September 16, 2020

Physician Mental Health During COVID-19: A Call to Action

I imagine that all healthcare professionals (HCPs) are experiencing a surge in stress during the COVID-19 pandemic. We all need resources to take care of ourselves so we can perform well in our care of patients. Physicians as a group are self-sacrificing, dedicated to helping others, and loathe to ask for help or show signs of weakness. Medical training amplifies all these characteristics. It is a painful irony that, at this time of surging HCP distress, the peer assistance organization to which we have turned for 34 years for confidential assessment and treatment monitoring is under serious threat. In this letter I will discuss HCP distress during the pandemic, consider how moral injury has been amplified by the pandemic, introduce the threat to CPHP as a unique cause of moral injury to Colorado physicians and physician assistants, and present potential solutions.

As early as March of this year we were seeing reports about mental health outcomes among health care workers in Wuhan. In June, the published results of a survey of HCPs in New York demonstrated that psychological symptoms were common, with 57% of respondents reporting acute stress, 48% endorsing depressive symptoms, and 33% acknowledging anxiety symptoms. Lack of control, fear of transmitting COVID-19 to family, and fear for the health of family and friends were the most upsetting stressors, each endorsed by over 70% of respondents. The survey found that, while physical exercise was the most common coping strategy (59%), the majority of participants (51%) expressed interest in one or more proposed mental health wellness activities, especially online self-guided counseling with access to an individual therapist (33%) and individual counseling (28%). Some medical centers have responded by creating innovative pandemic wellness programs for their workforce, such as this one from Rush University in Chicago. They describe Wellness Rounds, a Wellness Consult Service, onsite confidential counseling, and a crisis response algorithm.

Most reports of HCP distress highlight the difficulties of working with critically ill and dying patients who are isolated from the support of their families, the fear of becoming ill or transmitting the virus to loved ones, concerns about access to PPE, and a sense of lack of control or uncertainty. An additional concern has been moral injury, which comprises the feelings of anxiety, helplessness or outrage that occur when HCPs feel unable to surmount inequities or deficiencies in the health care system, such as when shortages of PPE or other resources force HCPs to make decisions that are contrary to their commitment to healing, and awareness of how deeply rooted structural racism has made people of color especially vulnerable to the pandemic. This pre-pandemic video from Dr. Z, who is best known for his satirical raps about health care, is a profoundly serious six-minute lesson that defines moral injury and its roots in a broken health care system. The problems discussed in the video have been amplified during the pandemic. This interview looks at the effect of “moral stress” on individual HCPs and explores lessons from the pandemic about our health care system. This APA guidance document on moral injury in the pandemic is a must-read for physicians, administrators and other leaders. It asserts that, “Moral injury is associated with strong feelings of shame and guilt and with intense self-condemnation and a shattered core sense of self.” It highlights the circumstances in the current crisis that may lead to moral injury and introduces three tiers of interventions that health care systems may implement to reduce risk for such injury.

Although the literature on moral injury is primarily focused on situations in which HCPs must make decisions about treatment that are counter to their moral commitments to providing the best possible care to patients, it is showing up in a unique way right now in Colorado health care. The Department of Regulatory Agencies (DORA), the state entity that oversees all the licensing boards including the medical board, has awarded the peer health contract to Peer Assistance Services (PAS) instead of the Colorado Physician Health Program (CPHP). For background about CPHP and the importance of a confidential peer health program for physicians, physician assistants and medical trainees, please read my summer 2019 newsletter article, “Safe Haven Is Integral to Physician Wellness.” At the time of this writing, CPHP has appealed DORA’s decision and is simultaneously encouraging a public education campaign about the vital importance of confidential treatment of physicians by other physicians in order to keep the medical workforce healthy and our patients safe.

To learn more about CPHP’s campaign, check out www.PatientSafetyColorado.com, a website that outlines key issues and calls us to action. CPS’ Executive Council voted unanimously to include CPS as a supporter of confidentiality for physician treatment. On the website you will find a copy of former State Senator Irene Aguilar’s Denver Post Guest Commentary, “Doctors in crisis deserve privacy as they seek treatment” (September 2, 2020). The website also contains examples of other letters to the editor written by physicians. CPS has submitted letters to the editor as well as a longer letter to the DORA Director who oversees the Procurement and Contracts Department, the Executive Director of DORA, Governor Polis and other leaders asserting our concerns about the change in the peer assistance contract. 

If you feel moved to write a letter to the editor of The Denver Post, The Boulder Daily Camera, The Colorado Springs Gazette, or your local paper, please do so. Especially if you have experience of any kind with CPHP, whether as a client, a clinician to whom they refer their clients, or a medical director who refers employees for evaluations, consider sharing your perspective about the value to the public of allowing physicians to have confidential assessment and treatment by highly vetted physicians and other clinicians. If a 150 word letter to the editor isn’t your style, please consider a Tweet: https://twitter.com/PatientSafetyCO.

In addition to this activism, there are other ways we can work to improve the mental health of our healthcare workforce during the pandemic.  This thoughtful opinion piece offers strategies for maintaining resilience and optimism during this crisis. This inspiring article proposes steps forward to humanize the health care system to address the pre-pandemic problems that lead to HCP burnout. Please also check out the last two articles in the Resources for Providers list below, one on global spikes in physician burnout during the pandemic, the other on effective wellness coaching of physicians.

As psychiatrists, we are in the best position to attend to the mental health of our health care colleagues. Whether through leadership in our institutions, through our clinical activities, or through activism, we are the definitive spokespeople for the power of prevention and treatment of emotional distress. I hope each of you will join me in standing up to advocate for what we know is right, and to identify and eradicate moral injury in all its manifestations.

Stay healthy,

Claire

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 September 16, 2020

Updates

THANK YOU to all the CPS members (and others) who have sent in resources, written articles or reached out to us about these emails! We love hearing from you!

 

 
Resources for Providers


(Mis)Understanding COVID-19 - piece by CPS Member John L Fleming, MD, DLFAPA (download)


American Journal of Psychiatry Residents' Journal - Involuntary Hospitalization During the COVID-19 Pandemic (9-10-20)


PsychNews - COVID-19 Psychiatric Units Meet Dual Needs (9-1-20) Quotes CO psychiatrist Francis Lotrich, MD, PhD.


PsychNews - Pandemic Puts Hold on Major Changes to Medicare Quality Payment Program (9-10-20)


PsychNews - Supportive Psychotherapy - A phased approach to psychotherapy for stress response syndrome can be adapted to symptoms that may be exacerbated by the pandemic (9-10-20)


JAMA - Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic - Lower income, having less than $5,000 in savings, lower social resources and having exposure to more stressors (eg, job loss) were associated with greater risk of depression symptoms during COVID-19 - and Invited Commentary: Mental Health Inequities in the Context of COVID-19 by Ruth S. Shim, MD, MPH (9-2-20)


JAMA - Assessment of Mental Health of Chinese Primary School Students Before and After School Closing and Opening During the COVID-19 Pandemic (9-11-20)


Pediatrics - Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey - more than a quarter of parents stated that their mental health has worsened since March and reported increasing behavioral issues with their children. Also discusses increases in food insecurity (9-1-20)


Psychiatric Services - COVID-19 Concerns Among Persons With Mental Illness (9-3-20). Also see https://www.forlikeminds.com/.


Psychiatric Services - The Importance of Psychiatric Rehabilitation Services During and After the COVID-19 Pandemic (9-1-20)


JAMA - COVID-19: Beyond Tomorrow Opportunities for Research on the Treatment of Substance Use Disorders in the Context of COVID-19 (9-1-20)


NYT - How the Aging Immune System Makes Older People Vulnerable to Covid-19 (9-8-20)


NYT - How the Coronavirus Attacks the Brain It’s not just the lungs — the pathogen may enter brain cells, causing symptoms like delirium and confusion, scientists reported (9-8-20)


Medscape - Physician Income Drops, Burnout Spikes Globally in Pandemic (9-11-20)


KevinMD - When coaching physicians with wellness, don’t lead with mindfulness (9-4-20)

 

 
Resources for Patients


Washington Post - The pandemic is ruining our sleep. Experts say ‘coronasomnia’ could imperil public health (9-3-20)


Rocky Mountain Welcome - COVID information in 19 languages specifically for immigrants and refugees in Colorado.


Colorado Health Foundation - 2020 Results - Key Takeaways from Conversations with 2,275 Coloradans - Coloradans' Views on COVID-19, Racial Equity and Major Health Issues Facing the State (9-9-20). Learn more at Pulse: The Colorado Health Foundation Poll .


The Mayo Clinic - COVID-19 safety tips for travel, restaurants, the gym, and more


KevinMD - In the rush to get back to school, let’s not forget teachers’ mental health (9-3-20)


Letters Against Isolation - Send Self-Isolating Seniors Letters to Brighten Their Days!


NPR - How To Care For Older People In The Pandemic (And A Printable Guide!) (article, minibook download and 4 minute audio) (9-4-20)


NYT - How the Aging Immune System Makes Older People Vulnerable to Covid-19 (9-8-20)


For Like Minds - Coronavirus Peer Support Group - online peer support community dedicated to the recovery and wellness of people living with or supporting someone with mental illness, substance use, or a stressful life event.


NYT - How the Coronavirus Attacks the Brain It’s not just the lungs — the pathogen may enter brain cells, causing symptoms like delirium and confusion, scientists reported (9-8-20)

 


Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page


REGION 8 HHS and FEMA COVID-19 RESOURCE DOCUMENT.pdf (download) (6-15-20) 


HHS Protect Public Data Hub

 

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.


 

September 2, 2020

Pandemic Rage and Its Vicissitudes

Have you noticed the anger? I feel it rise in me when an unmasked stranger infringes on my personal space. I see it rise in others when I step off the sidewalk to avoid them, and they yell at me for being unfriendly. I see it everywhere in the news about protesters and counter-protesters, in political speeches, in accelerating statistics about child abuse and homicide. My topic this week is pandemic rage, which I believe flows from our collective reduced capacity to manage mounting stress, and which may be connected to increases in general hostility, domestic violence and gun violence.

