PsychSummit: COVID-19 

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

July 1, 2020

Zoom Fatigue

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

Colorado Psychiatric Society COVID-19 Resource List

 July 1, 2020

June 24, 2020

Loneliness

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. I am particularly concerned about seniors and adolescents.

Earlier in the pandemic, 13.6% of U.S. adults reported symptoms of serious psychological distress, which is three times higher than two years before (3.9%), according to a recent survey. Among respondents age 18-26, 34% reported distress in April 2020, compared to only 3.7% in April 2018, a nine-fold increase. Paradoxically, loneliness tripled among those who live with others and “only” doubled among those who live alone. This highlights the importance of National Institute of Aging research demonstrating that social isolation and loneliness, although connected, are not equivalent.

A Harris Poll commissioned by 4-H in May asked 1,500 youth about their mental health. Among the results: 61% said that the pandemic has increased their feelings of loneliness, 55% reported anxiety, 43% reported depression, and 64% believed the pandemic will have a lasting impact on their generation’s mental health. The teens surveyed also reported that they spend 75% of their waking hours on screens. It will be interesting to see if screen time drops now that school is out for the summer. As psychiatrists, we all know that excessive screen time is associated with adverse outcomes for children and adolescents, particularly with regard to diet, weight, depressive symptoms and quality of life.

Solutions for adolescents may be relatively easy to negotiate, to the extent that one is able to negotiate with a given adolescent. CPS has gathered an impressive collection of activities for families and children to help engage youth in non-screen activities. Please encourage your patients to check out the links on our Resources for the Public webpage. Many parents of adolescents have decided to bend the rules for their kids, allowing them to venture out with their friends because of a recognition that social groups and friendships are like air and water for teens.

Among the resources missing from many children’s lives during the pandemic are their grandparents. There are countless heart-wrenching news stories about family members trying to connect with elders quarantined in nursing homes. Although the need for quarantine is understandable if the goal is isolation of the virus, the rigidity of the quarantine suggests that policy makers have lost sight of the larger picture of health for people living in nursing facilities. To lock an elderly person in a room with almost no human interaction is to invite cognitive, emotional and physical decline. Think about what we know about solitary confinement. Even elders who live independently are exhorted to maintain strict shelter-in-place protocols as the rest of society opens up a bit. Long before the pandemic, we knew that social isolation can induce depression, reduce immune function, increase oxidative stress and is associated with dementia in seniors.

Humans evolved as social animals. We need interpersonal connection for our very survival. Loneliness is harmful, and loneliness during a period of increased stress because of a deadly virus and social upheaval may be especially burdensome. This paper on the Neurobiology of Social Distance is the best I have found, and worth the time to read. For a shorter version, this commentary piece by Dr. Richard Friedman is a less academic discussion of the effects of social isolation on cognition.

Have we created a false binary: seniors must be completely isolated or else they risk dying from the virus? Could we imagine responsible ways to soften the degree of isolation without sacrificing safety? How might psychiatrists join the public health conversation about the way we’re treating our seniors? This call for research on combating loneliness contains excellent ideas, including for individual and societal interventions. The UK has created a “Campaign to End Loneliness;” the website includes some charming short videos about talking to strangers, making friends, and other forms of connection.

Perhaps the pandemic will be a catalyst for reprioritizing where we place our elders in the social fabric, recognizing the importance of the multigenerational family, and rethinking public policy to be more relationship-centered.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 June 24, 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.

June 17, 2020

Twin Pandemics

Dear Colleagues,

We are in the grip of twin pandemics: coronavirus and racism. One has been in the US for five months, the other for over 400 years. The emotional toll of the former has amplified the urgency of the response to the latter so that finally, finally our country is paying attention to what Black people have been telling us for years. Rosa Parks refused to give up her seat on a Montgomery bus 65 years ago. This iconic moment happened before most of us were born, which means visible, well-publicized struggle for equality has been going on our entire lives and we have not been paying enough attention. This letter will focus on the mental health toll of both COVID-19 and racism on the Black community, and on what we as psychiatrists must do to help.

It is well documented that Black, Native American, Latinix and other minority populations have been disproportionately affected by COVID-19. This CDC page explores factors that contribute to disparities in health during the pandemic, as well as advice to health care professionals and health care systems for addressing the problem. Because Black people are dying at a higher rate, Black families are experiencing more grief and loss. At the same time, Black families often have more difficulty adapting to the pandemic because their socioeconomic situation leaves them with fewer options. Although a common response to the pandemic is that “we’re all in this together,” the truth is that we are not all having the same experience. This British article expounds upon COVID-19 as “the great unequalizer.”

The pandemic and its resulting unemployment are inextricably connected to the current civil unrest in response to ongoing police murders of Black individuals, as articulated in this article in JAMA. Black people are feeling assaulted by simultaneous medical and existential threats, and the long term mental health effects of this level of trauma must be considered. A CDC survey cited here found that Black adults currently report more psychological distress, with 45% reporting anxiety or depression in the week following George Floyd’s killing, compared to 33% of white people.  Historically, Black people have had less access to and less trust in mental health treatment, and they may experience more stigma about seeking psychiatric care. If we are to support the Black community through these twin pandemics, we must support its mental health.

What can we do and where do we start? We must work harder to make health care settings welcoming and safe environments for Black patients and providers. We must speak up when we witness race-based humiliation, exclusion, invalidation or aggression. Psychiatrists can promote healing when treating patients who have experienced trauma by adopting a trauma-informed care approach and an attitude of cultural humility.

Part of our cultural humility must include an openness to learning more about race and racist oppression. APA’s President and four distinguished speakers met June 15^th in a webinar focused on structural racism and the way forward. A recording is now available for APA Members. If you did not attend the webinar, I suggest you carve out an hour and do so this week. It should be mandatory watching forany psychiatrist who wants a deeper understanding of the experience of Black psychiatrists in our training programs, hospitals, and organizations.

Four books were recommended during the webinar: White Fragility, Medical Apartheid, So You Want To Talk About Race? and Racism & Psychiatry. You may also read the statement on domestic terrorism and violence in America found on the Black Psychiatrists of America website. I also intend to spend more time on the Race & Medicine website, especially this page of resources for white physicians to use to delve deeper to understand privilege, bias, and how we can help address the racism we witness.

We must promote more equity in medical research. The exclusion of minorities from genomic testing has healthcare implications; although only 16% of the world’s population are descendants of Europeans, 78% of genomic testing used in the genome-wide association study is from people of European descent. We are basing medical research on a small segment of the human population with the arrogance of the white, European “majority” that we are all we need to know about.

As individuals and as a profession, we must take responsibility for the problem of racism in America and in healthcare. I welcome your suggestions for actions CPS and the APA might take to address racism and to rectify disparities in mental health care, medical care, and social equality.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 June 17, 2020

June 10, 2020

Suicide Risk and Prevention During the Pandemic 

Dear Colleagues,

The coronavirus pandemic is taking its toll on Americans' mental health, with more than 88,000 people developing anxiety or depression in May, according to a Mental Health America survey report. The per-day number of depression screenings was 394% higher and the per-day number of anxiety screenings was 370% higher in May than in January. Seventy-three percent of respondents with moderate-to-severe depression and 62% with anxiety also reported strong feelings of loneliness and isolation. Particularly hard-hit populations include LGBTQ individuals, caregivers, students, veterans and active duty military personnel, and those with chronic health conditions. Although the survey report doesn’t examine race/ethnicity, I would venture that communities of color, which are disproportionately impacted by the pandemic, also experience higher rates of depression and anxiety. More than 21,000 people considered killing themselves or harming themselves on at least 16 days during May. Nearly 12,000 had these thoughts almost daily. Between 40,000 and 50,000 Americans die by suicide every year, and in the month of May nearly half that many reported thinking about suicide. A crisis of suicide is looming, and psychiatrists must find ways to mitigate the factors that are accelerating suicide risk.

There was evidence of increased deaths by suicide during the 1918-19 influenza pandemic, and among the elderly in Hong Kong during 2003 SARS epidemic. This article in The Lancet identifies factors that increase suicide risk, including increased distress among people with preexisting mental health problems; increased rates of depression, anxiety and PTSD in previously mentally healthy individuals because of the stresses associated with social distancing; job loss and economic hardship; the stigma of having had COVID-19; and interrupted educational or occupational trajectories for teens and young adults. Furthermore, the increased prevalence of domestic violence as a result of shelter-at-home orders has been documented by the UN. Women, children and LGBTQ individuals are at increased risk of abuse, which may lead to suicide if the person feels trapped with no way out, or to homicide by the abusive person.

It’s too soon to know whether fears of increased deaths by suicide as a result of the pandemic will prove correct, but the CDC is analyzing information about excess mortality from all causes, including suicide, during the pandemic. The authors of this JAMA Viewpoint offer reasons for optimism as the rise of telehealth increases people’s access to treatment and a spirit of pulling together in adversity improves resilience.

On the other hand, a surge in firearms sales has been well documented, with sales up 71% nationally in April (1,797,910 guns sold) and up 85% in March (2,583,238 guns sold). Gun sales in Colorado were up more than 80% in April 2020 compared to the same time last year. Mind you, these are just the legal, registered sales.

