse, homelessness and suicide. What will they do without the community support and counseling found at school?
There are so many other special populations of students. Children with asthma, cancer, cardiac defects, cystic fibrosis or other chronic medical conditions that place them at higher risk need education, too, but the health risks for them to return to the classroom are higher. As we saw this spring, parents who are trying to work from home and simultaneously teach their children are inordinately stressed. What do these parents do if they are required to return to the workplace? Children with special developmental needs may be in an even more precarious position without the structure, specialized instruction and support of school.
There are no simple answers. Alex de Tocqueville wrote, “The public will believe a simple lie rather than a complex truth.” It is facile to make sweeping statements that “all schools should reopen,” or “all children should return to the physical classroom.” Each child exists within a unique family, which lives in its unique community, which has its unique experience with the pandemic. When and how to return to the classroom ought to be an individualized decision based on each child’s needs. Unfortunately, insufficient resources may force school districts into a one-size-fits-all strategy. Psychiatrists cannot singlehandedly resolve the policy differences of the various entities involved in this debate. What we can do is help our patients find the best solutions for themselves, guiding them towards rational rather than emotional decision-making.
Stay healthy,
Claire Zilber, MD, DFAPA
CPS President
July 22, 2020
Updates |
Notice - There will not be a CPS COVID-19 Resource Email sent next Wednesday, July 29th. You can expect an email in your inbox again on Wednesday, August 5th. |
CPS - REGISTER for PsychSummit: Psychiatry in an Evolving World - August 23rd from 4:30pm – 7:15pm (MST) - Psychiatrists from across the country will come together for a three-session event on psychiatry in 2020. We will begin with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools like digital tracking for medication adherence. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will address the biggest events of 2020 head on with a live panel conversation tackling the challenges of COVID-19 and structural racism. |
CO Mask Mandate - Executive Order D 2020 138 is a mandatory statewide mask order that went into effect at midnight on July 16, 2020, and will be in effect for 30 days. It may be extended. Also see CPR - Colorado Mask Order: When Do I Need To Wear A Face Covering? (And More Mask Questions Answered) and CDPHE - Questions & answers about the mask order. |
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
To see past resource lists for psychiatrist and messages from CPS Presidents, visit https://www.coloradopsychiatric.org/COVID19
To explore the COVID-19 Resource Page for the Public, visit https://www.coloradopsychiatric.org/coronavirus
Do you have a question, helpful resource, or tip for your colleagues? Email [email protected].
CPS has received resources from members concerning racism and the pandemic as well as more general resources on racism and psychiatry so we have decided to dedicate this edition of the CPS COVID-19 Resource Email to the topic. The first section contains resources and articles on the intersection between COVID-19 and historically marginalized communities. The second section focuses on resources for psychiatrists to help us better serve patients with skill and sensitivity, as well as resources for psychiatrists from historically marginalized communities.