There have been many descriptions of mounting anger during the pandemic. From a blog about “mom rage” to an international analysis of Twitter word clouds, which found that emotions have evolved from fear to anger as the pandemic has progressed, to an essay in Vice about pandemic-fueled hate that is just too fun a read to skip, we see many expressions of difficulty managing anger in the popular media. The scientific literature on pandemic rage so far includes a research report about increased stress and anger among youth since the pandemic began, and a Brazilian Journal of Psychiatry editorial that connects the anger to underlying fear. This interview of a Harvard psychologist also explores pandemic-related anger as a secondary manifestation of fear.

There is a lot to fear in a pandemic, and one fear that has been prominent among public health officials, mental health professionals, and advocates for women and children is a rise in domestic abuse and violence since the lockdowns began. This emergency medicine article, published in late April, describes increased reports of intimate partner violence from Wuhan, France, Cyprus and Singapore, and provides data about domestic violence reports and arrests in several US cities during the first month of lock-down. This news story describes a surge in domestic violence, including murders of women and children in the UK since March.

This trauma psychology commentary considers the surge in domestic violence during this pandemic within the context of other disasters, and suggests measures we should take, including increased funding to shelters and hotlines, heightened public and clinician recognition of domestic violence, and improved planning for women’s and children’s safety in future disasters. Those suggestions are elaborated further in this thoughtful paper about the role of psychiatry in addressing pandemic-related domestic violence. Here is an example of how a health system can directly educate the public about the intersection between domestic violence and COVID-19, including pragmatic steps a woman may take to ensure her and others’ safety. It includes a link to an app called MyPlan that offers safety plans for a variety of intimate partner violence situations, and provides assistance in assessing risks and locating resources.

It is impossible to talk about pandemic rage without also discussing firearms, which increase the lethality of all angry encounters including those in domestic violence. According to Guns Down, an American woman is fatally shot by a current or former intimate partner every 16 hours. This heart-wrenching report from the University of Pennsylvania notes that March 2020 was the worst month for gun violence in Philadelphia in the last five years, and describes the impact from the perspective of surgeons responding to gunshot wounds in the midst of a pandemic. This paper differentiates the gun buying surges this year in March and June from other such surges. An additional three million guns were sold from March through June compared to previous years. In 2020, the gun buying frenzy has been in response to the pandemic and the George Floyd (and related) protests; prior surges have been responses to uncertainty about changing gun policy.

Pandemic-fueled fear drove thousands of Coloradans to purchase guns.  From March through June of this year, the Colorado Bureau of Investigations conducted over 188,000 background checks for firearm transfers, an increase of 71% over the same period last year. Ceasefire Colorado reports that between January 1st and July 31st, there have been 142 firearms homicides in Colorado, up 29% from the same period in 2019 (data from Gun Violence Archive). As of August 5th, three Colorado children died as a result of “an accidental shooting.” Two of these children were only three years old.

Widespread increases in anxiety, fear, grief, economic strain, disruptions to daily routines, and racial and economic inequities have frayed all our nerves. Friction at home, on the sidewalks, in stores, and at the workplace is higher. Physical distancing regulations, including reduced access to school, childcare and extended family members, leaves partners and parents little chance to deescalate and reset. Adding a firearm to this tinderbox increases the risk of tragedy.

What can psychiatrists do for the public, our patients and ourselves? We can continue to offer policy guidance to public officials to increase social support to families, fund mental health treatment, and enact gun reforms. We can repeat the suggestion by our pediatrician colleagues to end active shooter drills in schools during the pandemic so as not to further traumatize children. We can treat our patients with compassion for their anger, and remember to assess their risks for being the perpetrator or recipient of violence. We can check in about our own mental wellbeing, including our own degree of anger, frustration, and fear.

Those of you who know me may feel a bit incredulous that I’m ending this letter with a Christian stay-at-home-moms’ blog. The author tapped into my own truth when she wrote, “There’s something no one tells you about anger: It’s the juice. Anger has energy and power in it. You shouldn’t let it hijack you, yes. But properly directed, anger catalyzes change.” I choose the vicissitude of my pandemic rage: sublimation. Let’s use the energy of our anger, but not the venom, to fuel our responses now.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 September 2, 2020

Updates

If you missed any of the PsychSummit: Psychiatry in an Evolving World sessions, they can be viewed here.

Register here for the APA 2020 State Advocacy Conference  - September 26 (virtual). Colorado House Representative Dr. Yadira Caraveo is one of the speakers!

APA's COVID-19 Information Hub - (downloads)

 

 
Resources for Providers


PsychNews - Talking Is a Good Place to Start by CPS Member Kartiki Churi - What do you tell your children of color when they feel unsafe because of recent events? (8-26-20)


Colorado Medical Society - Primer on New paid leave laws in the wake of COVID-19 (download) What Colorado Health Care Providers Need to Know for 2020 and Beyond (September 2020)


NYT - The Psychiatrist Will See You Online Now Experts have long predicted that psychotherapy was poised to go virtual. The pandemic may prove them right (8-28-20)


Colorado Health Institute - New Financial Map Tracks Federal Coronavirus Relief Funding in Colorado (8-29-20)


JAMA - The Impact of COVID-19 on Individuals With Intellectual and Developmental Disabilities: Clinical and Scientific Priorities (8-24-20)


PsychNews - Special Report: COVID-19 and the LGBTQ Community (8-27-20)


Psychiatric Services - Telehealth Beyond COVID-19 - Scroll down to Factors to Consider for the Future of Telehealth (8-19-20)


CDC - Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020 40% of 5,412 adults who responded to a survey in late June from the CDC reported dealing with mental health issues or substance use during the pandemic. Suicidal ideation was also elevated. Those at highest risk were 18-24 years old, Hispanic, or essential workers (8-14-20)


PsychNews - Update - HHS Issues Interim Rules on Sharing of SUD Treatment Records (8-31-20)


KevinMD - Who is taking care of the minority physicians? (8-21-20)


CDC - COVID-19 in Newly Resettled Refugee Populations (8-25-20)

 

 
Resources for Patients


Elemental - Your ‘Surge Capacity’ Is Depleted — It’s Why You Feel Awful Here’s how to pull yourself out of despair and live your life (8-16-20)


Washington Post - Time to ditch ‘toxic positivity,’ experts say: ‘It’s okay not to be okay’ (8-19-20)


NYT - Is the Lockdown Making You Depressed, or Are You Just Bored? We shouldn’t pathologize normal unpleasant emotions — which doesn’t mean we shouldn’t do something about them - by psychiatrist Richard Friedman who spoke at the CPS Spring Meeting (8-21-20).


Governor Jared Polis
-  Don’t forget to wear a mask today and wear it correctly!


Colorado Health Institute - Shifting Hotspots Show Progress, Challenges - See graphic of COVID-19 outbreaks in Colorado by size, date and setting (8-21-20)


NYT - 5 Things We Know About Flying Right Now As passengers cautiously return to air travel, there are a few issues worth considering — from middle-seat policies to questions about virus transmission on airlines (8-20-20). Also see CDC page on Travel during the COVID-19 Pandemic (updated 8-26-20)


LA Times - Isolation, confusion: What the COVID-19 pandemic is like for people with dementia (8-18-20)


CDC - COVID-19 Parental Resources Kit Ensuring Children and Young People’s Social, Emotional, and Mental Well-being Includes resources by age group: Early Childhood (0-5y); Childhood (6-12y); Adolescence (13-17y); Young Adulthood (18-24y)(Updated 8-20-20)


The Academy for Lifelong Learning - Online Course for the general public - Experts Struggle and Decide: Contemporary Issues in Medical Ethics Starting September 15 and continuing for eight Tuesdays from 10 to 11:15 AM, experts from various fields - including CPS Members Jeremy Lazarus and Abraham Nussbaum - will examine in depth some of the most pressing issues in medical ethics.


MHA - Do you feel like drugs or alcohol negatively affect your day-to-day life? Take a free, anonymous screening today.


The Colorado Sun - Coronavirus moved some substance treatment services online in Colorado — possibly permanently Private and group therapy sessions are now happening over Zoom. Clinicians in rural areas are connecting with clients over the phone. Even AA took 12-step programs online. For many, it's working well (8-21-20)


NYT - How to Help Your Child Wear a Mask There are ways you can help make wearing one more tolerable, like adjusting the straps for a better fit, sewing it onto a baseball cap or headband, or distracting children with bubble gum or toys while you slip it on. (8-19-20)

 


Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page


REGION 8 HHS and FEMA COVID-19 RESOURCE DOCUMENT.pdf (download) (6-15-20) 


HHS Protect Public Data Hub

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.


August 19, 2020

Pregnancy and the Postpartum in a Pandemic

Two of my patients delivered babies in the last month, and my niece is due in a few weeks. All three women, two of them health care professionals, have had very different pregnancy and delivery experiences than they had anticipated when they first learned they were pregnant, pre-pandemic. Fortunately, all have remained physically and emotionally healthy, although two of the three have had to contend with more worry than usual. This is in contrast to the stories of three other Colorado women, each of whom had COVID-19 during their pregnancy or delivery.  In this letter, I’ll summarize the known medical risks to women and babies posed by COVID-19, and then delve into the experience of pregnancy and the post-partum, including what we know so far about mental health outcomes during the pandemic.