We all know that suicide attempts by guns are the most likely to be lethal, with 82.5% of people who use a firearm sustaining a fatal injury. Although Colorado’s Red Flag Rule went into effect January 1, 2020, whereby family members or police can ask a judge to temporarily remove a person’s firearms if that person is deemed a danger to self or others, it’s not clear how or whether the unusual social restrictions of the pandemic will interfere with the law’s potential effectiveness. This article on preventing suicide by guns includes useful tips on storing guns outside the home, including with family members, a federally licensed firearms dealer, or a local police department. In Colorado, a friend may not take possession of a weapon for more than 72 hours unless a background check has been performed by the gun owner.

In my own experience with patients in the last ten weeks, I have noticed several trends. In patients with previously stable bipolar disorder who are also health care providers, the stress and sleep deprivation of adapting health care practices have precipitated manic or hypomanic episodes. Some patients with recurrent major depression or chronic anxiety disorders struggle with the disruption of their work and other routines. Perhaps most striking is the effect of the stress on patients who experienced abuse in childhood. For these patients, the masks recall episodes of suffocation; the adrenal hyperactivity recalls that state in childhood and seems to prompt regression to that traumatized state; the social isolation rekindles feelings of being left alone to fend for themselves. In my practice, this group of patients is struggling the most right now with thoughts about ending their lives. 

I am now more likely to suggest ketamine in response to serious suicidal ideation, rather than inpatient admission. I’m mindful about which medications I’ll give in a 90-day supply, and which I won’t because of potential lethality in overdose. This article offers other pragmatic suggestions for actions psychiatrists can take now to forestall a suicide pandemic.

Psychiatrists may serve as beacons in the storm for our patients, our health care colleagues, and the person we encounter on the street who doesn’t even know we’re a psychiatrist. We may not know who is on the verge of despair, yet with each human encounter we have the opportunity to make a difference through a gentle demeanor, a kind gesture, a neighborly expression of concern, or an unexpected act of generosity. If we collectively strive to embody the ideal of the warm, patient, accepting psychiatrist in all our interactions, we add more grace to a world in dire need of courteous goodwill.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 June 10, 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.

June 3, 2020

Psychiatric Disorders and the Pandemic

Dear Colleagues,

Today’s column was supposed to be about the psychiatric effects of the pandemic, and it still will be. But first I must touch on current events. If you’re like me, you may have been settling into the new normal of practicing psychiatry, running a home and maintaining relationship connections during the pandemic. Recently I found myself thinking that I could live this way for the year or more that will be required: “I’ve got this.” Then Minneapolis police killed George Floyd and the country erupted. Sickened and enraged by yet another instance of police brutality towards a black man, protesters took to the streets. Unfortunately, perhaps exacerbated by the stress of the pandemic and its political and economic consequences, some of the protesters turned violent. Denver joined dozens of other cities with riots, curfews and the deployment of the national guard.

The murder of George Floyd has taken a psychological toll on many of us, but none more so than the black community. People of color, and black men in particular, live with the terror of police brutality in a way that I don’t. The riots also take a toll: from the sinus-inflaming smell of tear gas and pepper spray wafting over from downtown, to the noise of police helicopters circling overhead all night for the last five nights, to the swirl of emotions about the violence of both the rioters and police, to the outrage about how the White House is responding, all of this wears on me and everyone else I know. It adds to the urgency and gravity of the topic I’m covering today, which is the mental health effect of the pandemic on the general public, on people with preexisting mental illness and on the healthcare workforce.

A tidal wave of depression and anxiety is on its way, and we are already seeing the first of its surging swells. The UN has published a policy brief, COVID-19 and the Need for Action on Mental Health, highlighting the importance of mental health to a functioning society and concerns about the effects of the pandemic. This article from The Atlantic cites Colorado School of Public Health researcher Jennifer Leiferman, who found that Colorado residents have been nine times more likely to report poor mental health than during pre-pandemic times. Tom Insel of the NIMH discusses his concerns about the tsunami of mental illness about to hit us. Prescriptions for benzodiazepines rose 10% in March of 2020 compared to the same month in 2019, while antidepressant prescriptions rose at least 9%; as the stress of physical distancing, economic hardship and civil unrest continues, we can expect to see these rates soar, as discussed here. Although scientific studies have yet to be published about these impacts, we are already seeing case reports in the literature about COVID-19 related mental illness, such as this letter about new onset psychosis in a patient with no preexisting psychiatric history.

The impact of the pandemic on patients who already have psychiatric disorders cannot be overestimated. This letter in the Asian Journal of Psychiatry delineates concerns about exacerbation of anxiety disorders, depression, substance use disorders, and a host of other likely consequences of this “apocalyptic” pandemic on our patients. This case report describes an exacerbation of previously well-controlled OCD because of coronavirus contamination fears.

This literature review considers the effects of previous epidemics and pandemics on patients with chronic psychosis, which may help clinicians, researchers and policymakers address the needs of psychotic patients now. This detailed and thoughtful letter to the editor identifies challenges to optimizing psychiatric care during the pandemic, from changes in routines and social interaction, to increased vulnerability to infection and homelessness,  to reduced use of treatment resources. Finally, this paper addresses the special adaptations to mental health treatment required for patients in detention.

The third population of special concern is the health care workforce, especially those on the frontline of COVID care. This survey of Italian healthcare providers revealed high rates of PTSD, depression, anxiety, and insomnia. Similar findings were found in a Chinese survey, which additionally identified that women, nurses and people at the epicenter of the pandemic were most likely to experience symptoms of distress. This interview with Eileen Barrett, MD, PhD, includes information about her experiences of physician distress among colleagues, how preexisting burnout among physicians complicates our adaptation to the additional burdens imposed by the pandemic, and suggestions for personal and institutional measures to ease the stress. This Perspective piece recommends three interventions at the institutional level and two at the national level to safeguard the health and wellbeing of health care providers responding to the pandemic.

In addition to national and institutional measures, which are critical, individual healthcare providers may take some steps to protect our wellbeing. We all know them: healthy diet, regular exercise, protecting sleep, emotional support from love ones, meditation or other mindfulness activities, psychotherapy and medications if indicated. Although I have a robust self-care regimen, I’ve noticed recently that my motivation to exercise hasn’t always been as perky as usual. This article offers advice about how to cope with this. (Washington Post, 5/12/20: Losing your motivation to exercise as the pandemic drags on? Here’s how to get it back.) PsychHub has developed a series of short videos on adaptation. Two of them are specifically targeted to HCPs, and may be helpful for individuals who struggle to manage their emotions. Although not specific to the pandemic, this thoughtful article on the power of physician self-care may help us break through the stoicism and stigma that prevent physicians from acknowledging our emotional struggles and seeking treatment for ourselves.

Governor Polis is aware that the pandemic is creating a mental health crisis. He has formed a Behavioral Health Task Force COVID-19 Special Assignment Committee to help address this. CPS member Kim Nordstrom has been appointed to the committee, and I hope she will share details from the draft report when it is available later in the summer.

Please scroll down to browse additional resources we’ve curated for you and for your patients this week.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 June 3, 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.

May 27, 2020

CPS has a new President - Welcome, Dr. Zilber! Thank you to Dr. Westmoreland for her service and for writing the first 10 editorials for the CPS COVID-19 emails!

Substance Use Disorders and the Pandemic

Dear Colleagues,

Patricia Westmoreland, CPS’s immediate past president, set an outstanding example of leadership. Her weekly letters in our COVID-19 update were informative, friendly and encouraging. I intend to continue the weekly letters as long as people are reading them and finding them useful. Please remember to direct your patients to the CPS website to browse among the Resources for Patients available in each issue for links to self-care sites, taking care of children’s emotional needs at this stressful time, tips for social distancing as the regulations ease, and much more.

As the pandemic wears on into its third month in Colorado, we are moving out of the “acute response” phase and into the “settling in for a long haul” phase. The professional and lay press have been sounding alarms all along about the mental health consequences of the pandemic, so I want to take some time to address at least three specific topics in greater depth. In this letter, I discuss the effect of the pandemic on substance use disorders in three populations: the general public, people with preexisting substance use disorders, and health care providers. Next week, I’ll take a deeper look at mood and anxiety disorders during the pandemic in three similar population groups. The following week, barring a more pressing issue arising in the meantime, I’ll examine what we know about suicide in the pandemic.

When Governor Polis first announced the shut-down of all but essential services, marijuana dispensaries and liquor stores were to be closed. That lasted a few short hours. The outcry from the populace was deafening: we cannot get through this crisis without the ability to self-medicate our anxiety. I say this without a shred of judgment; I notice that, when I have a glass of wine now, I am tempted to pour a second glass more often, and I have reined in that impulse only because of an over-abundance of self-discipline (in other words, I’m a control freak). Apparently, I’m not alone. An editorial in the BMJ notes that alcohol sales in the UK were up 67% in mid-March, whereas grocery sales were up only 43%. The editorialists identify two populations of concern: those who already have an alcohol use disorder, and those who are on the brink of developing such a disorder as a result of bereavement, job insecurity or troubled relationships. According to the AP, alcohol sales in the US were up 55% in the week ending March 21. We would do well to ask repeatedly about alcohol, marijuana and other substance use in all our patients, even those for whom substance use has not been a problem.