PsychSummit: Psychiatry in an Evolving World - registration opening soon Psychiatrists from across the country begin the three-session event with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools like digital tracking for medication adherence. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will cover COVID-19 and structural racism. |
July 15, 2020
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For the most complete and up-to-date race and ethnicity data on COVID-19 in the United States, see The COVID Racial Data Tracker - a collaboration between the COVID Tracking Project and the Boston University Center for Antiracist Research. Also see NYT - The Fullest Look Yet at the Racial Inequity of Coronavirus - New data — made available after The New York Times sued the federal government — shows the extent of racial disparities: The contraction rate is almost three times as high for Black Americans as white Americans and more than three times higher among Latinos than whites. |
CDC webpage on COVID-19 in Racial and Ethnic Minority Groups - contains data, recommendations on what healthcare systems and healthcare providers can do and discussion of factors that explain why racial and ethnic minority groups are at increased risk during COVID-19 (6-25-20) |
JAMA - Taking a Closer Look at COVID-19, Healthcare Inequities and Racism (transcript article and 31 minute video) (6-29-20) |
NIH - Director Francis Collins, MD, PhD, discusses the heartbreaking disproportionate impact of COVID-19 on Black and Hispanic communities and the importance of building stronger relationships with minority communities to build trust as COVID-19 vaccine development progresses (see article not 2 minute video) (6-23-20). Also see STAT - COVID-19 Vaccine Research Must Involve Black and Latinx Participants. Here are 4 Ways to Make That Happen (6-26-20) |
Virtual Forum: Healthcare Disparities through the Lens of Diversity During the COVID-19 Pandemic (slidedeck (download) and 2 hour 17 minute video) - AACAP hosted this virtual forum on June 13 highlighting mental health, COVID, and other healthcare disparities related to race and ethnicity among children and adolescents of color. |
New York Times - The Challenges of the Pandemic for Queer Youth - Issues include limited access to community support and counseling and, in some cases, quarantining with unsupportive family members (6-29-20) |
PsychNews - Hispanic Community and COVID-19: Addressing Health Inequalities Can No Longer Be Delayed (6-23-20). Also see NYT - Many Latinos Couldn’t Stay Home. Now Virus Cases Are Soaring in the Community (6-26-20) |
AMA - Widening Social and Health Inequalities During the COVID-19 Pandemic (6-10-20) |
JAMA - Strategies for Digital Care of Vulnerable Patients in a COVID-19 World—Keeping in Touch - Without action to address the digital divide, existing health and healthcare disparities will be exacerbated for the nation’s most vulnerable individuals and communities. Article explores these potential dangers and offers strategies to mitigate them (6-12-20) |
KFF - Chart of the Week: The Disproportionate Impact of COVID-19 on Black and Hispanic Medicare Recipients (6-26-20) |
Hopkins Bloomberg Public Health Magazine - Racism and COVID-19 - In this Q&A, Lisa Cooper, a practicing physician and epidemiologist, discusses racism’s role in COVID-19 cases in African American communities and solutions for the inequities. |
AMA Ethics - Ethics Talk: Antiracism, Health Equity, and a Post-COVID Future (22 minute podcast) - AMA Ethics Journal editor in chief, Dr Audiey Kao, talks with Dr Ibram Kendi, founding director of the Antiracist Research and Policy Center and a professor of history and international relations at American University, about the impact of racist policies on historically discriminated-against groups and what it means to be an antiracist (06-20). Kendi uses the metaphor of cancer and its treatment to discuss racism and anti-racism. He also addresses the importance of antiracism among healthcare providers in order to appropriately address health disparities. Of special interest is a section towards the end (approx. minutes 17-19) about the difference between truth and lies, and why it’s so difficult to communicate complicated truths to people who prefer simple one-liner answers. |
JAMA - COVID-19 Pandemic, Unemployment, and Civil Unrest: Underlying Deep Racial and Socioeconomic Divides (6-12-20) |
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Selected APA Resources:
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American Association For Community Psychiatry - The Leadership Role of Community Psychiatry in Combating Structural Racism (1 hour video) (6-3-20). Many excellent speakers, including a presentation by Dr. Shim on structural racism (starting around minute 6). Also see her article in Stat - Structural racism is why I’m leaving organized psychiatry - a piece by Ruth S. Shim on why she has made the difficult decision to end her membership with organized psychiatry, specifically the American Psychiatric Association (7-1-20) |