We know that pregnancy causes changes in a woman’s immune system to reduce the likelihood of her body rejecting the fetus. This immunosuppression may increase a woman’s susceptibility to the novel coronavirus. Data from the CDC released in late June suggest that pregnant women may be more susceptible to COVID-19, and that Black and Hispanic women are disproportionately affected. Among 91,412 women of reproductive age with coronavirus infections in the first five months of 2020, the 8207 who were pregnant were 50% more likely to end up in intensive care units (ICUs) than their nonpregnant peers. Pregnant women were also 70% more likely to need ventilators, although they were no more likely to die. However, a much smaller study from Sweden cited in this article found that women with COVID-19 were nearly six times as likely to be admitted to an ICU than their nonpregnant, COVID-19-infected peers. The latter article elaborates on several possible mechanisms through which pregnant women are more susceptible to the effects of the virus.

So far, there are reassuring reports about fetal health despite the mother’s COVID-19 infection. Most babies are born uninfected and without evidence of placental infection, although there have been reports of both of those occurrences. However, because the pandemic is relatively new, we have limited data about the consequences of first trimester exposure.

Because of concern about exposing pregnant women to health care settings during the pandemic, they may have fewer in-person prenatal visits. One of my patients who had second trimester spotting struggled with the decision about whether to go in to the clinic to be checked, or stay home to protect herself and her baby from coronavirus. Reassuringly, this Mass General study found no meaningful association between the number of obstetrical visits and novel coronavirus infection.

We know that attentive prenatal care improves outcomes for women and their infants, and is one of many healthcare disparities for women from minority populations. This news story and interview discusses the pandemic’s effects on Black mothers, including their experiences of implicit bias in healthcare settings.

The pandemic has drastically changed the delivery experience as well. As outlined in this article, hospitals vary in their labor and delivery (L&D) policies depending on the status of the pandemic in their community and other factors.  If a laboring woman tests positive or has symptoms suggestive of COVID, she may be allowed only one companion. Women who are not infected may be allowed more companions, but everyone must remain masked the entire time. The Colorado Department of Public Health and the Environment (CDPHE) released helpful guidance for L&D practices and breastfeeding. Earlier in the pandemic, the American Academy of Pediatrics (AAP) advised separation of potentially infected mothers from their newborns. In late July, AAP changed their recommendations to reflect recognition of the importance of breastfeeding and bonding, and the additional knowledge gained over time about the relative safety of newborns even when their mothers have COVID-19.

This article proposes areas for future research, and emphasizes the need for “mega-studies” to gather meaningful data about true incidence of maternal coronavirus infection, mother-to-child transmission, breastfeeding recommendations, long-term effects on fetal and child development, and long-term health service delivery changes. One way to gather large cohorts is through international registries, and there is now an International Registry of Coronavirus Exposure in Pregnancy.

From a medical standpoint, we now know that pregnant women are at greater risk from the coronavirus, but that their newborns are relatively safe. From a mental health perspective, the experience of pregnancy during the pandemic is complex and the issues are not yet well defined. A Canadian study found doubled rates of depression and anxiety in pregnant women in April 2020. Here is a link to the abstract, from which you may download a PDF of the entire study. Alternatively, you may prefer the news story associated with the study, which summarizes the results and suggests that social distancing may be the cause of this phenomenon, although I would add that heightened anxieties about health and the delivery could also play a role.

Becoming a new mother during a pandemic also entails disappointing changes from one’s expectations of this usually joyous time of life. This article dubs this phenomenon “social pressure shift” and offers an empathetic view of how a mother’s experience may differ from her expectations, from not having a regular baby shower, to not having parents from out of town present for the delivery, to steeply curtailed social visits after the birth. Furthermore, lactation consultants, essential resources for new moms or mothers of babies with problems latching on, are no longer as accessible. This article makes connections between the support of a lactation consultant, successful breastfeeding, infant health, and post-partum depression. I would add that frustration or failure in breastfeeding may also impact mother-infant bonding, with potential long-lasting relational impacts.

Increased stress and decreased social support may explain the rise in observed post-partum depression and anxiety since the pandemic began. Although there is no firm data yet, this news story quotes an external relations officer for a maternal mental health clinic in New York who says call volume has increased three-fold. This article by a researcher offers a sneak peek at results from a global survey of pregnant women in the pandemic. In the survey, over 70% of women reported clinically significant depression or anxiety, and over 40% screened positive for post-traumatic stress disorder (PTSD).

Psychiatrists know that maternal mental health has profound implications for child development and the mental health of subsequent generations. It is imperative that we meet maternal mental health needs during this pandemic. This article offers pragmatic suggestions for obstetricians and mental health providers, including ensuring that our patients are not being excessively strict in their physical distancing precautions to the point of isolating at home, and being proactive in our surveillance for and treatment of antenatal and postpartum psychiatric disorders. We may also guide our pregnant patients toward new resources, such as this site designed to help women identify doulas, lactation consultants and other supports in their area.

In conclusion, we are still learning about the medical and mental health implications of the COVID pandemic, but what we know so far suggests that obstetricians, pediatricians and psychiatrists must team up to bolster the safety and wellbeing of pregnant women, new mothers, and babies. We need more research, but we must not wait for the research to take action now. I am meeting more often with my pregnant and post-partum patients, emphasizing self-care and social support, helping them manage excessive anxiety, and judiciously adjusting medication when needed.

This is both a challenging and gratifying time to be a psychiatrist. Keep up your own well-being so you remain available for our important work.

My sincere gratitude goes to Kartiki Churi, MD, for assistance gathering resources for this letter.

Stay healthy,

Claire Zilber, MD, DFAPA

CPS President

Colorado Psychiatric Society COVID-19 Resource List

 August 19, 2020

Updates

CPS -REGISTER for PsychSummit: Psychiatry in an Evolving World - THIS SUNDAY, August 23rd from 4:30pm – 7:15pm (MST) 2.25 AMA PRA Category 1 Credits - APA Members: $20; Residents and Med Students: Free thanks to APA, Inc - Psychiatrists from across the country will come together for a three-session event on “Psychiatry in 2020”. We will begin with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will address the biggest events of 2020 head on with a live panel conversation tackling the challenges of COVID-19 and structural racism.

 

 
Resources for Providers


APA COVID-19 Pandemic Guidance Document - Moral Injury During The COVID-19 Pandemic (download) - Prepared by the APA Committee on the Psychiatric Dimensions of Disaster and COVID-19


Elsevier - Science Direct - Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors (7-30-20)


Our Family's Tragedy: Dr. Lorna Breen Is the Canary in the Coal Mine 'My sister died because she was an emergency room physician in a pandemic.' (7-28-20) This article addresses how concerns about confidentiality create barriers to physicians seeking psychiatric care.


Patch.com/Colorado Newsline - Worst Year For Overdose Deaths Feared As Fentanyl, COVID-19 Afflict Colorado Scant rural resources and stigma also present challenges to health care officials. Quotes CPS Member Thida Thant! (8-13-20)


PsychNews - Psychiatrists Advocate for Expanded State Telehealth Laws APA and its district branches across the country have been advocating to ensure broadened telehealth laws and reimbursement parity at the state level. Discusses CPS and quotes CPS Member Patricia Westmoreland! (8-13-20)


Washington Post - Black psychiatrists are few. They’ve never been more needed (8-11-20)


Amplifier recently launched a campaign of shareable public health and safety messages to promote mental health, well-being, and social change work during the pandemic. Initially shared by CDPHE / CO Office of Health Equity. Scroll along the images to find a poster to download for your workplace!


Sentinel - STRESS TEST: Mental health care services pushed to brink amid COVID-19 Quotes CPS members Patricia Westmoreland, Monica Uppal, and Geoffry Harris! (8-16-20)


Order PPE supplies through CMS to protect your practice - The Colorado Medical Society has teamed up with ActionPPE.org to give CMS members access to medical-grade PPE supplies. You can also purchase PPE through APA & Project N95 for a limited time by logging into psychiatry.org/ppe and following the directions to register. You must register with Project N95 by Wednesday, August 26 to be eligible to place an order.


A Virtual Symposium Hosted by the HHS Office of Minority Health - Advancing the Response to COVID-19: Sharing Promising Programs and Practices for Racial and Ethnic Minority Communities September 17, 2020 | 10:00 PM to 4:00 PM MT

 

 
Resources for Patients


NYT - Five-Minute Coronavirus Stress Resets How to get unstuck from your anxiety (8-6-20)


HuffPost - Create A Mental Health Shelf – And 8 Other Tips To Calm Anxious Kids Children showed an increase in mental health issues during lockdown. Here's how parents can help (7-31-20)


Montefiore-Einstein Virtual Support Center - Coping and Emotional Health During the COVID-19 Pandemic - See the Wellness and Self-Care, Emotional Health and Coping, and Minorities pages.


CDPHE - New guidance released to help schools respond to COVID-19 cases and outbreaks - This case and outbreak guidance, in addition to the school opening guidance, CDE’s toolkit for the 2020-21 school year, and guidance from local public health agencies will provide districts with the information they need to start the school year in a way that makes sense for their local communities. Includes A home checklist for parents and school staff to help parents and staff determine if they or their child should go to school.


HuffPost - 5 Sneaky Signs Your Kid Is Anxious About Going Back To School From outbursts to changes in imaginative play, here's what to look for (8-6-20)


PsychNews -Psychological First Aid in Time of COVID-19 - including the COVID Coach app, created for everyone to support self-care and overall mental health during the pandemic (8-4-20)


KevinMD - Pandemic dysphoria and pandemic paralysis: How to get through it (8-17-20)


NBC - COVID-19 losses and uncertainty have led to a mental health crisis. Here's how to help. Nearly one-third of Americans are experiencing symptoms of depression or anxiety. Recognizing when and how to help is key to getting assistance (8-2-20)


WebMD - Coronavirus in Context: Why "Caution Fatigue" May Be Causing More COVID Cases (8 minute video and transcript)


KHN - Nearly Half Of Americans Delayed Medical Care Due To Pandemic


HuffPost -  7 Ways To Help Your Kids Practice Social Skills In Distance Learning Parents can teach their children these skills at home during the coronavirus pandemic. (7-31-2020)


KFF - Racial Disparities in COVID-19: Key Findings from Available Data and Analysis - Article addresses the disparate burden of COVID cases and deaths in minority populations as well as the disparities in access to testing (8-17-20)

 


Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page


REGION 8 HHS and FEMA COVID-19 RESOURCE DOCUMENT.pdf (download) (6-15-20) 


HHS Protect Public Data Hub

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.