For our patients in recovery, the pandemic has created a host of new stresses. Depending on the municipality, 12-step meetings have been closed for the last eight to ten weeks. The large one in my neighborhood only opened up last week, and under strict rules that limit attendance in order to comply with physical distancing regulations. A Buddhist alternative to AA, Recovery Dharma, has many online resources, including online meetings. Although it was published in 2009, I only recently became aware of Rami Shapiro’s interfaith book on the 12 steps, Recovery: The Sacred Art, which may appeal to people who associate AA with Christianity and/or who don’t feel comfortable with group settings. Seniors, who are at higher risk in the pandemic, are still advised to stay home, so in-person meetings aren’t available to them. Seniors with substance use disorders have additional health risks. Dr. Volkow discusses the effects of addiction on people’s risk for and susceptibility to infection with the novel coronavirus, challenges for maintaining recovery, and areas for future research in this short NIDA video. Dr. Volkow’s ideas are elaborated more fully in her Annals of Internal Medicine opinion.

There is concern that the pandemic may worsen the opiate crisis. Telehealth access and temporarily relaxed restrictions have enabled some patients to continue their treatment with buprenorphine, in effect removing a barrier to treatment. It remains to be seen whether some of these changes will become permanent policy. The variability among state regulations and the requirement of in-person dispensing means access to methadone has been more tenuous. Addiction recovery programs are finding creative ways to adapt to the pandemic, as summarized in this article.

A quick search on Google Scholar for papers related to substance use among health care providers responding to the pandemic came up empty. A search for papers on moral injury and emotional distress among healthcare workers in the pandemic yielded dozens of papers. I imagine that eventually the stress and moral injury may be reflected in an increase in physician impairment, but that data has yet to surface. In the meantime, please remember that CPHP’s COVID Care Line for Physicians is free and confidential.

Please scroll down to browse additional resources we’ve curated for you and for patients this week.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 May 27, 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.

May 20, 2020

PASSING THE TORCH  – A REFLECTION OF LIFE LESSONS IN A TIME OF TRANSITION

Dear Colleagues,

It is with a mixture of sadness and anticipation that I write this last editorial as your President. I am honored to have served as President of the Colorado Psychiatric Society and I am also thrilled to pass the torch to Dr. Claire Zilber, who I hold in high esteem as a psychiatrist, an ethicist and a dear colleague. I can’t think of a person better equipped to provide compassionate and thoughtful leadership at this critical time in the history of medicine and psychiatry. As my farewell, I have put a short essay reflecting what I have learned as your leader during the pandemic that has changed all of our lives.

OUR TIME IS NOW

In her virtual address, AMA President Dr. Patrice Harris pointed out, “Physician leadership is critically important, and even more so now.” The AMA is currently advocating for loan forgiveness for frontline workers, urging Vice President Pence to exempt international medical graduates from immigration bans and requesting CMS make policy changes that improve the quality of care. The APA also supports these initiatives.  At no time has it been more crucial that we psychiatrists stand up and count ourselves as members of the house of medicine and advocate for what is required to get us, our colleagues in other specialties and our patients through this pandemic. It is up to us to lead the charge in identifying and treating the mental health consequences of quarantine, isolation, loss and trauma. Mahatma Gandhi said: “First they ignore you, then they laugh at you, then they fight you, then you win.” Over the years, psychiatry has been dismissed by many, derided by some and challenged on a frequent basis. As I noted in my editorials on mental illness during the pandemic, psychiatrists are needed now more than ever. Several  patients over the last few weeks admitted to inpatient psychiatry have told me how being isolated and having their lives turned upside has led to worsening of their symptoms. Our colleagues on the frontlines are suffering too. May is Mental Health Awareness month: now IS the time for us to lead the charge using our skill and knowledge to help our patients, our colleagues and ourselves.

WE ARE ALL IN THE SAME STORM (EVEN IF WE ARE IN DIFFERENT BOATS)

In addition to its many consequences, COVID 19 has highlighted the crisis of loneliness faced by many Americans. Loneliness, according to a New Yorker article, “is not just a feeling. It’s a biological warning signal that instructs us to seek out other human beings.” In addition to its psychological effect, loneliness takes a toll on us physiologically, inciting inflammation, wearing down our immune system making us more susceptible to illness. Dr. Sue Varma, founding medical director of the World Trade Center Mental Health Program at NYU, noted that while previous disasters have been finite, the uncertainty regarding the longevity of this pandemic is what makes it so hard to accept. According to a Time magazine article, a third of American adults feel lonely as a result of the pandemic. Who feels the most alone? Perhaps surprisingly it is not always those who live alone. Many individuals who are quarantined in a household where they get little time for self care also feel a sense of loneliness. Interestingly, elderly individuals appear to be less lonely once introduced to to social media, while Gen Xers may feel less lonely when they engage in activities away from social media. Clearly I am trending towards the former end of the spectrum:  I enjoy scheduled FaceTime with friends and family, and waking (as I did one morning) to 50 “What’s App” text messages between my “international cousins,” the group of wily, wise and humor filled women alongside whom I was raised and now live in all corners of the earth. I will continue to set aside time to reach out to my family, my friends and my colleagues whose works of support and encouragement have guided me through my presidential year, especially the last few months.

“SOME DAYS I FEEL LIKE I AM MELTING:” PARENTING AND WORKING DURING A PANDEMIC

“Workenting” (working plus parenting): a word invented by me describing: a) completing my work as efficiently as possible so that I can devote a few uninterrupted hours to my children b) sitting on the sofa and watching a movie while working or c) the constant feeling that I am not devoting sufficient time to either pursuit. I previously described the multifaceted difficulties of parenting during this pandemic and they remain as such, especially for single parents – most of whom are single mothers. The New Yorker article I referred to is, I believe one of the best articles of the topic and is worth re-citing. A recent piece by Sheryl Sandberg, in which it is noted that  women are working an average of 71 hrs per week on household and childcare related endeavors during the pandemic before they even begin to tackle the work for which they are paid, casts light on this problem. Sandberg advocates for companies to increase their flexibility with regard to work hours and eschew traditional metrics of job performance during the pandemic.  As the uncertainty regarding school and college re-openings grows, and parents continue to struggle with managing their children (and keeping their jobs), having a support system is paramount, as is asking for help where we can, and marshaling our inner resources when we can’t. One such resources is humor – not only does laughing about the absurdity of lives improve our mood and strengthen our inner resources, but it also fosters a sense of togetherness. My favorite laugh of the week was this Washington Post article in which readers were invited to review their quarantine experiences as if they were reviewing a hotel.  Tyrannical toddlers and lazy dog butlers aside, many of us are concerned about the psychological affects of the pandemic on our children – but there are some upsides of forced togetherness. In many homes (including mine) board games, neighborhood walks and bike rides, art projects, puzzles are more commonplace than ever before. It is important to cherish these moments especially at times where we feel that we are not doing enough, or being enough for our children and our partners. These are hard time, count your cherished moments and aspire to small successes every day.

“I AM BECAUSE MY LITTLE DOG KNOWS ME” (GERTRUDE STEIN)

My tenure as editorial writer of CPS COVID-19 Resources would not be complete if I didn’t mention the huge role that our dogs have played in helping me maintain my sanity over these last months. I am hardly alone in this regard. In “My co-anchor in pawing at the door” weather forecasters and newsreaders discuss adapting to the new normal of pets zoom-bombing their meetings in adorable fashion. Some of these adorable pets (kid Betty and cat) have gone viral (even if not in the COVID sense). There has also been an increase in pet fostering and adoption since the beginning of the COVD-19 pandemic (https://www.nytimes.com/2020/03/19/us/coronavirus-foster-pets.html and https://www.nytimes.com/2020/04/24/realestate/youre-quarantined-is-it-time-to-get-a-puppy.html). However in “America’s Pets can’t take quarantine anymore”  we are cautioned to ensure that our animals get their space during our extended time at home. As the popular meme goes: “Dogs think we have given up our jobs to be home with them. Cats believe we have been fired for being the lousy humans they know we are.” Laughter aside, at no time has it been more clear to me how much we cherish the non-human loves in our life. Case in point my homicidal chihuahua mix. The warmth of his body, the smell of his fur and the sweet noises he makes as he falls asleep are an immediate panacea for moments of stress and anxiety. My partner (knowing how much I love this beast) gave me a dog DNA kit for my birthday. We anxiously await the results. His bet: part Chihuahua, Dachshund, possum and snake. I think he is thoroughbred Russian Toy dog (I learned that from my daughter’s dog breed book – she knows something about almost every breed). Wrigley’s genetic make-up is beyond the subject of this editorial. However, being invested in our dogs (and we have an additional two of known genotype), walking them together in the morning, curling up with them at night gives us a sense of shared purpose during these uncertain times.

THE WORLD CHANGED IN A MATTER OF MONTHS – BUT WE ARE IN CHARGE OF HOW WE RESPOND

During a weekend hike (this time thankfully sans rattlesnakes), my son and I reflected on how our world has changed in a few short months. Things that we had looked forward to – travel, school outings, skiing and visits with friends suddenly vanished. We also mourned the disappearance of events that would have marked milestones in our lives – for me, the CPS Spring Meeting where we would have hosted Dr. Patrice Harris here in Colorado; for my son, his elementary school commencement. Although we have much for which to be grateful, it is important to acknowledge these moments of grief. Former President Obama’s virtual commencement address encapsulated the feelings of disappointment felt by graduates, but was helpful in pointing out that events such as graduation ceremonies are transitory, but graduating into adulthood and having the power to make choices that reflect our values is what moving ahead is all about. In a previous editorial I wrote about the importance of resilience and how our sense of meaning and purpose, together with an ability to be creative in dealing with life’s curveballs, can shape our destiny. A recent New Yorker article expounds on how resilient people view the world differently, and discusses how resilience can be learned through dealing with the hard times in our lives.