Taking Back Our Voices — #HumanityIsOurLane by psychiatry resident Chase T.M. Anderson, M.D. (6-30-20) - Also see Race and Medicine on NEJM.org - a new page presents a selection of articles on race and medicine, with implications for improving patient care, professional training, research, and public health. |
Treating Mental Health in the Black Community (1.5 hour video) - Learn how you can better serve Black clients (6-9-20) |
Kevin MD - A physician awakens to racism in America (6-15-20) |
MD Edge/Clinical Psychiatry News - Examining bias (6-18-20), includes link to Harvard researcher designed Implicit Association Test. |
75 Things White People Can Do for Racial Justice (the list now includes 97 things!) |
On Being with Krista Tippett - ‘Notice the Rage; Notice the Silence’ (51 minute podcast) - The best laws and diversity training have not gotten us anywhere near where we want to go. Therapist and trauma specialist Resmaa Menakem is working with old wisdom and very new science about our bodies and nervous systems, and all we condense into the word “race” (6-4-20). Visit https://www.educationforracialequity.com/resmaa for details on a two session online event on July 25th and August 1 - Reclaiming our Birthright: An Embodied Gathering for Black Men held by Resmaa Menakem and Dr. Kenneth Hardy as well as other events. Also see https://www.resmaa.com/. |
Focus - Trauma-Informed Care and Cultural Humility in the Mental Health Care of People From Minoritized Communities (download - open with PDF reader) Dr. Ranjbar is a panelist at the upcoming CPS PsychSummit event! |
Focus - Diversity and Inclusion in Psychiatry: The Pursuit of Health Equity (download - open with PDF reader) (6-24-20) |
Focus - Affirmative Care Across Cultures: Broadening Application (download - open with PDF reader) - recommendations for affirmative care in practice with African-American, Asian, Indigenous, and Latinx individuals, as well as those living in rural communities.) |
MD Edge/Clinical Psychiatry News - How can we better engage black men as patients? (6-24-20) |
MD Edge/Clinical Psychiatry News - Management of race in psychotherapy and supervision (6-22-20) Dr. Isom is a panelist at the upcoming CPS PsychSummit event! |
HHS - National CLAS Standards - The National Culturally and Linguistically Appropriate Services Standards are a set of 15 action steps intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. If the website is not loading, click here. Also see HHS - Improving Cultural Competency for Behavioral Health Professionals (Free Online Training - This program is accredited for 4 – 5.5 contact hours for psychiatrists) |
Dismantle Collective - White Allyship 101 (list of articles and books). Also see Power Shift Collective - Checklist for White Allies |
Psychology Today - Uncovering the Trauma of Racism - includes new tools for clinicians and examples of race-related traumas that may meet DSM-5 criteria for PTSD. |
MD Edge - The fallout from George Floyd's death: Physicians, how are you? How are your patients? A conversation on race for psychiatrists (45 minute podcast) - Lorenzo Norris, MD, welcomes fourth-year psychiatry resident Brandon C. Newsome, MD, for a discussion on race relations as a physician in the wake of the death of George Floyd. The pair discuss what their patients are experiencing and what they're experiencing as black physicians (6-5-20). Transcript available at George Floyd, race, and psychiatry: How to talk to patients (6-24-20) |
NPR - 'Bear Our Pain': The Plea For More Black Mental Health Workers (article and 4 minute audio) (6-25-20, aired 6-6-20) |
HuffPost - This Is What Racial Trauma Does To The Body And Brain Racism, injustice and brutality — experienced directly and indirectly — can have a lasting effect on a person's mental health (7-1-20) |
MBK Alliance Town Hall Series: Mental Health and Wellness in a Racism Pandemic (1 hour video) - President Obama joined Congressman John Lewis, founder and executive director of the Equal Justice Initiative Bryan Stevenson, writer and survivor of police brutality Leon Ford, Jr., and youth leader LeQuan Muhammad, in a conversation moderated by activist and author Darnell Moore, to discuss the mental toll racism takes on people of color. |
HuffPost - One Way To Be An Ally Right Now? Support Black Mental Health (updated 6-18-20) |
HuffPost - Racism Is A Mental Health Crisis. Here's How To Fight It. - “Being a Black person is often described as being in “fight or flight” mode, and honestly, that is the best way to explain it.” (6-11-20) |
HuffPost - What Not To Say To Someone Who Has Experienced Racial Trauma (article and 5 minute video) - What white people and other allies do in conversations about the mental health effects of racism matters (7-3-20) |