August 5, 2020

The Pandemic Time Warp

Claire Zilber, MD, DFAPA
CPS President

“That really drives you insane,
Let’s do the Time Warp again.” 
(The Time Warp, from Rocky Horror Picture Show)

During the first weeks of the novel coronavirus pandemic, every day seemed interminable. What I had accomplished in the morning, by evening felt like it had occurred days ago. A whole week seemed grindingly long, and the weekends fleetingly short. More accustomed now to the flow of the days and weeks, there remains a distortion about the duration of our altered lifestyle. Working from home, avoiding the gym, going grocery shopping once every two weeks, and drastically curtailing my social life seems to have been the norm almost forever, yet it’s only been five months. What’s going on?

A disconnect between objective time, measured by clocks and calendars, and subjective time, measured by our internal perceptions, has been amplified by the pandemic. Changed routines and uncertainty about the future contribute to our distorted experience of the passage of time. This article describes this phenomenon in more detail (note - the author uses the f-word once) and suggests some common-sense ways to help combat the distortion: set up a regular schedule (social rhythm therapy), change the focus of your thoughts when you find yourself ruminating (cognitive therapy), and introduce some fun (behavior therapy).

In addition to the loss of normal time flow benchmarks, the trauma of the pandemic further contributes to distorted perception of time. This article describes the psychological literature on time perception and trauma. Essentially, trauma interrupts the normal flow of time, forcing us to be hyper-focused on the present moment. “Interrupting the flow of time creates perceptual distortions such as feeling like time has stopped or that everything is in slow motion, experiencing a sense of timelessness, confusing the order of time and days, and perceiving a foreshortened future.” The authors propose specific areas of research related to the effects of distorted time perceptions in the pandemic.

Pre-pandemic research about passage of time judgements has demonstrated that positive affect and high arousal are associated with time passing more quickly than normal, whereas negative affect and low arousal are associated with time passing more slowly than normal. “Time flies when you’re having fun” is subjectively true.  A British study of time perception before and after lockdown found that more than eighty percent of participants experienced changes in how quickly they perceived time passing during lockdown compared to pre-lockdown. Subjects who were older or less satisfied with their current levels of social interaction were more likely to experience slower passage of time over the course of a day or week. Higher stress and a lower task load were also associated with slower passage of time over the course of a day. The paper includes an excellent review of the psychology of time experience. If you don’t want to read the whole paper, here is its press release, which succinctly summarizes the findings.

We need additional research about the pandemic time warp. Simon Grondin, a professor of psychology at Université Laval in Québec City, and author of The Perception of Time, is conducting a study of how physical distancing may distort time perception. If you are interested in participating in the study, follow the link within this announcement.

What we know so far from psychological research is that disruption of routines, uncertainty about the future, trauma, stress, task load, age, and perhaps physical distancing all contribute to our pandemic time warp experiences. Although less scientific, this article introduces an important additional perspective to the discussion about our collective experience of distorted time during the pandemic. Optimistically, I propose that this and other lighthearted ways of viewing the pandemic will reduce stress, ease trauma, increase a feeling of social affiliation, and thereby restore more accurate perception of the passage of time.

Colorado Psychiatric Society COVID-19 Resource List

 August 5, 2020


Updates

HHS - COVID-19 Public Health Emergency Extended - Declaration of Public Health Emergency for COVID-19 was extended for an additional 90 days. This renewal keeps important regulatory changes and waivers relevant to psychiatrists in effect for 90 more days (7-23-20)

CPS - REGISTER for PsychSummit: Psychiatry in an Evolving World - August 23rd from 4:30pm – 7:15pm (MST) The APA has designated this live activity for a maximum of 2.25 AMA PRA Category 1 Credits (TM) - APA Members: $20; Residents and Med Students: Free thanks to APA Inc - Psychiatrists from across the country will come together for a three-session event on “Psychiatry in 2020”. We will begin with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will address the biggest events of 2020 head on with a live panel conversation tackling the challenges of COVID-19 and structural racism.

 

 
Resources for Providers


Register for APA Webinar - APA Addresses Structural Racism Town Hall Part 2: The March Continues August 24, 2020 | 6:00 - 7:30 p.m. MT


APA Survey - APA’s Presidential Task Force to Address Structural Racism Throughout Psychiatry second short survey. Complete by August 6. The results from the brief initial survey are available: The top 4 ways that structural racism affects patients are: 1. Access to care, 2. Professional diversity, 3. Experiences of racism, and 4. Education.


The City and County of Denver - Personal Protective Equipment (PPE) Program for Small, Micro Businesses and Nonprofits - free PPE kits


The Atlantic - We Need to Talk About Ventilation (7-30-20) Before returning to an office setting, it may be helpful to learn more about ventilation


KFF - KFF Health Tracking Poll - July 2020 - Scroll two thirds of the way down the page to view the Continuing Impact Of The Coronavirus Pandemic On Mental Health, Wellbeing, And Financial Health. Most (60%) now say “the worst is yet to come,” three times the share (20%) who say “the worst is behind us.” The share saying the worst is yet to come is up 10 percentage points since May (7-27-20)


Science Magazine - From ‘brain fog’ to heart damage, COVID-19’s lingering problems alarm scientists (7-31-20)


Psychiatric Services - Meditations on Involuntary Civil Commitment Amid a Pandemic COVID-19 has altered the decision-making process for psychiatrists considering involuntary civil commitment. Clinicians need to consider which poses the greatest risk to their patients: contracting COVID-19 in the hospital or being discharged before their mental health crisis has resolved (7-24-20)


As a Black Psychiatrist, She Is "Exhausted" and "Furious" (7-9-20)


Asian American Psychological Association (AAPA) - COVID-19 Related Resources


Asian and Pacific Islander American health forum

 

 
Resources for Patients


Teen Vogue - How to Talk to People Who Won't Wear Face Masks Shame won't work. Empathy is a smarter approach: Acknowledge what people dislike about masks, instead of telling them to stop whining (7-8-20)


KOAA - Getting help with the stress of uncertainty during a pandemic with CPS Member John Fleming, MD (7-23-20)


Today - How to mentally cope if you're living with your parents again during the pandemic Here's how to handle tensions and arguments between parents and young adult children who have moved back home during the coronavirus pandemic (7-20-20)


NYT - 8 Tips for Writing a Thoughtful Condolence Note Trying to find the words for a condolence note — for someone who’s lost a job or a loved one? (7-17-20)


APA Foundation - Virtual Town Hall: Mentally-Healthy Schools in Times of a Pandemic August 19th from 6:00 pm - 7:00 pm MT, free of charge - psychiatric experts will participate in a candid discussion about what to consider when choosing to return to the classroom, how to keep both students and staff safe and mentally healthy, how to notice changes in behavior that might indicate a need for support, and how communities can address barriers preventing youth from receiving mental health care.


University of Colorado - Mind The Brain Podcast, moderated by CPS Member Dr. Neill Epperson, Chair of the Department of Psychiatry - What Brain Science Can Teach Us About Adolescent Stress and Resilience (7-22-20). You can listen to episodes by clicking “full story” and “listen” in each written version of the podcasts.


NYT - This opens a page where users can click to see windows from locations around the world, a calming portal to somewhere else.


AACAP - Racism Resource Library Includes Anti-Racism Resources for Kids (07-20)


Black Emotional and Mental Health (BEAM) - BEAM’s mission is to remove the barriers that Black people experience getting access to or staying connected with emotional health care and healing. Many of the following resources are from Mental Health Colorado - Resources for Black, Indigenous, and People of Color Mental Health (click here to download the full list)


The Loveland Foundation - includes the Loveland Therapy Fund which provides financial assistance to Black women and girls nationally seeking therapy. Partners with Therapy for Black Girls and the National Queer and Trans therapist of Color Network


National Queer and Trans Therapist of Color Network


Therapy for Black Men - directory of therapists for black men seeking therapy


Black Female Psychologist Creates First Ever Therapy Card Deck for Women of Color


Asian and Pacific Islander American health forum


Asian American Health Initiative - Some very helpful resources including info on the ECHO project, capacity building, food distribution, and COVID-19 testing. Also has resources and podcasts available in several Asian languages.


Asian American Psychological Association (AAPA) - COVID-19 Related Resources


One Sky Center - a National Resource Center for American Indian and Alaska Native Health, Education and Research.


WeRNative - For Native Youth, By Native Youth


Trevor Project - provides crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, queer & questioning (LGBTQ) young people under 25. Need help? Call 1-866-488-7386 24/7


GLSEN - works on LGBTQ issues in K-12 education - LGBTQ+ education. Great resources for educators, students, patients - could be helpful for C/A psychiatrists and adult psychiatrists with teachers as patients


Human Rights Campaign - the largest national lesbian, gay, bisexual, transgender and queer civil rights organization

 


Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page


REGION 8 HHS and FEMA COVID-19 RESOURCE DOCUMENT.pdf (download) (6-15-20) 


HHS Protect Public Data Hub

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.


July 22, 2020

To School or Not to School?

Dear Colleagues,

So many opinions, so few data points. The news is full of conflicting recommendations from the Administration, health care organizations, teachers, parents and pundits. In this letter you will find scientific data about SARS-CoV-2 transmission in pediatric populations, as well as clarification of the position statements of various healthcare organizations. This may assist you in conversations with your patients or their parents to help them determine the most appropriate solution as they consider their options.