I leave you with the wise words of Nelson Mandela, a giant of a man whose courage and resilience shaped a nation. “I never lose. I either win or I learn.” May we embrace the power of everything this pandemic has taught us as we move forward with fortitude and grace.

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 May 20, 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.

May 13, 2020

COVID-19 as a teachable moment in uncertain times

Dear Colleagues,

“In a time of fear and uncertainty the best thing to have is a protocol,” wrote Lisa Rosebaum MD in an article in New England Journal of Medicine Perspectives. Of all the characteristics that people recognize me for, I would say that “takes on new challenges” is fairly well known. Not as widely known, perhaps, is the angst that follows the initial surge of enthusiasm. Was this a good decision? Do I have what it takes to handle this new challenge? What are the pitfalls? Such were the threads of my post-decision thought process after I decided to accept the job as psychiatry residency training director for a newly accredited program in the Denver area. I had a vision as to how I might prepare for stepping into this role, and what it would be like to do so, and what issues I would need to address at the outset – i.e. the beginning stages of developing a protocol. Then COVID came along. Like everyone else, many of my plans for the upcoming months turned to dust. Aside from the constants of my home and loved ones, I was in that strange no man’s land that comes with exiting one job and beginning another. All of this transpired in a rapidly changing world. Adjustment, as we psychiatrists know, takes time. Although I am only now adjusting to a new normal, I will soon have the challenge of shepherding residents through a rough terrain with no identifiable roadmap. To say that I am thrilled, excited, honored and at the same time apprehensive is to only begin to fathom the myriad of emotions I feel – and the enormity of the challenge that lies ahead.

What is known about residency training during the COVID pandemic? What has been expected from residents and how have they responded to this massive disruption in their journey? In “We signed up for this! – Student and Trainee Responses during the COVID-19 pandemic," Drs. Gallagher and Schleyer discussed  the role of medical students and trainees (residents and fellows) during the emerging days of COVID-19, and how to balance clinical and educational objectives with the safety and wellbeing of these students and trainees. To learn more about how their students and trainees were affected, they conducted an anonymous survey of 316 students and trainees.  Respondents’ anxieties were amplified the closer they were to the frontlines and their safety concerns were complicated by concerns about transmitting infection to their loved ones (see Am I Part of the Cure or Am I Part of the Disease? Keeping coronavirus out when a doctor comes home). Students and trainees also reported moral distress at seeing patients dying alone, feeling they themselves could not be useful and many were beset by practical challenges such as childcare. Interestingly (but not surprisingly), despite their anxieties, students and trainees frequently expressed a desire to help, often volunteering for extra duties – an admirable esprit de corps.

When residents voluntarily go the extra yard, as training directors we should be right there with them. What can we do to help residents through these unprecedented times? Although not psychiatry specific, ACGME reminds us of the importance of balancing the increased demands for clinical care with training requirements, ensuring we adhere to resident work hours, as well as adequate instruction in use of PPE and other infection control measures. A brief article from the American Association of Directors of Psychiatric Residency Training (AADPRT) reminds us to advocate for our residents, express gratitude for their working under extraordinary circumstances, and monitor their wellbeing. Communicating frequently with residents as well as maintaining structure were also seen as key. Authors of a letter to Psychiatry Research entitled “Disrupting the Disruption: using digital tools to support psychiatry residency training in Singapore during the COVID-1 pandemic” noted that the last event that significantly disrupted residency training (i.e. the SARS epidemic in 2003) was contextually different in several aspects, one of the most notable being technology. At that time, videoconferencing capabilities were not as advanced as they are currently are. Despite constraints on social gatherings, residents can continue to discuss cases with their supervisors and supervisors can assess the skills of their residents. The authors noted that in their institution, participation rates in clinical case presentations and discussions have been good, and the expansion of the availability of didactic lectures to various sites (which was not as well developed before the pandemic) has proved useful. Videoconference modalities can also be used to assess resident wellbeing (remembering that loss of social connectedness is a major contribution to physician burnout) as well as to update residents on schedule and logistical changes as they occur. However, the letter cautions that we must also remember the difficulties that could be encountered by trainees, many of whom are still learning the communication skills inherent to interviewing patients, which is made doubly difficult by having the use of telemedicine – or the use of videoconference in supervision where subtle nonverbal clues between supervisor and supervisee’ may be missed or misinterpreted. Teamwork can thus become fractured, and the opportunity to learn from mistakes (i.e. teachable moments) is therefore missed. The work of Harvard Business School’s Amy Edmonton (as noted in an Editorial on teamwork) teaches us that, while teams who work closely together don’t necessarily commit more errors, they are just more likely to learn from them.

The authors of “We signed up for this” denoted COVID-19 as a teachable moment, stating that the “chaos and uncertainty” engendered by this pandemic “demand an unyielding focus on core medical principles and consistent modeling of professionalism, altruism, quality and safety.” How do we, as leaders, expand on these objectives in a clear, consistent and reassuring manner, while at the same time dealing with our own fears and uncertainties? To quote Mark Whatney, fictional astronaut in The Martian (one of my all-time favorite movies): “You just begin. You do the math. You solve one problem then you solve the next problem then the next…And if you solve enough problems, you get to come home.” I plan to teach my residents, in the coming weeks and months: residency is by and large about learning to confront uncertainty, ask for help, learn from your mistakes, improve the lives of your patients - and solve problems. It is about growing intellectually as well as emotionally and learning from teachers who have had as steep a learning curve as any in the past few months. According to Buddha, “Your worst enemy is your best teacher.” And from COVID-19 have come both.

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 May 13, 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.

May 6, 2020

A PANDEMIC IS NOT A TIME FOR PERFECT

Dear Colleagues,

Last week I wrote about “okay parenting.” Not a distinguished title or aspiration for a parent but one that I felt was befitting for a time when managing (rather than excelling) is the order of the day. I was reminded of this during a recent attempted hike in Boulder. At the foot of the trail a large sign warned: “Be aware: rattlesnakes have recently been seen on the trail. Be careful when hiking trails in this area. Rattlesnakes are common this time of the year.” About 10 yards further up the trail we were treated to the sight of a large ominous rattler who had recently recently consumed something of sizable proportions. I about died. I am deathly afraid of snakes – especially the venomous ones. I tried to take a few steps forward but found that I could not go on. “Where’s your persistence Mom?,” came the response from my bold 11 year old. “Sometimes,” I said, “its good to know when to call it quits.”

According to those who are seasoned at hiking rattlesnake country I made a good choice. But giving up is not in my nature and I had a tough time with ending a hike that had barely started. That said, there are times when our sense of perfection and the need to have everything turn out as planned is self defeating at best and (in the case of the rattlesnake) potentially lethal.

During the beginning stages of our quarantine, an article in the New York Times lamented, “the internet wants you to believe you aren’t doing enough with all that extra time you now have.” The author of the article noted that, as the Coronavirus has kept us home, many people are feeling pressured to organize every room in their homes, become expert chefs, write a book or get in shape. The article goes on to state that the urge to over-achieve (even during a pandemic) “reflects America’s always-on work culture.” The idea that we have the extra time during lockdown to achieve a myriad of things (and the extra energy to realize those goals) is a fantasy. Balancing work and family responsibilities, all of which often occur under the same roof, is enough in and of itself.

An article in Bloomberg Businessweek indicated, now is not the time to be perfect. The drive to be perfect may also be be lethal to physicians. In a New York Times op-ed memorializing Dr. Lorna Breen, the New York emergency room physician who committed suicide after both treating COVID-19 patients and becoming ill with the virus herself, author Jennifer Senior wrote “physicians are perfectionists who suffer in silence.” She noted that we are trained to project confidence and move forward, and seeing ourselves as vulnerable is antithetical to our self concept. Ms. Senior wrote that, while we cannot extrapolate too much from Breen’s case, it should be noted that she was the second known American health care worker to die from suicide in this pandemic – and neither Dr. Breen nor the 24 year old Staten Island paramedic who died as a result of suicide had a known history of depression or suicidal ideation. Being driven and identifying as a high-achiever who wants to solve problems has become inordinately difficult in the face of a virus that defies our previously held notions that, when faced with an illness, physicians are able to manage that illness treat it and the patient most often gets better.

The feelings of helplessness described by ER physicians in treating COVID-19 patients is not new to us as psychiatrists. Psychiatric illness is much less well understood than other illnesses – including infectious diseases. There are no metrics that tell us with great certainty whether our patients are going to kill themselves or others. We can’t verify our patient’s affective symptoms though laboratory tests or imaging modalities. While there have been major improvements over the years, our medications are not always effective and, despite the advent of genetic testing, we don’t know which medication to try first. While that does not mean we are necessarily less perfectionistic than our colleagues in other specialties, and although we have not experienced death in the numbers seen by our ER colleagues during the last few months, we are accustomed to a greater degree of uncertainty which may help us navigate this crisis both personally and professionally.