YoungMinds - How racism impacts my mental health - Sian, 19, shares how racism affects her mental health, and what helps her cope - watch movies with more Black people, or follow Black YouTubers or influencers. This will just make you feel more comfortable with seeing Black people and, eventually and maybe subconsciously, you will learn to love yourself and what you are.(6-23-20) Also explore the Good Black News website. |
Psychology Today - Is Your Therapist Qualified to Treat People of Color? Ten questions that all culturally-informed therapists should be able to answer (5-31-19) |
Ourselves Black - Racial Inequality, Police Brutality & Black Mental Health (56 minute video) - presentations by two young black male psychiatrists - Dr. Christopher Hoffman and Dr. Walter E. Wilson, Jr. |
Kevin MD - How racial issues affect both doctors and patients (11 minute podcast) (6-25-20) |
KFF - Officials Seek To Shift Resources Away From Policing To Address Black ‘Public Health Crisis’ - on declaring racism a public health crisis (6-25-20) |
The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
PsychSummit: COVID-19 includes an interview with APA President Bruce J. Schwartz, MD, on his experience on the ground in the epicenter and takeaways for psychiatrists in other states and see glimpses into the lives of NYC New York psychiatrists during COVID-19. PsychSummit is a partnership between the Colorado Psychiatric Society and the New York County Psychiatric Society. From the beginning it has been a VIRTUAL INTERACTIVE conference designed to bring together psychiatrists from across the country (and beyond) to discuss some of the most pressing issues the profession faces. www.PsychSummit.org
Dear Colleagues,
The planet is eight months into the pandemic, and although it’s been only four months in Colorado, the only other four months that felt this long to me were those in the second half of my pregnancy. It is not news to any of us that there are psychiatric sequelae of living in a pandemic. We are all aware of surges in depression, anxiety, trauma-related symptoms and substance use. What is less clear are the neuropsychiatric sequelae of COVID-19. Information emerging from Wuhan and other early centers of the pandemic, as well as research on prior coronavirus pandemics, begins to suggest a picture of both direct, virally-mediated neuropsychiatric illness, and illness mediated by immunological or other host responses to infection. Although we are at the stage where there are more questions than answers, this letter will provide a summary of the current state of knowledge.
There are several case series of patients with COVID-19 that describe neurological symptoms. This series of 214 patients in Wuhan, China, describes cerebrovascular events and impaired consciousness in 45.5% of patients with severe infection. A review of 27 autopsies of patients who died from COVID-19 in Germany describes detecting the virus in multiple organs, including the brain. This brief report details neurologic findings in a case series of four pediatric cases with multi-system inflammatory syndrome from COVID-19. The most common neurologic complaints in COVID-19 are anosmia, ageusia, and headache, but stroke, impairment of consciousness, seizure, and encephalopathy have also been reported. It may be that the encephalopathy results from toxic-metabolic factors (cytokine storm, inflammation, renal dysfunction, etc.) rather than directly from the virus. This review article on neuropathogenesis and neurologic manifestations of COVID-19 goes into more depth.
While many have reported that COVID-19 patients have experienced vascular and neurological problems, a recent study of 153 patients in Lancet Psychiatry reports that patients are also showing symptoms of psychiatric disorders, including psychosis and depression. The British researchers found that 77 patients experienced a cerebrovascular event (primarily stroke), 39 experienced altered mental status, six experienced peripheral nervous system problems, and three experienced other nervous system–related complications. Among the 39 patients with altered mental status, 16 were diagnosed with encephalopathy, and 23 were diagnosed with a psychiatric disorder. Ten of these 23 patients developed psychosis, six developed cognitive problems, and seven developed mood problems including depression and mania. One striking finding is that the neuropsychiatric manifestation may differ according to the patient’s age. Specifically, 49% of the patients who experienced altered mental status were under age 60, whereas 82% of patients who experienced a cerebrovascular event were over age 60.
Past coronavirus epidemics, including SARS (2002) and MERS (2012), may shed light on the current pandemic. Based on their review of the literature on psychiatric and neuropsychiatric presentations during prior coronavirus outbreaks, these authors opine that SARS-CoV-2 may cause delirium in a significant proportion of acutely ill patients. They also warn about the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the longer term.