One concern about allowing children back to school is that they will bring the virus home to more vulnerable members of the household. As explored in this Kaiser Family Foundation report, 6% of US seniors live in homes with school-aged children. Initial data from China and this more recent report from Switzerland suggest that most children have mild or asymptomatic illness, and that transmission within family clusters is much more likely to be from adult to child than the other way around. In only 8% of households did children develop symptoms before others in the home. That reassuring news is offset by a Korean study that suggests that older children (ages 10-19) may spread the virus to household members more readily than adults do. They followed nearly 60,000 contacts of 5700 COVID-19 index patients for roughly 10 days. Their findings included that 12% of household contacts were infected, versus 2% of non-household contacts. When the index patient was aged 10–19 years, 19% of household contacts were infected. In contrast, when the index patient was aged 30–49, 12% of household members were infected, and when the index patient was aged 0–9 years, just 5% of household contacts were infected. The authors acknowledge that they "could not determine direction of transmission."

A second concern is that a small number of children who are infected with the virus develop an inflammatory multisystem syndrome with presentations ranging from fever and inflammation to myocardial injury, shock, and development of coronary artery aneurysms. Of course, no parent wants to risk such a serious outcome for their child, but we must remember that this is an exceedingly rare occurrence. This JAMA editorial, Should Coronavirus Disease 2019–Associated Inflammatory Syndromes in Children Affect Social Reintegration?, argues that we should not allow fear of a condition that may affect hundreds be a basis for restricting millions of children from school. This public health approach is rational but may be difficult to apply when dealing with parents’ emotional, protective instincts.

More convincing may be data about the pandemic effects on kids’ social and emotional health. This report from China, Behavioral and Emotional Disorders in Children During the COVID-19 Pandemic, describes a preliminary study of children’s responses during the lockdown phase of the pandemic response. They found high rates of clinginess, fear of infection, inattention, irritability, sleep disorders, nightmares and other symptoms indicative of stress. As psychiatrists, we are already aware of the importance of daily routines, social bonds with classmates, and mentorship from teachers and coaches. These experiences, all provided by school, help children develop self-regulation and self-esteem. We know that when these processes are interrupted by abuse, neglect or serious medical illness, the child’s developmental trajectory is thrown off course. What we don’t know is what happens when an entire population of children experience massive stressful disruption all at the same time. From this perspective, a return to school feels like it could be protective, but that is conjecture, not data.

Another argument for returning to school is concern about the impact of remote learning on academic “health,” especially for students with home environments that aren’t able to provide access to technology or to the calm and structure that promotes learning. This NYT article describes several studies of academic progress during springtime lockdowns that showed loss of academic skills, particularly among students from less privileged zip codes. Can our society afford to allow disparities in education to get larger than they already are, especially now that we are more acutely aware of the history and consequences of these disparities?

The question about whether and under what conditions schools should reopen has become a political hot button recently as the White House and the CDC have publicly disagreed, as seen for example in this CNN report. The CDC, whose mission is to prevent the spread of disease, takes the position that remote learning is safest, but they also offer pages of guidance to parents, teachers and school administrators about how to be safer while in school.

In contrast, The American Academy of Pediatrics (AAP) has recommended that schools reopen in August so that students can be “physically present in school” as much as possible.  AAP’s recommendation to reopen schools is based on concern that continuing remote learning is likely to result in severe learning loss, an increase in mental health symptoms, an increase in both physical and sexual child abuse, an increase in adolescent substance use, and an increase in suicide. AAP reports that they have already seen some of these outcomes in children and adolescents between March and May 2020 when school was remote.

This interview with Dr. Sean O’Leary, a pediatrician at CU Anschutz, a father of two teens, a survivor of COVID-19, and one of the authors of the AAP position statement, illuminates the balance pediatricians are trying to strike between emerging knowledge about the impact of distance learning and the risk of COVID-19 transmission by children.

As a result of this recommendation by the AAP, Denver Public Schools was considering reopening in August, with precautions.  However, after meeting with health officials from Denver Health, they announced that they will delay in-person learning. The first day of school will be August 24, but it will be in a remote learning format. They will consider a gradual return to in-person learning starting September 8. 

The APA and AACAP (American Academy of Child and Adolescent Psychiatry) issued a joint statement supporting the reopening of schools if possible, and highlighting the importance of social interactions for healthy development, the need for adaptive techniques for some students to learn remotely, and the role of mental wellbeing for students, teachers and parents.

The two largest organizations representing teachers, the American Federation of Teachers (AFT is the teachers’ union) and the Association of American Educators (AAE is non-union), have websites rich with COVID-19 related resources. The AFT website includes a plan for reopening schools. The AAE website has an interesting report on results of their springtime teacher survey about COVID-19. One striking finding is that 84% of responding teachers agreed with school closure.

Teachers do more than educate. One of their roles is to monitor the health of children in the classroom, including for signs of child abuse and neglect. Ordinarily, 20% of abuse and neglect reports come from teachers. This paper highlights concerns about increased child abuse and neglect during the pandemic, combined with less reporting of such abuse because children are not in school.

Schools do more than educate. They provide a safe space, a daily meal (sometimes two, if breakfast is provided), opportunities to form friendships with peers, interaction with caring adults, and access to school nurses and mental health counselors. This thoughtful interview with psychologist Elena Hontoria Tuerk about supporting children’s development during the pandemic addresses many of these important functions of schools, as well as the importance to parents of having a break from their children.

One group of students about which I am especially concerned are LGBTQ youth. Many of these kids aren’t safe coming out to their parents and they rely on peers for crucial support. These children are at higher risk than others for physical abuse, homelessness and suicide. What will they do without the community support and counseling found at school?

There are so many other special populations of students. Children with asthma, cancer, cardiac defects, cystic fibrosis or other chronic medical conditions that place them at higher risk need education, too, but the health risks for them to return to the classroom are higher. As we saw this spring, parents who are trying to work from home and simultaneously teach their children are inordinately stressed. What do these parents do if they are required to return to the workplace? Children with special developmental needs may be in an even more precarious position without the structure, specialized instruction and support of school.

There are no simple answers. Alex de Tocqueville wrote, “The public will believe a simple lie rather than a complex truth.” It is facile to make sweeping statements that “all schools should reopen,” or “all children should return to the physical classroom.” Each child exists within a unique family, which lives in its unique community, which has its unique experience with the pandemic.  When and how to return to the classroom ought to be an individualized decision based on each child’s needs. Unfortunately, insufficient resources may force school districts into a one-size-fits-all strategy. Psychiatrists cannot singlehandedly resolve the policy differences of the various entities involved in this debate. What we can do is help our patients find the best solutions for themselves, guiding them towards rational rather than emotional decision-making.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 July 22, 2020

Updates

Notice - There will not be a CPS COVID-19 Resource Email sent next Wednesday, July 29th. You can expect an email in your inbox again on Wednesday, August 5th.

CPS - REGISTER for PsychSummit: Psychiatry in an Evolving World - August 23rd from 4:30pm – 7:15pm (MST) - Psychiatrists from across the country will come together for a three-session event on psychiatry in 2020. We will begin with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools like digital tracking for medication adherence. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will address the biggest events of 2020 head on with a live panel conversation tackling the challenges of COVID-19 and structural racism.

CO Mask Mandate - Executive Order D 2020 138 is a mandatory statewide mask order that went into effect at midnight on July 16, 2020, and will be in effect for 30 days. It may be extended. Also see CPR - Colorado Mask Order: When Do I Need To Wear A Face Covering? (And More Mask Questions Answered) and CDPHE - Questions & answers about the mask order.

 

 
Resources for Providers


PsychNews - Reopening Your Practice During Pandemic (7-9-20)


PRMS - Coronavirus FAQs (Updated 7-15-20), includes State Licensure Waiver Information (download) and Preparing For What's Next - To Do List (download). Also see PRMS - Free Telepsychiatry On-demand Tutorial (06-20) - this on-demand tutorial covers changes to the regulatory framework during COVID-19, including the lifting of various laws and regulations, such as licensure and prescribing laws and also addresses preparing for what’s next, tips for practicing telepsychiatry, and professional liability insurance considerations.


KFF - Mental Health and Substance Use State Fact Sheets (7-10-20). If you click on Colorado on the map, it will take you to the page on Mental Health in Colorado - Mental health issues have increased during the COVID-19 pandemic. Average weekly data for June 2020 found that 34.2% of adults in Colorado reported symptoms of anxiety or depressive disorder, compared to 36.5% of adults in the U.S.


AMA - Mental health and COVID-19: How a psychiatrist tackles fear, anxiety - includes links to free surveys to help health care organizations monitor the impact COVID-19 has on their workforce (6-1-20)


AMA - Virtual resilience rounds help physicians navigate moral distress (6-25-20)


KHN - Due to the financial impact of COVID-19, Colorado state lawmakers had to cut over $3 billion from the state budget this past legislative session. Colorado is one of the many states having to cut back on health care programs and new policy initiatives as part of the economic fallout of the pandemic. These cuts, which in Colorado include slashing $1 million from a program designed to keep people with mental illness out of the hospital and $5 million for addiction treatment programs in underserved communities, come amid the century’s largest health crisis when people may need those services most. You can hear the conversation here (Minutes 1-6:30) (7-13-20)


APA - Advancing the Use of Telehealth Through Education and Advocacy -  1.5 hour webinar featuring CPS’s Jay Shore (Minutes 5-25 and Q and A). Dr. Shore discusses regulatory changes, hybrid care and tips for video conferencing, including the importance of comfort, ergonomics, multiple monitors, and diversity of scheduling. Dr. Harris then covers reimbursement and coding and Dr. Kennedy discusses the APA’s advocacy efforts. Dr. Shore is a moderator for the upcoming CPS PsychSummit event!