A New England Journal of Medicine article entitled “Physician burnout, interrupted,” promotes the idea that operating in a new and imperfect world may actually invigorate medicine. Drs. Hartzbrand and Groopman write that, during these times of uncertainty, a sense of altruism towards the medical field has “unexpectedly catalyzed the restoration” of some of the elements that had traditionally led to burnout: lack of autonomy, competency measured mostly by meaningless metrics, and lack of relatedness.

While there has been some gain in autonomy and the relaxation of rules governing how we practice medicine, psychiatrists should probably be most cognizant of the relatedness piece. Not because we don’t relate, but because we may relate too much. Wading in the uncertain quagmire of human emotions is a difficult experience especially during one of the few times in history when we are faced with the same nemesis as our patients, and this may be where our professional sense of perfection is challenged. In “Therapists and patients find common ground: virus-fueled anxiety,” Sarah Maslin Nir notes the parallel processes of therapist and patient during COVID-19. She writes about a psychiatrist who specializes in women’s health who stated that the effect of absorbing the same worries as her patients made her collapse into bed at the end of the day. The psychiatrist, who said she had formerly experienced her patients’ worries as separate from her own, felt the same worries encroaching into her emotional life. However, she knew weathering the storm meant having goals that were more modest than she might have had in times past.

How do I get through that storm? Winston Churchill said, “If you are going through hell, keep going.”For me that means getting my job done, dealing with my loved ones, checking in on friends, reading my novels and being even more attentive to my dogs than they can tolerate (more on that later). I have no compulsion to forge every possible path (especially those with rattlesnakes). At least not today. As web designer Izey Victoria Odiase said, “don’t aim for perfect. Aim for better than yesterday.”

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 May 6, 2020

Updates

CPS Virtual Meeting - COVID-19, Physician Leadership, and the Urgency of the Moment in Medicine Saturday, May 16, 2020 5pm MT REGISTER HERE! Non-members welcome! Patrice A. Harris, MD, MA, president of the American Medical Association (AMA), will discuss the AMA’s multi-faceted response to the COVID-19 pandemic, including specific ways of responding to the mental health needs of physicians and the public during this time of crisis. The evening will begin with an opening session featuring an interview between New York Times Op-Editor Dr. Richard A. Friedman and comedian Gary Gulman of HBO's The Great Depresh. REGISTER HERE

CMS changes to billing for audio only - CPS and the APA are advocating for you and your patients! Last week we sent a letter to Senator Gardner asking him to join efforts encouraging CMS to revise its telehealth rules to allow for telephone audio-only appointments and appropriate reimbursement. CMS has updated the telehealth list with those codes that can be done via audio only. On April 30, 2020, CMS issued a new ruling permitting audio only telephone care for the following psychiatry codes: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90853. CMS also announced they will be increasing payments for audio-only telephone visits (99441, 99442, 99443) between Medicare beneficiaries and their physicians to match payments for similar office and outpatient visits. The changes to billing for audio only are retroactive to March 1, 2020. The updates are for patients that cannot do the video piece; members can still bill as they always have if they do both audio and video. 99441   (5-10 min; $46) 99442   (11-20 min, $76) 99443   (21-30 min; $110) Since the add-on psychotherapy codes, 90833, 90836, and 90838 have been permitted for just audio, the APA believes CMS is recognizing it will be acceptable to bill for an E/M with one of these codes even when only audio is available using the point of service for where the encounter would have taken place were it not for the public health emergency, and the modifier 95 is to be used to indicate the care was provided via telemedicine. The APA is waiting for confirmation from CMS that this is the case and will provide updates here.

 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.

April 29, 2020

 Okay To Be Good Enough: Parenting In The Age Of Covid-19 

 Dear Colleagues,

I woke up with the burglar alarm blaring and my phone ringing. It was 2am and I was barely awake but conscious enough to know that I needed to check things out. Armed with cellphone (ADT operator in tow) and a small but potentially lethal canine, I made my way downstairs. The door that has given trouble previously was shut tightly. Could it have been open and closed in haste by a fleeing intruder? Was there someone in the house? Although nothing seemed out of place I agreed to have the operator notify police. “Do you have any weapons in the house Mam?,” asked the officer “Not unless you count an 8lb chihuahua,” I responded. A member of the Denver Police Department (complete with face mask) dutifully inspected the premises and left, my son went back to sleep. Our labradoodle slept through the entire event, befitting her reputation as a great family dog, but lousy watch dog. Pint-sized killer dog and I remained vigilant for several hours until we fell into a fitful slumber.

Last night’s alarm episode closely mimics the new reality that I, as well as others, now face on a daily basis. COVID-19 has disrupted our lives. We have had to wake up quickly and respond. We are fearful. Our immediate instinct is to protect our families. We try to do our best. We feel off-kilter. We try to find humor in our up-ended lives. Parenting during a pandemic takes these feelings to a whole new level. The complexities of home schooling, keeping our children occupied when they have completed their schoolwork and helping them navigate this strange new world seem endless. For those working from home, as meme doing its rounds on Facebook instructs us, “You are not working from home; you are at your home during a crisis trying to work…I think it’s an important distinction worth emphasizing.”

“We are all stressed out” is the title of a USA Today article discussing the feelings of experiences by both parents and children during this pandemic. Disruption in their normal routines, anxiety over outside threats and diminished social interactions may lead to anxiety and depression in children. The USA Today article indicated that over half of the 562 parents surveyed in a University of Michigan study noted that self-isolating and financial worries were hampering their abilities as parents. Over 60% admitted to shouting and screaming at least once since being secluded in their homes, and one in six admitted to spanking their children. The study’s lead author cited concern that, with continued absence from school, there will be fewer adults to whom these children can report the abuse. The American Psychological Association has also expressed concern that the incidence of child abuse (as well as spousal abuse) will increase during this pandemic as it has with prior disasters such as hurricanes. Factors that increase the risk of violence are reduced access to resources, increased stress related to job loss or finances, and disconnection. Sadly, sex abuse hotlines have experienced a surge in calls as victims and their abusers are housebound together.

Caught between Scylla and Charybdis, those who are single parents have already had to choose between having a partner who is unhelpful at best (downright violent at worst) and the uncertainties of going it alone. COVID-19 has intensified that burden and added some strange legal twists. “How are parents supposed to deal with joint custody now?” asks an article in The Atlantic. According to a New York Times article, child custody is now the “new battle” for frontline workers. The article details the case of a New Jersey internist whose husband presented her with a court order demanding sole custody of their daughters. A google search indicates such a situation is not uncommon: frontline workers feel they should not be punished for their role in helping others while their counterparts contend that that they are risking their children’s lives. With courts either having no roadmap for dealing with the current status quo, or are just not open at all, warring exes may feel entitled to re-write their custody agreements sans judicial oversight.

“Some days I feel like I am melting,” reads the title of an April 21st New Yorker article. While the burdens of COVID-19 are hurting all parents, they fall disproportionately on single mothers. Author Emily Bobrow noted that almost a quarter of children in the US live with a single parent (a higher percentage than anywhere else in the world) and most of these single parents are single mothers. In addition, it is the industries that employ large numbers of women (childcare, housekeeping, hospitality, retail and travel) that have been affected the most by COVID-19 related restrictions. They also frequently work in jobs that expose them to contagion (nursing) and which lack protections such as paid sick leave (Time Magazine article). For women who have been able to keep their jobs, one in three jobs held by women are categorized as essential: but how do these women do their work as well as be the chef and the teacher and find time for self care? In contrast to the “silver linings” of the pandemic that has been touted for traditional nuclear families e.g. having a husband (or wife) who can now pitch in and assist with schoolwork and household tasks, social distancing has rendered single parents more alone than ever. Social media intensifies feelings of guilt and failure (also see Why mothers are bearing such a huge mental load during coronavirus pandemic). It is hard to feel good about one’s own goal of surviving the day when faced with everyone else’s perfect family pictures on Facebook, even though we may know that the pictures likely tell only half of the story.

“Its okay to be a different kind of parent during the pandemic,” (What Losing My Husband Taught Me About Pandemic Parenting) wrote Mary Katharine Hamm, who was seven months pregnant and raising a two-year-old when her husband died in a cycling accident. In a scene reminiscent of Joan Didion’s book “The Year of Magical Thinking”, in which Ms. Didion’s husband dies at the dinner table (and her daughter dies shortly thereafter), Ms. Hamm writes, “You’re probably feeling like you’re seated at that table now. The Coronavirus is serving up a rare and tragic mix of grief, drastic life changes and economic stress.”

Ms. Hamm noted that, “When something outside your control changes your life, it’s what you do with what you can control that really shapes your children.” She writes that believing in one’s abilities and practicing those abilities with a view to “small wins” is key. Tradeoffs and perspective are also important. I think about this a lot as I try to juggle work and kids: time to play ping pong with my exuberant son or watch a dog movie with my animal-crazy daughter are no less important than a home cooked meal (especially one cooked by me). And nobody will die if the laundry is not neatly folded and put away as soon as it exits the dryer. It was far more beneficial both intellectually and for my feelings of connectedness to participate in the APA assembly than be enslaved by laundry.

Lowering our expectations during this pandemic might actually be beneficial (CPR News article (download)), and parents may struggle more if they set too high a bar for keeping their children engaged while trying to manage their own new reality. UC Anschutz Child psychiatrist Dr. Amy Lopez noted that its okay for children to be bored and “their boredom is not your problem.” Those of us who grew up in the 70’s would agree with Dr. Lopez’s contention that working parents today spend more hands on time with their children than did stay at home mothers in the 70’s, an era when “go play outside and play” meant just that, and our boredom engendered our creativity.