This excellent review discusses the psychological, neurological, and neuropsychiatric manifestations that COVID-19 may take, as well as addressing some of the potential immunologic mechanisms for the symptoms. Importantly, the authors remind us of the association between maternal influenza and subsequent development of schizophrenia in offspring. They warn us that we may see a late wave of neurological (eg: Parkinson’s disease) or psychotic illness decades after the pandemic.
Most of the neuropsychiatric illness seen in patients with COVID-19 is probably due to delirium or other encephalopathic states caused by the inflammatory response, metabolic toxicities or hypoxia. However, it is possible that some neuropsychiatric manifestations could be caused directly by the virus. SARS-CoV-2 uses spike proteins on the viral surface to bind to angiotensin converting enzyme 2 (ACE2) receptors on host cells. Humans have ACE2 receptors on airway epithelia, kidney cells, small intestine, lung parenchyma, and vascular endothelia throughout the body. ACE2 receptors are also found on neurons, astrocytes, and oligodendrocytes, and are highly concentrated in the substantia nigra, ventricles, middle temporal gyrus, posterior cingulate cortex, and olfactory bulb. As detailed in this article, it remains unclear whether the virus directly attacks neural tissues; although isolated case reports suggest it may, others suggest the neurologic effects are a result of cytokines (headaches), hypercoagulability (strokes) or other secondary factors.
If you only have time to click on one link in this letter, choose this outstanding and comprehensive article, which includes helpful, colorful diagrams explaining possible mechanisms of pathogenesis. You may feel like you’re back in medical school. Helpfully, toward the end of the article the author describes the roles psychiatrists may play in the pandemic, and suggests pragmatic treatment considerations such as drug-drug interactions between psychotropic medications and antivirals.
We have learned a lot, but there is so much more to learn. This brief report calls for long term study of the neuropsychiatric outcomes of the pandemic. Ultimately, we need prospective studies of neuropsychiatric illness in COVID-19, including long-term outcomes, to fully understand the nature of this beast.
Stay healthy,
Claire Zilber, MD, DFAPA
CPS President
July 8, 2020
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APA Survey to inform the work of the new Presidential Task Force to Address Structural Racism Throughout Psychiatry. Please complete the short survey by Friday, July 10th. Please note that the survey is a Google Form, so if individuals cannot access it through their institution’s servers, it can be completed at home. Answers will be anonymous and not shared on this platform. |
Partnership COVID-19 Document (download) - CPS is a founding member of the Behavioral Health Partnership, a long-standing group of stakeholders made up of consumer and provider organizations in Colorado. The group has created a COVID-19 document for the public on steps we can all take to ensure we are caring for our mental wellbeing. Please share with patients, family, friends and anyone else who may find it helpful. |
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JAMA - Attitudes and Psychological Factors Associated With News Monitoring, Social Distancing, Disinfecting, and Hoarding Behaviors Among US Adolescents During the Coronavirus Disease 2019 Pandemic (6-29-20) |
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Key Resources |
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The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.
Dear Colleagues,
We would be having a very different pandemic experience if not for videoconference technology. Three hundred million people attended meetings through Zoom in April of this year, compared with ten million people at the end of 2019. Psychiatrists have adopted telepsychiatry en masse as a result of the pandemic, and we have enjoyed the smallest reduction in visits of all ambulatory medical practices. We also may reap some benefits from doing telehealth from home: more time with family members and pets, less time in traffic, healthier lunches, and the ability to start a load of laundry between appointments. Despite these and other efficiencies, many of us feel more drained at the end of the day. In this letter I explore the reasons for “Zoom fatigue” and share some potential strategies to help manage it.
Social science research informs us that interactions by videocall are not the same as those in person. Our brains evolved to see the entire human form in three-dimensional space, not a two-dimensional disembodied head and shoulders. Research shows that video calls disrupt the pattern of communication we have developed over millennia for our survival. Normal human communication requires a complex synchrony between each person’s spoken words, gestures, and body movements. Synchrony may be somewhat achievable over video, but the lag in transmission between visual and audio, as well as reduced nonverbal cues make it more difficult. We are left over-focusing on words, which can be especially exhausting if the audio connection is fuzzy. Multi-person video meetings magnify this phenomenon, challenging the brain’s central vision by trying to focus on a gallery of participants. It’s a new kind of multitasking for which our brains are not designed. In addition, the constant eye contact invited by a video call requires extra energy and can feel unnerving. I have had at least one patient exclaim, “Stop staring at me!”