AJPM - Perceived Discrimination and Mental Distress Amid the COVID-19 Pandemic: Evidence From the Understanding America Study (7-6-20)


JAMA - Now Is the Time to Support Black Individuals in the US Living With Serious Mental Illness—A Call to Action (7-17-20)


Psychiatric Services - An epidemiologic study of COVID-19 in state psychiatric hospital: High penetrance rate despite following initial CDC guidelines (download) (06-20)


Community Mental Health Journal - Community mental health care delivery during the COVID-19 pandemic: Practical strategies for improving care for people with serious mental illness (6-19-20)


HCPF - Provider Leader Webinars on July 16 (recording available), Aug. 20, Sept. 17, Oct. 15, Nov. 19 and Dec. 17, 2020. Details at HCPF Provider Leader Resource Center. Relevant to providers and agencies that accept, or are considering accepting, Health First Colorado (Colorado’s Medicaid Program) and Child Health Plan Plus (CHP+).


Washington Post - Hospital officials, experts say new federal rules for covid-19 reporting will add burdens during pandemic (7-15-20). For an update and link to the new HHS website, see CNBC - HHS unveils new coronavirus hospitalization database, says it’s more complete than CDC’s (7-20-20).


PsychNews - COVID-19 and Psychotherapy: Addressing Blocked Mourning (7-9-20)


PsychNews Residents’ Forum - COVID-19 Raises Difficult Dilemma About Touching Patients for Comfort (7-10-20)


American Journal of Psychiatry - New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders—The Perfect Storm (7-14-20)

 

 
Resources for Patients


University of Michigan Dept of Psychiatry - Importance of Physical Activity and Exercise during the COVID-19 Pandemic


USA TODAY's Staying Apart, Together - How to not feel powerless in the fight against COVID (7-11-20) Texting a friend who lives alone is doing something. Ordering takeout from a local restaurant is something. Donating to a food bank or a mutual aid fund is something. Video chatting with your grandparents is something.


MHCD - Watch a five-minute guided meditation led by CPS member Dr. Carl Clark. For closed captioning in English, press the small CC button in the lower right-hand corner of the video screen.


University of Colorado - Mind The Brain Podcast with CPS Member Dr. Neill Epperson, Chair of the Department of Psychiatry - Sleep and Stress During COVID-19 (7-16-20). You can listen to episodes by clicking “full story” and “listen” in each written version of the podcasts.


University of Colorado - Mind The Brain Podcast with CPS Member Dr. Neill Epperson, Chair of the Department of Psychiatry - Reversing the Cycle of Depression Through Action (6-30-20). Drs. Neill Epperson and Sona Dimidjian discuss behavioral activation and how it can be helpful when struggling with depression. You can listen to episodes by clicking “full story” and “listen” in each written version of the podcasts.


NYT - 10 Steps to Take to Try to Prevent Your Own Eviction - Eviction protection programs created in response to the pandemic are expiring across the country. Some federal relief is about to expire. Local assistance is spotty. Congress may not act quickly. Here’s how to get help, or help yourself - The Covid-19 Eviction Defense Project in Denver estimates that 19 million to 23 million Americans are at risk of eviction by the end of September. But as harrowing as eviction is, it’s a process that plays out over weeks, at a minimum. And it may be possible to stop it. (7-11-20)


CDC Launches Natural Disasters and COVID-19 Response Website that includes information on preparedness and recovery during the COVID-19 response and what the general public can do to keep themselves safe.


CO Mask Mandate - Executive Order D 2020 138 is a mandatory statewide mask order that went into effect at midnight on July 16, 2020, and will be in effect for 30 days. It may be extended. Also see CPR - Colorado Mask Order: When Do I Need To Wear A Face Covering? (And More Mask Questions Answered) and CDPHE - Questions & answers about the mask order.


KHN - States Allow In-Person Nursing Home Visits As Families Charge Residents Die ‘Of Broken Hearts’ (7-13-20). Also see Social isolation: The COVID-19 pandemic's hidden health risk for older adults, and how to manage it (7-6-20); USA Today - Are you worried about your elderly parents? 8 tips to help seniors stay mentally acute in isolation (7-15-20); and AARP - 7 Ways to Boost Your Loved One's Morale During the Coronavirus Epidemic.


Be The Change Coloring Co - Coloring book created by 4 high school students to teach kids about the coronavirus through the wise words of Al E. Gator, Sam the Snail, and Wally the Narwhal.


Take a virtual tour of the Louvre in Paris.


Street artist Banksy sprayed coronavirus art on the London Underground (7-15-20). Also see his tribute to Britain’s National Health Service workers with a painting that depicted a young child playing with a nurse superhero toy as Batman and Spider-Man lay abandoned nearby.


CDC webpage on COVID-19 in Racial and Ethnic Minority Groups (6-25-20)


PsychHub - Race, Racism, & Mental Health Resources - comprehensive list of resources to help Black people and other people of color care for their mental health through the trauma of racism (06-2020)


HuffPost - This Is What Racial Trauma Does To The Body And Brain (7-1-20)


Support for Isolated Trans People - The Validation Station is a free text service which sends daily support to isolated trans people.


The COVID-19 Health Literacy Project was started by Pooja Chandrashekar, a first-year medical student at Harvard Medical School, and quickly expanded into a national coalition of over 150 medical students representing over 35 institutions and 34 languages. Here is a link to Covid-19 fact sheets in multiple languages https://covid19healthliteracyproject.com/#languages


PBS - Drug overdoses: The hidden epidemic in the pandemic (8 minute video and transcript) 7-5-20) Narcan can counteract an overdose . . . And the key is getting it into enough people's hands.


University of Colorado - Mind The Brain Podcast with CPS Member Dr. Neill Epperson, Chair of the Department of Psychiatry - Mind the Drink. You can listen to episodes by clicking “full story” and “listen” in each written version of the podcasts.

 


Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page


REGION 8 HHS and FEMA COVID-19 RESOURCE DOCUMENT.pdf (download) (6-15-20) 

The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.


July 15, 2020 *Special Edition*

Psychiatrist Resources on Historically Marginalized Communities

To see past resource lists for psychiatrist and messages from CPS Presidents, visit https://www.coloradopsychiatric.org/COVID19
To explore the COVID-19 Resource Page for the Public, visit https://www.coloradopsychiatric.org/coronavirus
Do you have a question, helpful resource, or tip for your colleagues? Email [email protected].

Welcome to this special edition of the CPS COVID-19 Resource Email!

CPS has received resources from members concerning racism and the pandemic as well as more general resources on racism and psychiatry so we have decided to dedicate this edition of the CPS COVID-19 Resource Email to the topic. The first section contains resources and articles on the intersection between COVID-19 and historically marginalized communities. The second section focuses on resources for psychiatrists to help us better serve patients with skill and sensitivity, as well as resources for psychiatrists from historically marginalized communities.

PsychSummit: Psychiatry in an Evolving World - registration opening soon

SAVE THE DATE of August 23rd from 4:30pm – 7:15pm (MST) to join us for the next PsychSummit, which includes a session that will address the biggest events of 2020 head on with a live panel conversation tackling the challenges of COVID-19, structural racism, and the intersection of the two leading to negative healthcare outcomes. Our panel will be live to answe
r your questions and cover needed skills for addressing the challenges of 2020 - both as psychiatrists and as humans.

Psychiatrists from across the country begin the three-session event with an exploration of technology and psychiatry through a discussion on the use of apps and other emerging tools like digital tracking for medication adherence. Turning to psychiatry’s intersection with current events, Border Mental Health will focus on the mental health challenges faced by migrants in detention and the impacts of family separation on children. Our final session will cover COVID-19 and structural racism.

 
Colorado Psychiatric Society COVID-19 Resource List
*SPECIAL EDITION*

 July 15, 2020


Psychiatrist Resources on Historically Marginalized Communities - Resources related to the pandemic

For the most complete and up-to-date race and ethnicity data on COVID-19 in the United States, see The COVID Racial Data Tracker - a collaboration between the COVID Tracking Project and the Boston University Center for Antiracist Research. Also see NYT - The Fullest Look Yet at the Racial Inequity of Coronavirus - New data — made available after The New York Times sued the federal government — shows the extent of racial disparities: The contraction rate is almost three times as high for Black Americans as white Americans and more than three times higher among Latinos than whites.

CDC webpage on COVID-19 in Racial and Ethnic Minority Groups - contains data, recommendations on what healthcare systems and healthcare providers can do and discussion of factors that explain why racial and ethnic minority groups are at increased risk during COVID-19 (6-25-20)

 JAMA - Taking a Closer Look at COVID-19, Healthcare Inequities and Racism (transcript article and 31 minute video) (6-29-20)

NIH - Director Francis Collins, MD, PhD, discusses the heartbreaking disproportionate impact of COVID-19 on Black and Hispanic communities and the importance of building stronger relationships with minority communities to build trust as COVID-19 vaccine development progresses (see article not 2 minute video) (6-23-20). Also see STAT - COVID-19 Vaccine Research Must Involve Black and Latinx Participants. Here are 4 Ways to Make That Happen (6-26-20)

Virtual Forum: Healthcare Disparities through the Lens of Diversity During the COVID-19 Pandemic (slidedeck (download) and 2 hour 17 minute video) - AACAP hosted this virtual forum on June 13 highlighting mental health, COVID, and other healthcare disparities related to race and ethnicity among children and adolescents of color.