While the list of resources I have enclosed is certainly not exhaustive, the “parenting during COVID-19” articles I selected (see below) share several common themes: navigating uncertainty, picking our battles, establishing routines, encouraging virtual social interaction, making time for physical activity, validating our children’s feelings and taking care of our own mental health. The latter is more important than we have been taught to believe: there is a difference between self-indulgence and self care. The tragic death by suicide of physician Dr. Lorna Breen, who had both survived COVID-19 and treated Coronavirus patients is a painful reminder that we are all vulnerable. While we do not know why Dr. Breen took her own life, her death is indicative of the wave of mental anguish arising from the pandemic and its impact on our daily lives. Let’s start small, be thankful for what we did get done today (even if it wasn’t perfect) and teach our children and our patients to strive for the same goals.

Patricia Westmoreland MD
President

Parenting During Covid-19 Articles

How To Care For Your Kids' Mental Health During The COVID-19 Pandemic (download)

Parenting amid COVID-19_ Expert tips on how to help kids at home (download)

Colorado Psychiatric Society COVID-19 Resource List

April 29, 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.

April 22, 2020

SAVING OUR COLLEAGUES, SAVING OURSELVES

Dear Colleagues,

After rounds on Saturday morning, I stood on my partner’s deck, a mandatory six feet apart, waiting for the Thunderbirds to fly over. I joined a Facebook watch party. I started my own Facebook watch party. I was overwhelmed by the response: watching the Thunderbirds fly over Denver with childhood friends, medical school compatriots and my Denver friends and colleagues was an experience unlike no other. Those who know me have described me as hard-charging, matter of fact, self deprecating and not usually given to displays of public emotion. The appearance of the Thunderbirds turned me into into a tear- soaked mess. Turns out I was not alone. In reference to the Thunderbirds, a child psychiatrist friend wrote, “I’ve made an unintentional habit of breaking down in some form of cathartic tears every time I’ve gone for a run during this lockdown and I thought I was going to make it through today’s run and then this happened…We are all dealing with many emotions today.”

In a stirring tribute to her physician mother (youtube video), a young woman composed a melody entitled “Doctors are the Heroes of the Day.” Her powerful lyrics eloquently praise our sense of duty in getting up every morning and “running towards the fight.” She reflects that, although we do not have the “super-strengths” of traditional super-heroes, doctors inspire hope in others. In so stating, she captures the essence of Pascal’s statement: “Small minds are concerned with the extraordinary, great minds with the ordinary.”

COVID -19 has become the struggle of the ordinary: doctors, nurse and other healthcare workers have been subjected to its daily ravages en masse. What is it like to stare down one’s own fears on a daily basis and what is the cost of doing so day in and day out? I suspect that we are going to find out in the not too distant future. Once the mode of operating at critical capacity begins to slow down, our frontline healthcare workers will begin to take a true accounting of what they have witnessed and endured. How they fare will be determined in large part by how proficient we become at acknowledging their heroism as well as their suffering, and helping them find a way through their pain.

In one of the first published articles detailing the mental health effects of caring for patients with COVID-19, Lai et al described the results of a cross sectional study of 1257 healthcare workers in 34 hospitals caring for individuals with COVID-19. They found that over 70% of healthcare workers reported feeling distressed, 50% experienced depression, over 40% experienced anxiety and almost 35% experienced insomnia. The most detrimental effects were noted in frontline workers, nurses, females, and hospitals at the epicenter of the outbreak. The authors of the study recommended the immediate implementation of special interventions to promote mental health in these workers.

In a CNN opinion piece living apart from spouse and children, frustration over work conditions,  feelings of helplessness, frustration at lack of resources, the trauma of multiple deaths, seeing colleagues fall ill and fear of their own death were identified as contributing to the distress experienced by healthcare workers. A Time Magazine article (add link) added several more areas of concern: the fear experienced by physicians who are afraid not only of becoming ill but of infecting their families, the exhaustion of working long hours with no end in sight, and feelings of deep sadness at seeing patients die. The death of such patients, without their loved ones at their side incurs an even greater burden for healthcare workers who take on the role of passing emotionally laden farewells from family members to patients. An ICU nurse interviewed for that article noted, “We’re all affected. To say that we’re not would be a lie.”

“I’m an ER doctor in New York. None of us will ever be the same” details the struggle of an ER physician in adapting to the rapidly changing and horrifying status quo of fighting COVID-19. She discusses the immense burden on physicians of being accused of “playing God” in allocating resources, how to best distribute risk amongst healthcare workers and the perils of incubating patients without face shields because none were available. Dr. Ouyang noted that mental health professionals “especially those who treat combat veterans” worry that doctors will sustain moral injury from having to allocate medical equipment and care. However, she noted that what will probably cause the most moral injury is seeing people die over and over again; “that I am the last person they see before they die – not their families – and that I won’t remember them at all because there will be a hundred more just like them. That it will become routine.” Dr. Ouyang also writes that she has never felt less useful as a doctor but “the one thing I can do - what I think will matter most, in the end, is to just be a person first for those patients and their families.”

How can we, as psychiatrists, support our colleagues in being “a person first” given the desperateness of the situation in which they find themselves? Our President-elect, Claire Zilber, reminded me that this week marks the birthday of one of the founders of Psychiatry, Dr. Philippe Pinel. Dr. Pinel, born in 1745, became the chief physician at a Paris insane asylum, by all accounts a horrific place where patients were chained to the walls and people could pay a fee to see them. Pinel put a stop to these practices. Instead of believing that the insane were possessed by demons, he started treating patients by talking to them about their problems on a regular basis, which paved the way for modern psychotherapeutic practice.

Jump ahead almost 300 years and the time to employ those skills is upon us. Our colleagues who have witnessed so much need us as never before. It is our duty to listen as they voice their inner heartbreak, and our calling to support them as they re-emerge into a world that can barely comprehend the horrors of their daily struggles. According to the Time magazine article, healthcare workers have found their most meaningful relief through the support of their families, friends, and colleagues. Hospitals have also come to the aid of their workers. Mount Sinai, for example, set out to provide assistance based on Maslow’s hierarchy of needs – assisting staff with the most basic needs such as childcare, cab fare (when taking the subway has become too perilous), as well as counseling and psychosocial support (see AMA report). Helplines have been set up around the country to assist with the mental health crises of healthcare workers even though this is not likely to come fully into focus until the immediate needs engendered by the pandemic have ebbed. We need to continue cheering our fellow healthcare workers as they do (with nightly applause) in New York and Thunderbirds in Colorado.

As my child psychiatry colleague wrote: “And to the Air Force Thunderbirds, you’re welcome. I am honored to be a physician and proud to be doing the work that I do.” Let’s extend that pride to helping our colleagues through a time like no other.

Thank you to Hannah and Dan Hyatt, Dr. Barbara Kessel and CPS President-elect Dr. Claire Zilber for their contributions to this editorial

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 April 22, 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.

April 15, 2020

Dear Colleagues,

“I treasure our walks.” The intense emotion behind this statement stopped me in my tracks. While walking our dogs has always been a favorite part of our time together, it never entered my mind that it would be the only time that we could safely spend together, and any misstep in our social distance could endanger the man I love. Such is life under the regime of COVID-19. We demonstrate our love by physically separating, despite having the technology to connect virtually. However, the privilege of 21st century technology is not without detriment. The more technologically connected we are, the more we are bombarded by news feeds (each with more dire predictions than the one that preceded it). The more we see pictures of friends and family on FaceBook and other social media platforms, the more we are reminded of the physical connection that we miss. I suspect that all of us have moments of petulant rage and self pity as we survey our lives and take stock of what we think we have lost. Is this the next phase of COVID-19 and will it ultimately be more damaging to humanity than the one that preceded it? What is the nature of that damage to ourselves and our patients and how do we mitigate it? CPS and NYCPS are hosting a free event this Sunday evening for psychiatrists across the country to learn from each other, share experiences, brainstorm solutions--and raise conversation topics for the next phase of the pandemic. We hope you can join us.

In a news article entitled “Mental illness will be ‘next wave’ of the COVID-19 pandemic” a reporter for a Canadian news channel noted that continued physical distancing will take a toll on our mental health. Quoting a public health expert who studied the psychological effects of the SARS epidemic, journalist Eva Ugeun-Csegne noted that the isolation - as well as the uncertainty about how long it may last - all contribute to increased anxiety, along with depression and increased substance use. The stress of caring for and home-schooling children, financial strain and unemployment adds to the burden.

South African psychiatrist Dr. Stoffel Grobler termed these stressors “burn-in,” likening them to cabin-fever – i.e. the psychological response to being cooped up in confined spaces during winter. Dr. Grobler wrote that the feelings of restlessness, depression, irritability, and decreased motivation all sounded “very familiar considering how people have been reacting to the lockdown measures.” He added, “In many countries including South Africa, the rate of domestic violence has also increased. Glaring reminders that we are all suffering psychologically.” According to Dr. Grobler “it seems logical that the prevalence of mental illness is about to increase exponentially” (SAMA Insider, May 2020, in press).