In addition to neurologically derived difficulties with video calls there are psychological and social reasons that we may feel exhausted after a day of interacting this way. As we try to look into our patient’s eyes, we know we are not actually looking in their eyes. We are looking at an image of their face on the screen or looking at the camera. This sets up a kind of cognitive dissonance: I’m connecting yet not really connected. Interacting only on a screen means we lose the energy boost that we might ordinarily get when we break up the day by meeting someone for coffee or greeting a colleague in the hallway. Also, it’s not normal behavior to smile all the time, but in a video meeting, especially with the thumbnail image of ourselves in the upper right corner, we may feel self-conscious about needing to smile.
Psychiatrists are fortunate that we can rely on video calls for much of our work; however, telehealth may exacerbate problems inherent to the practice of psychiatry. Ours is largely a solitary profession. Whether employed by an academic medical center, a community mental health clinic or in private practice, we spend much of our time seeing patients alone in our offices. Telehealth may further isolate us from our colleagues. We may have difficulty creating reasonable separation between work and home tasks if we are working from our dining room or home office. This article was written before the pandemic, yet it speaks in relevant ways to both the potential benefits and pitfalls of telehealth for psychiatrists.
How might we modify our telehealth protocols to mitigate the exhaustion? This PsychNews article has seven simple and pragmatic suggestions for our professional videocalls. We might also try to differentiate professional videocalls from personal ones. For example, I use DoxyMe only for my clinical work, and rely on Zoom or FaceTime for personal events. I hold my professional calls in the same two locations (depending on whether I need to be plugged in to ethernet or if wifi is good enough). I avoid these two settings for personal calls. I dress up in work attire for my professional work day, just as if I were going into my office. To give myself a break, I decline some requests for social Zoom events, which is tricky to do without hurting feelings; this article offers some tips. Read the section toward the end of this article on “how to dial it back” for some creative ways to rest our brains from excessive screen time.
This, too, shall pass. One day, we will all be back in our offices or clinics or ERs or wherever we work, seeing patients face to face, touching their arms as we examine for dystonia, passing a box of tissues with which to wipe their tears. Some of us may choose to continue to use telehealth some or all of the time, but it will be a choice, not a requirement. In his 1996 novel, Infinite Jest, David Foster Wallace imagines a future in which videophones are invented. Initially met with enthusiasm, then adapting with slightly improved resin masks of their own faces so they can look better during calls (there’s a setting for that in Zoom, by the way), then fatigue, the trend collapses after a year, and everyone goes back to audio-only calls. For now, I choose to adapt with humor:
Stay healthy,
Claire Zilber, MD, DFAPA
CPS President
July 1, 2020
Updates |
NEW Section on CPS website - CPS has added a new section on Racial and Ethnic Minority Community Issues to our COVID-19 Resource documents - see below or visit Resources for the Public. We will also be adding a new section with resources for psychiatrists. If you know of any resources that would be helpful, please send them to [email protected]. |
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Amid pandemic, prison psychiatrists adjust and persist (6-22-20) |
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Dear Colleagues,
Now into our fourth month of the pandemic lifestyle, the novelty has worn thin. The trips I had planned for 2020 are all cancelled, the long-weekend family reunion to celebrate a speed-limit birthday (although the only place in the country you may go this fast legally is on Texas State Highway 130) has been replaced by a 90 minute Zoom call, and annual traditions with friends are scrapped. The most difficult part for me is not knowing when I will see certain people again. I realize I am lucky: I live with a partner I love and the best dog in the universe. The pandemic is creating unprecedented disruption in social connectedness for all of us, but especially for those who live alone