New York Times - The Challenges of the Pandemic for Queer Youth - Issues include limited access to community support and counseling and, in some cases, quarantining with unsupportive family members (6-29-20)

PsychNews - Hispanic Community and COVID-19: Addressing Health Inequalities Can No Longer Be Delayed (6-23-20). Also see NYT - Many Latinos Couldn’t Stay Home. Now Virus Cases Are Soaring in the Community (6-26-20)

AMA - Widening Social and Health Inequalities During the COVID-19 Pandemic (6-10-20)

JAMA - Strategies for Digital Care of Vulnerable Patients in a COVID-19 World—Keeping in Touch - Without action to address the digital divide, existing health and healthcare disparities will be exacerbated for the nation’s most vulnerable individuals and communities. Article explores these potential dangers and offers strategies to mitigate them (6-12-20)

KFF - Chart of the Week: The Disproportionate Impact of COVID-19 on Black and Hispanic Medicare Recipients (6-26-20)
Hopkins Bloomberg Public Health Magazine - Racism and COVID-19 - In this Q&A, Lisa Cooper, a practicing physician and epidemiologist, discusses racism’s role in COVID-19 cases in African American communities and solutions for the inequities.
AMA Ethics - Ethics Talk: Antiracism, Health Equity, and a Post-COVID Future (22 minute podcast) - AMA Ethics Journal editor in chief, Dr Audiey Kao, talks with Dr Ibram Kendi, founding director of the Antiracist Research and Policy Center and a professor of history and international relations at American University, about the impact of racist policies on historically discriminated-against groups and what it means to be an antiracist (06-20). Kendi uses the metaphor of cancer and its treatment to discuss racism and anti-racism. He also addresses the importance of antiracism among healthcare providers in order to appropriately address health disparities. Of special interest is a section towards the end (approx. minutes 17-19) about the difference between truth and lies, and why it’s so difficult to communicate complicated truths to people who prefer simple one-liner answers.
JAMA - COVID-19 Pandemic, Unemployment, and Civil Unrest: Underlying Deep Racial and Socioeconomic Divides (6-12-20)

 


Psychiatrist Resources on Historically Marginalized Communities -
General Resources

We recognize this is an opportunity for growth so while the following resources are not directly COVID-related, we hope you find them useful.

Selected APA Resources:

American Association For Community Psychiatry - The Leadership Role of Community Psychiatry in Combating Structural Racism (1 hour video) (6-3-20). Many excellent speakers, including a presentation by Dr. Shim on structural racism (starting around minute 6). Also see her article in Stat - Structural racism is why I’m leaving organized psychiatry - a piece by Ruth S. Shim on why she has made the difficult decision to end her membership with organized psychiatry, specifically the American Psychiatric Association (7-1-20)

Taking Back Our Voices — #HumanityIsOurLane by psychiatry resident Chase T.M. Anderson, M.D. (6-30-20) - Also see Race and Medicine on NEJM.org - a new page presents a selection of articles on race and medicine, with implications for improving patient care, professional training, research, and public health.

Treating Mental Health in the Black Community (1.5 hour video) - Learn how you can better serve Black clients (6-9-20)

Kevin MD - A physician awakens to racism in America (6-15-20)

MD Edge/Clinical Psychiatry News - Examining bias (6-18-20), includes link to Harvard researcher designed Implicit Association Test.

75 Things White People Can Do for Racial Justice (the list now includes 97 things!)

On Being with Krista Tippett - ‘Notice the Rage; Notice the Silence’ (51 minute podcast) - The best laws and diversity training have not gotten us anywhere near where we want to go. Therapist and trauma specialist Resmaa Menakem is working with old wisdom and very new science about our bodies and nervous systems, and all we condense into the word “race” (6-4-20). Visit https://www.educationforracialequity.com/resmaa for details on a two session online event on July 25th and August 1 - Reclaiming our Birthright: An Embodied Gathering for Black Men held by Resmaa Menakem and Dr. Kenneth Hardy as well as other events. Also see https://www.resmaa.com/.

Focus - Trauma-Informed Care and Cultural Humility in the Mental Health Care of People From Minoritized Communities (download - open with PDF reader) Dr. Ranjbar is a panelist at the upcoming CPS PsychSummit event!

Focus - Diversity and Inclusion in Psychiatry: The Pursuit of Health Equity (download - open with PDF reader) (6-24-20)

Focus - Affirmative Care Across Cultures: Broadening Application (download - open with PDF reader) - recommendations for affirmative care in practice with African-American, Asian, Indigenous, and Latinx individuals, as well as those living in rural communities.)

MD Edge/Clinical Psychiatry News - How can we better engage black men as patients? (6-24-20)
MD Edge/Clinical Psychiatry News - Management of race in psychotherapy and supervision (6-22-20) Dr. Isom is a panelist at the upcoming CPS PsychSummit event!
HHS - National CLAS Standards - The National Culturally and Linguistically Appropriate Services Standards are a set of 15 action steps intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. If the website is not loading, click here. Also see HHS - Improving Cultural Competency for Behavioral Health Professionals (Free Online Training - This program is accredited for 4 – 5.5 contact hours for psychiatrists)
Dismantle Collective - White Allyship 101 (list of articles and books). Also see Power Shift Collective - Checklist for White Allies
Psychology Today - Uncovering the Trauma of Racism - includes new tools for clinicians and examples of race-related traumas that may meet DSM-5 criteria for PTSD.
MD Edge - The fallout from George Floyd's death: Physicians, how are you? How are your patients? A conversation on race for psychiatrists (45 minute podcast) - Lorenzo Norris, MD, welcomes fourth-year psychiatry resident Brandon C. Newsome, MD, for a discussion on race relations as a physician in the wake of the death of George Floyd. The pair discuss what their patients are experiencing and what they're experiencing as black physicians (6-5-20). Transcript available at George Floyd, race, and psychiatry: How to talk to patients (6-24-20)
NPR - 'Bear Our Pain': The Plea For More Black Mental Health Workers (article and 4 minute audio) (6-25-20, aired 6-6-20)
HuffPost - This Is What Racial Trauma Does To The Body And Brain Racism, injustice and brutality — experienced directly and indirectly — can have a lasting effect on a person's mental health (7-1-20)
MBK Alliance Town Hall Series: Mental Health and Wellness in a Racism Pandemic (1 hour video) - President Obama joined Congressman John Lewis, founder and executive director of the Equal Justice Initiative Bryan Stevenson, writer and survivor of police brutality Leon Ford, Jr., and youth leader LeQuan Muhammad, in a conversation moderated by activist and author Darnell Moore, to discuss the mental toll racism takes on people of color.
HuffPost - One Way To Be An Ally Right Now? Support Black Mental Health (updated 6-18-20)
HuffPost - Racism Is A Mental Health Crisis. Here's How To Fight It. - “Being a Black person is often described as being in “fight or flight” mode, and honestly, that is the best way to explain it.” (6-11-20)
HuffPost - What Not To Say To Someone Who Has Experienced Racial Trauma (article and 5 minute video) - What white people and other allies do in conversations about the mental health effects of racism matters (7-3-20)
YoungMinds - How racism impacts my mental health - Sian, 19, shares how racism affects her mental health, and what helps her cope - watch movies with more Black people, or follow Black YouTubers or influencers. This will just make you feel more comfortable with seeing Black people and, eventually and maybe subconsciously, you will learn to love yourself and what you are.(6-23-20) Also explore the Good Black News website.
Psychology Today - Is Your Therapist Qualified to Treat People of Color? Ten questions that all culturally-informed therapists should be able to answer (5-31-19)
Ourselves Black - Racial Inequality, Police Brutality & Black Mental Health (56 minute video) - presentations by two young black male psychiatrists - Dr. Christopher Hoffman and Dr. Walter E. Wilson, Jr.
Kevin MD - How racial issues affect both doctors and patients (11 minute podcast) (6-25-20)
KFF - Officials Seek To Shift Resources Away From Policing To Address Black ‘Public Health Crisis’ - on declaring racism a public health crisis (6-25-20)

 
The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.


 

PsychSummit: COVID-19 


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 8, 2020

Neuropsychiatric Sequelae of COVID-19

Dear Colleagues,

The planet is eight months into the pandemic, and although it’s been only four months in Colorado, the only other four months that felt this long to me were those in the second half of my pregnancy. It is not news to any of us that there are psychiatric sequelae of living in a pandemic. We are all aware of surges in depression, anxiety, trauma-related symptoms and substance use. What is less clear are the neuropsychiatric sequelae of COVID-19. Information emerging from Wuhan and other early centers of the pandemic, as well as research on prior coronavirus pandemics, begins to suggest a picture of both direct, virally-mediated neuropsychiatric illness, and illness mediated by immunological or other host responses to infection. Although we are at the stage where there are more questions than answers, this letter will provide a summary of the current state of knowledge. 

There are several case series of patients with COVID-19 that describe neurological symptoms. This series of 214 patients in Wuhan, China, describes cerebrovascular events and impaired consciousness in 45.5% of patients with severe infection. A review of 27 autopsies of patients who died from COVID-19 in Germany describes detecting the virus in multiple organs, including the brain. This brief report details neurologic findings in a case series of four pediatric cases with multi-system inflammatory syndrome from COVID-19. The most common neurologic complaints in COVID-19 are anosmia, ageusia, and headache, but stroke, impairment of consciousness, seizure, and encephalopathy have also been reported. It may be that the encephalopathy results from toxic-metabolic factors (cytokine storm, inflammation, renal dysfunction, etc.) rather than directly from the virus. This review article on neuropathogenesis and neurologic manifestations of COVID-19 goes into more depth.

While many have reported that COVID-19 patients have experienced vascular and neurological problems, a recent study of 153 patients in Lancet Psychiatry reports that patients are also showing symptoms of psychiatric disorders, including psychosis and depression. The British researchers found that 77 patients experienced a cerebrovascular event (primarily stroke), 39 experienced altered mental status, six experienced peripheral nervous system problems, and three experienced other nervous system–related complications. Among the 39 patients with altered mental status, 16 were diagnosed with encephalopathy, and 23 were diagnosed with a psychiatric disorder. Ten of these 23 patients developed psychosis, six developed cognitive problems, and seven developed mood problems including depression and mania. One striking finding is that the neuropsychiatric manifestation may differ according to the patient’s age. Specifically, 49% of the patients who experienced altered mental status were under age 60, whereas 82% of patients who experienced a cerebrovascular event were over age 60.