Dr. Grobler in not alone in his concerns. In their article “Mental Health and the COVID-19 pandemic” published yesterday in the New England Journal of Medicine, Drs. Pfefferbaum and North wrote that the effects of public health emergencies “translate into a range of emotional reactions” (such as distress or psychiatric conditions) and unhealthy behaviors (e.g. substance use). In enumerating the emotions which result from being quarantined, they described the symptoms enumerated in Dr. Grobler’s “burn-in” hypothesis down to the last word. They also sounded the alarm that individuals with pre-existing psychiatric problems are at greatest risk for adverse psychosocial outcomes. This sentiment was echoed by APA President elect, Dr. Jeffrey Geller, in a recent Psychiatric News article in which he and his co-author noted, “for many individuals with mental illness, being alone is a terrible burden, far beyond that experienced by others."

Sometimes that burden is impossible to bear. In their article “Suicide mortality and Coronovirus disease 2019 – a perfect storm,” published last week in JAMA, Drs. Reger, Stanley and Joiner enumerated factors inherent to this pandemic that increase the risk for suicide. These factors are economic difficulties, isolation from family, decreased access to community and religious support, increased firearm sales, increased substance use and most unfortunately the coinciding of the peak season for suicide (late spring/early summer) with the predicted peak of COVID-19 infections. On a more positive note, the authors noted that there could be a “silver lining” to our current status quo. They hypothesized that the reason for a decline in the rate of suicide after past national disasters is a so-called pulling together effect where a community whose members are all subject to a detrimental event come together to support one another. In another recent JAMA article, The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention, the authors outline 3 steps, taken now, that can help prepare for the inevitable increase in mental health conditions. To those of us who are psychiatrists, our job is to cement that effort for our patients who cannot do this on their own. As psychiatrists we are obligated to help our patients deal with this pandemic, leading by example even on days when we are beset by our own pain and limitations.”

Ronald Reagan stated, “To sit back hoping that someday, someway, someone will make things right is to go on feeding the crocodile hoping he will eat you last, but eat you he will.” Mental health must not be given the last thought. A recent article in Forbes magazine summarized the strategies used by world leaders whose countries are thought to have had the best response to COVID-19. A realization of the seriousness of the problem, decisiveness, a willingness to embrace technology and empathy were all cited as characteristics of these progressive world leaders.

Is it a coincidence that all of these leader are female? Regardless, we as psychiatrists would do well to embody their forthright manner in dealing with COVID-19. We can do this! A foray into the travails of mental illness is a journey into the land of the uncertainty, and we have been trained to deal with it head on. Self-selected by our choice to become psychiatrists, we are usually adept at intuiting the feelings of our fellow human beings and empathizing with their struggles. We also need to be reminded that we have these qualities.

“I miss you,” I told my partner as we marched six feet apart through the bitter cold day. “Why?” Came his reply. “I am right here.”

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 April 15, 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.

April 8, 2020

CPS COVID-19 Resources - April 8th 2020 - Resilience: finding meaning and challenging reality with unity and ingenuity

Do you have a question, helpful resource, or tip for your colleagues? Email [email protected]

Dear Colleagues,

On a recent walk through the neighborhood my son asked, “When do think people will be able to shake hands with one another without thinking about COVID-19?” In posing a previously unthinkable question, my 11-year old touched on a singularly bizarre aspect of this pandemic that distinguishes it from most other calamities in history: our need to ensure physical distance from one another, even those we love. Last week I wrote about physicians and other healthcare workers making the gut-wrenching choice to separate from loved ones. This week, I too have begun that separation. Despite the physical distance (or perhaps because of it), I am learning to find meaning in this strange touchless world. Although it seems a distorted and upside down version of my prior life, I now know that loving someone can mean staying away from them -  and finding new and ingenious ways to love and appreciate them from afar. Early morning walks (albeit six feet apart), FaceTime cocktails and good night wishes are now the fabric of my life. Others in my profession have also written about how disconnection can invigorate connection (see CPS Member Kartiki Churi's article).

In his book, Man’s Search For Meaning, psychiatrist Dr. Viktor Frankl noted that human beings can survive almost anything if they find meaning in their suffering. A Holocaust survivor, Dr. Frankl, imagined himself giving lectures on his experience during the Holocaust while at the same time enduring the daily struggles that permeated his life in the camp. In her May 2002 Harvard Business Review article entitled “How Resilience Works,” Diane Coutu quoted, “More than education, more than experience, more than training, a person’s level of resilience will determine who succeeds and who fails. That’s true in the cancer ward, in the Olympics and its true in the boardroom." Ms. Coutu posited that there are three characteristics that make up resilience (whether it be in an individual or an institution): acceptance of reality (without false optimism), a deep belief that life is meaningful and what she described as “an uncanny ability to improvise.” Although written almost twenty years ago, this sums up what it will take for us to survive the ravages of COVID-19 in our personal and professional lives.

Acceptance of reality (or not?)

It’s sobering to think of the reluctant initial response of our government (and perhaps our own personal reactions) to COVID-19. But as we have learned, the world changes on a dime. The harsh reality is a deluge of critically ill patients, whose physicians are forced into making life and death decisions, all the while fearing for their own safety. We hear on a daily basis about lack of PPE and shortages of essential equipment such as ventilators and now of medications that are needed in order to safely ventilate patients. We have to arm ourselves with information (see JAMA article The COVID-19 Pandemic in the US: A Clinical Update) and let facts be our weapons, even when others wish to deny them. Several of you have written to me and expressed concern that your own facility has lagged behind in accepting the necessity of telepsychiatry and masking of staff, and reluctance to accept ideas of how to decrease infection risk. This is not the sort of reality we should accept. In its condemnation of the firing of Dr. Ming Lin, of Bellingham, WA, for taking his concern about lack of PPE to social media after hospital administration failed to respond to repeated requests, the American Academy of Emergency Medicine wrote, “it is an essential duty of a physician to advocate for the health of others.”

Meaning and ingenuity

A call  to action during this time of crisis applies not only to physicians who are working in emergency rooms and intensive care units. It applies to all physicians (see YouTube video: Stop Silencing Doctors: a clinical manifesto). In addition to speaking out against injustices in other areas of medicine, we have got to advocate for our patients. Our time for action is now. Our knowledge, experience and beliefs are important. There will be a tsunami of mental illness in the wake of the COVID-19 pandemic, and we must develop safe and effective ways to deliver behavioral health care. The way in which we practice psychiatry has changed at warp speed, and therein are some beautiful examples of ingenuity: an Israeli hospital developed an inpatient unit for psychiatric patients with COVID-19 that is managed on an almost exclusively virtual platform, both Peakview Behavioral Hospital and Centennial Peaks have units for psychiatric patients with COVID-19 (see below), and the APA held a well-informed webinar on caring for such patients (also see JAMA Addressing the COVID-19 Pandemic in Populations With Serious Mental Illness psychiatry). In terms of assisting our fellow physicians, CPS and CMS are holding a webinar this Friday on physician wellness during the crisis and  the Colorado Physicians’ Health Program (CPHP) has already set up a helpline (720-810-9131) for doctors who are trying to manage their own fears and anxieties as they treat individuals with COVID 19. Last week Governor Polis issued executive order 20-E-05 requiring carriers to reimburse providers for provision of Telehealth services including those that are solely audio-based. We need more of these examples.

We did not choose this pandemic. But we can choose how we react to it. Knowing what to accept or not is the first step. From there, what is required is the deep belief that life is meaningful and adopting an uncanny ability to improvise. As I told my son, “When else in history would we have been so thoughtful about what we value in life, the people we love and how to connect to them?"

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 April 8, 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.

April 7, 2020

If you are interested in COVID-19 volunteer opportunities, please see the information below.

Thank you for your interest in volunteering during the COVID-19 crisis.
CPS is grateful to have members like you who are willing and able to share your time and expertise!

Do you have a question, helpful resource, or tip for your colleagues? Email [email protected]

Colorado Psychiatric Society COVID-19 Resource List

April 3, 2020
Please note links and opportunities are provided as a convenience and do not imply endorsement, legal or financial advice. Users should seek appropriate accounting, legal or other professional advice to address specific facts and circumstances

April 1, 2020

Do you have a question, helpful resource, or tip for your colleagues? Email [email protected]

Dear Colleagues,

Another week has gone by and it seems like a month. During this time we have seen our country receive the auspicious designation of number one in Coronavirus cases worldwide with a third of those cases occurring in New York. Two-thirds of the country is now locked down. Worldwide, although the number may be different, the trend and the restrictions are similar.

For me, these last few weeks have been a reminder to appreciate the beauty of life during my early morning runs around the neighborhood, knowing that in my country of origin (South Africa) such sojourns are currently forbidden. I am also grateful that I have a home in which to shelter – and that my engagement in spring cleaning has led to the discovery of childhood mementos. Sharing these treasured items with my children has made our relationship closer, as have our daily walks and discussions as we share household chores (i.e. I clean the guinea pig cage while my daughter watches…a refrain that I am sure many parents will understand). I have also learnt to socialize virtually, reminding my introvert friends to put down their books and check on us extroverts – as the meme goes, “we are NOT okay with this.” In addition, although I am currently seeing patients via telepsychiatry, I know that those days are numbered and once I begin inpatient work again I will very likely have to make the heart-wrenching decision that many of our colleagues have already made (see NYT Opinion article Doctors Are Writing Their Wills): living separately from my significant other and my children. And updating my will. Sobering to think of this, but it has very quickly sharpened my focus on what is important to me: my family (including those family members with four legs), and my commitment to advocating for the safety and welfare of our patients and colleagues.

We hear the outrage from our colleagues in New York and elsewhere regarding lack of PPE and shortage of other essential equipment. Physicians and other health care professionals who have spoken out about the condition in their hospitals are being muzzled and, in some instances, threatened with disciplinary action (see Bloomberg and Kevin MD articles). This is happening not only in emergency rooms and medical units, the frontline for COVID-19, but also in some behavioral health units. Absent a clear dictum for how we manage patients with mental illness through this crisis, facilities have adopted various approaches, with each hospital system apparently developing its own plan as to how to streamline admissions, maximize virtual care, and isolate positive patients. I believe history will judge harshly those who continue to place profit before safety of patients and staff, and we have a duty to speak out against such practices when we see them.

Thankfully, the actions of many institutions have been laudable: numerous entities have been quick to embrace telepsychiatry in order to mitigate exposure of their staff members to potentially positive patients – and vice versa. Many hospitals and behavioral health units have also adopted the strategy of masking all staff members – and in some cases, patients, too. In addition, with a reduced number of admissions many psychiatric units are in a better position than they would previously have been to promote social distancing. Although I don’t by any means have all the answers to this, I do think that reaching out to our colleagues in facilities around the country is useful. To this end I am including a document sent by a colleague at Mt. Sinai and I am also hoping that you will register for (or watch the recording of) the APA’s webinar on inpatient psychiatry. I am also including a link for Peakview Behavioral Hospital, which has opened a unit dedicated to COVID-19 positive patients.

In addition to providing links for telepsychiatry, resources for inpatient admission (although they be disparate and currently scattered), how else can we assist our colleagues, ourselves and our patients?

I invite you to attend townhall meetings and other virtual events with the house of medicine in our state. I think we may need to draft our own letter in the coming weeks detailing the resources we will need to manage the psychological effects of this pandemic not only on our patients but on healthcare providers. In terms of assisting our fellow professionals, CPHP has already set up a helpline (720-810-9131 - additional information below). I, too, need help in the form of hearing from you about the struggles you are faced with in providing care to your patients during this time and how you are managing to take care of your own mental health and that of your family and loved ones. After all, psychiatry is about detailing the experience of humanity in stories, we all have stories to tell, some uplifting, others sobering and yet more filled with humor and hope. As my cousin, an artist herself, posted: “Writers! You have the most incredible story unfolding before your eyes. Take copious notes, and let your imagination soar.” I am hopeful that, in sharing our stories and our resources we will be instrumental in the creation of some positivity in this strange new world.

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 April 1, 2020

March 25, 2020

CPS Resource list is below the Message from the President
To see past resource lists, messages, and articles, click here
Do you have a question, helpful resource, or tip for your colleagues? Email [email protected]

Dear Colleagues,

I can’t believe that it’s only been a week since I first wrote you, hoping to provide resources you might find useful as we band together (albeit at a social distance) in our fight against COVID-19. Since then, it’s been a week of restaurant, store and business closures. Though some of these businesses are labeled ‘non-essential’ they are all but that for the workers whose livelihoods depend on them. In addition, one in four Americans has been ordered to shelter in place. For those of us not yet in this position, the rhythm of our day to day lives has been severely disrupted. Yet, as we grapple with our own grief at the loss of life as we knew it, as well as the fear of further loss, we are forced to get our act together in a hurry to protect and care for our families and our patients. We also need to maintain our strength and sanity as we learn to adapt to this strange new world.

In my interactions both with members of our psychiatric community in Colorado as well as around the country, I have found an overwhelming thirst for knowledge and discourse as we scramble to find our way forwards. It has been sobering to find that our virtual meetings have run hours longer than expected as we share information about COVID-19 and find ways to help each other. Here’s what’s come up this week:

Telepsychiatry

Many of you have already been using telepsychiatry in your practices previously. Rules and regulations regarding the use of telehealth in total (and telepsychiatry in particular) have evolved rapidly over the last week. Some of the changes include lifting of restrictions regarding HIPAA compliant modalities and seeing patients across state lines, and CMS mandated changes in billing (with many insurance companies following suit).

Inpatient psychiatric facilities and correctional facilities

While telepsychiatry has been useful in the outpatient setting, some facilities are using it for partial hospital, residential and inpatient care, although there may be greater logistical difficulties in its implementation. Nonetheless, patient check ins, rounding and treatment team meetings may still be accomplished virtually, thus enabling us to adjust medication, provide counsel and exchange information all the while reducing exposure. That being said, for many institutions the mere act of getting the patient in front of the virtual setting may prove cumbersome and take up additional staff time. In addition, there are some tasks and procedures that require physician presence (ECT, ketamine infusion). Perhaps having physicians attend in person on a rotating schedule (and exempting those at high risk from direct patient contact altogether) may be useful - suggestions welcome! But what do we do to prevent COVID-19 from taking hold in an inpatient unit and killing our patients as it did in a psychiatric unit in South Korea? Dr. Dinah Miller’s article in MD Edge Psychiatry details concerns particular to inpatient units and our treatment of acutely psychiatric patients and provides some preliminary thoughts and guidance. However, many of us are still grappling with the peculiarities of our local situation and how each hospital chooses to identify and isolate potential COVID-19 cases and protect their staff - or not.

While the sobering piece by Dr. Hylton is written from the perspective of a pediatric ER doctor, her statements apply to us, too. As Dr. Hylton writes, some hospital administrators “emboldened by the lack of consistency in the CDC’s guidelines are insisting that masks and PPE are unnecessary for all but certain high-risk procedures and patients.” Ignoring the potential for widespread community spread through asymptomatic individuals, some facilities have expressly forbidden front line staff from wearing PPE in the name of “not scaring the patient” even if they are able to procure such equipment from a third party source. This issue has been discussed with APA leadership, and it is likely that local and state government involvement will be required to address this concern.

Concern for the psychological effects of COVID-19

We likely all experienced our profession being the forgotten stepchild of medicine. Now is no different. There are few if any media reports about psychiatric illness and even less consideration as to how patients, already mentally fragile, are coping with a new and troubling reality. According to my APA colleagues in the State of Washington, there is already an increase in domestic violence and substance use (even in those who had maintained sobriety for an extended period of time). Individuals with eating disorders are particularly vulnerable as they suffer both the mental and physical stigmata of their illnesses. Dr. Jennifer Gaudiani provides us with an excellent outline of her concerns regarding COVID-19 and eating disorders. I will be providing more information on the effects of COVID-19 on our patients in future communications. If you have articles you would like us to share, please send them to [email protected].

I do believe that we will see a greater need for mental health care as our new “normal” emerges, so let’s continue our virtual banding together and keep each other strong and help each other move forward. Thank you to my colleagues on the CPS Executive Council, Area 7 and the APA for their ideas and discourse.

Patricia Westmoreland MD
President

Colorado Psychiatric Society COVID-19 Resource List

 March 25, 2020

March 16, 2020 

Dear Dr. ,

As President of CPS I have heard from many of you in response to the rapidly evolving developments surrounding the spread of COVID-19. I am concerned about the impact of this pandemic on my family, my patients and the more vulnerable members of our society. How we protect those we hold dear? How do we honor our obligations to the patients we care for? How do we minimize the risk of becoming ill ourselves? Minds wiser than mine have pondered these issues, and sadly countries other than our own have grappled with the consequences of not being prepared - let’s hope we can learn from these lessons.

As we all scramble to wash our hands more frequents and practice social distancing, I think it’s important to remember that it is now in this time of crisis that we as human beings need each other more than ever. As a social person I am disappointed in the cancellation of meetings as well as social gatherings. I enjoy exchanging ideas with others as well as interaction on a personal basis. Nonetheless, I strongly believe it is our moral obligation to carefully evaluate our travel plans, stay put and minimize the risk not only of getting infected ourselves, but passing COVID-19 to others, especially those who are vulnerable in our society. To this end I am sharing a Newsweek article that has been distributed on the APA Area 7 and Assembly listservs as well as by an ID colleague whose work I greatly respect. I sincerely hope that by delaying the gratification we all feel will help us “flatten the curve” and reduce the impact of COVID-19 on our healthcare system.

Speaking of which – what is like to care for patients with COVID-19? Dr. Brooke Parish, MD, New Mexico Representative to APA gave me permission to share with you her beautifully articulated piece regarding her experience in caring for individuals with COVID-19. Dr. Parish, who is also an internist, traveled to Lackland Air Force Base several weeks ago to care for patients from the Diamond Princess.

Along with our CPS Executive Council and our Disaster Representative Scott Simpson, I am monitoring the rapidly evolving situation. While we do not want to be duplicative, in response to member requests, we have compiled a list of resources that may be helpful (attached). Many of you have asked about the role telepsychiatry will play. To this end we have included information from PRMS as well as the APA. Please contact us if we can be of further assistance. Best wishes for your continued health and safety.

Patricia Westmoreland MD

CPS President

CPS COVID-19 Resources 3-13-2020(2).docx

PRMS-coronavirus alert_1(1).pdf

PRMS-coronavirus-alert-2+telechecklist(1).pdf