Past coronavirus epidemics, including SARS (2002) and MERS (2012), may shed light on the current pandemic. Based on their review of the literature on psychiatric and neuropsychiatric presentations during prior coronavirus outbreaks, these authors opine that SARS-CoV-2 may cause delirium in a significant proportion of acutely ill patients. They also warn about the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the longer term.

This excellent review discusses the psychological, neurological, and neuropsychiatric manifestations that COVID-19 may take, as well as addressing some of the potential immunologic mechanisms for the symptoms. Importantly, the authors remind us of the association between maternal influenza and subsequent development of schizophrenia in offspring. They warn us that we may see a late wave of neurological (eg: Parkinson’s disease) or psychotic illness decades after the pandemic.

Most of the neuropsychiatric illness seen in patients with COVID-19 is probably due to delirium or other encephalopathic states caused by the inflammatory response, metabolic toxicities or hypoxia. However, it is possible that some neuropsychiatric manifestations could be caused directly by the virus. SARS-CoV-2 uses spike proteins on the viral surface to bind to angiotensin converting enzyme 2 (ACE2) receptors on host cells. Humans have ACE2 receptors on airway epithelia, kidney cells, small intestine, lung parenchyma, and vascular endothelia throughout the body. ACE2 receptors are also found on neurons, astrocytes, and oligodendrocytes, and are highly concentrated in the substantia nigra, ventricles, middle temporal gyrus, posterior cingulate cortex, and olfactory bulb. As detailed in this article, it remains unclear whether the virus directly attacks neural tissues; although isolated case reports suggest it may, others suggest the neurologic effects are a result of cytokines (headaches), hypercoagulability (strokes) or other secondary factors.

If you only have time to click on one link in this letter, choose this outstanding and comprehensive article, which includes helpful, colorful diagrams explaining possible mechanisms of pathogenesis. You may feel like you’re back in medical school. Helpfully, toward the end of the article the author describes the roles psychiatrists may play in the pandemic, and suggests pragmatic treatment considerations such as drug-drug interactions between psychotropic medications and antivirals.

We have learned a lot, but there is so much more to learn. This brief report calls for long term study of the neuropsychiatric outcomes of the pandemic. Ultimately, we need prospective studies of neuropsychiatric illness in COVID-19, including long-term outcomes, to fully understand the nature of this beast.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 July 8, 2020


Updates

APA Survey to inform the work of the new Presidential Task Force to Address Structural Racism Throughout Psychiatry. Please complete the short survey by Friday, July 10th. Please note that the survey is a Google Form, so if individuals cannot access it through their institution’s servers, it can be completed at home. Answers will be anonymous and not shared on this platform.

Partnership COVID-19 Document (download) - CPS is a founding member of the Behavioral Health Partnership, a long-standing group of stakeholders made up of consumer and provider organizations in Colorado. The group has created a COVID-19 document for the public on steps we can all take to ensure we are caring for our mental wellbeing. Please share with patients, family, friends and anyone else who may find it helpful.

 

 
Resources for Providers


CNN - Smoking weed and coronavirus: Even occasional use raises risk of COVID-19 complications


PsychNews - COVID-19 Takes Toll on Mental Health of Hospital Health Professionals (6-26-20)


JAMA - Attitudes and Psychological Factors Associated With News Monitoring, Social Distancing, Disinfecting, and Hoarding Behaviors Among US Adolescents During the Coronavirus Disease 2019 Pandemic (6-29-20)


JAMA - Telehealth for Substance-Using Populations in the Age of Coronavirus Disease 2019 Recommendations to Enhance Adoption (7-1-20)


American Journal of Psychiatry Letter to the Editor - COVID-19, Medication-Assisted Treatment, and Increased Risk for Further Respiratory Depression - Patients prescribed opiates and benzodiazepines should be advised of these risks and collaborate with their care team to establish the lowest effective dosage of their medications during this pandemic.


Greater Long Island Psychiatric Society President, Dr. Scott Krakower, has been ill with Covid-19 since April. While he is improving, he is far from fully recovered. Links to print and TV interviews give excellent descriptions of the illness from a doctor-as-patient perspective.


NEJM - Community Health Centers and Covid-19 — Time for Congress to Act (6-26-20)


Thank you to those who participated in the APA’s survey on telehealth. Here are the results (6-30-20)


Psychiatric Services - Dynamic Trainee Support for Residents Involved in COVID-19 Treatment and Response - formal trainee support programs and COVID-19 psychiatric response (CPR) elective (7-1-20). Also see Psychiatric Training During a Global Pandemic: How COVID-19 Has Affected Clinical Care, Teaching, and Trainee Well-Being (6-30-20)


More Than Physical Health: Gym Helps 91-Year-Old Battle Isolation (KHN) An inspiring story that urges us to continue to weigh the risks vs benefits of activities

 

 
Resources for Patients


CNN - Smoking weed and coronavirus: Even occasional use raises risk of COVID-19 complications


Articles on reopening schools - Why a pediatric group is pushing to reopen schools this fall Guidelines from the American Academy of Pediatrics encourage “having students physically present in school.” Dr. Sean O’Leary, an author of that advice, explains why. Also see NPR - U.S. Pediatricians Call For In-Person School This Fall (6-29-20) and NYT - Research Shows Students Falling Months Behind During Virus Disruptions The abrupt switch to remote learning wiped out academic gains for many students in America, and widened racial and economic gaps. Catching up in the fall won’t be easy (6-5-20)


HuffPost - 5 Questions Parents Should Ask Before A Coronavirus Pandemic Play Date (7-1-20)


WebMD - The Importance of Physical Activity During the Pandemic - Consider “activity snacks” where you can sneak in movement throughout the day.


Here's what type of face mask you should be wearing, according to CDC (video and article) - The Centers for Disease Control and Prevention (CDC) gave more guidance Monday on the public’s use of cloth face masks in stopping the spread of COVID-19 (7-6-20)


The Atlantic - A Devastating New Stage of the Pandemic (6-25-20)


The Atlantic - Our Minds Aren’t Equipped for This Kind of Reopening As states ease restrictions on businesses, individuals face a psychological morass (7-6-20)


CDC - Resources in American Sign Language (videos)


Thinking Together: Don't Touch Your Face - Tips from a Habit Reversal Therapist!

 


Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page


REGION 8 HHS and FEMA COVID-19 RESOURCE DOCUMENT.pdf (download) (6-15-20) *NEW resource* (added 6-24-20)

The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.


 

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

Updates

NEW Section on CPS website - CPS has added a new section on Racial and Ethnic Minority Community Issues to our COVID-19 Resource documents - see below or visit Resources for the Public. We will also be adding a new section with resources for psychiatrists. If you know of any resources that would be helpful, please send them to [email protected].

 

 
Resources for Providers


JAMA - Management of Patients With Severe Mental Illness During the Coronavirus Disease 2019 Pandemic  (6-24-20)


Time - The Hidden Deaths Of The COVID Pandemic - Sara Wittner had seemingly gotten her life back under control. After a December relapse in her battle with drug addiction, the 32-year-old completed a 30-day detox program and started taking a monthly injection to block her cravings for opioids. She was engaged to be married, working for a local health advocacy group in Colorado, and counseling others about drug addiction. Then the COVID-19 pandemic hit. (6-22-20)


Amid pandemic, prison psychiatrists adjust and persist
(6-22-20)


Department of Psychiatry - Mind the Brain: Child and Adolescent Anxiety in the Time of COVID-19 with Joel Stoddard, MD (6-23-20)


Psychiatry Online - The Digital Mental Health Genie Is Out of the Bottle (6-24-20)


JAMA Viewpoint - The Coronavirus Disease 2019 (COVID-19) Outbreak and Mental HealthCurrent Risks and Recommended Actions (Internet as Major Source of Information During COVID-19 Outbreak) - Comments on how the internet can help and harm the psychosocial health of the population. (6-24-20)


APA Webinar -
Advancing the Use of Telehealth Through Education and Advocacy - July 8, 2020 7:00 PM ET - This APA webinar will focus on how to refine the use of telehealth to better serve your patients and highlight advocacy efforts at the federal and state levels to continue telehealth flexibilities.


AMA Journal of Ethics- new videocast about the health consequences of social isolation during the pandemic: Ethics Talk: Social Isolation, Loneliness, and COVID-19 (6-24-20) (25 minute video)


Colorado Health Institute - Informal Caregivers — Especially Those from Communities Of Color — Are Getting Left Behind

 

 
Resources for Patients


303 Magazine -
A Master Guide to Mental Health Resources In and Around Denver (6-18-20)


Resilient Colorado
-
Mindful Minute Cards a collection of printable cards (click the link to download and print cards front and back) to guide you in brief mindfulness practices (6-18-20)


The Chronicle of Philanthropy - ‘Be Gentle’: How to Stay Healthy Emotionally During Social Isolation (6-2-20)


NYT - School’s Out. Parental Burnout Isn’t Going Away and Eight families on the brink of collapse share how they’ll fill their kids’ days. (6-23-20)


NPR - What Parents Can Learn From Child Care Centers That Stayed Open During Lockdowns (6-24-20)


CDPHE - Outdoor visitation guidance for residential care facilities


NEJM - Challenges of “Return to Work” in an Ongoing Pandemic (6-18-20)

 


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

 
Resources for Providers


APA - Register for SMI Adviser Webinar "Practical Tools for Behavioral Health Staff Supporting the Medical Care of People With Serious Mental Illness" -Thursday, July 9, 1-2 pm MT. This webinar will examine the mortality gap in those with serious mental illness and activities to support better health and medical care for these patients.


AACAP - Tips to Improve Care with LGBTQ Youth During the Pandemic and Beyond (download)


STAT: To Understand Who’s Dying of COVID-19, Look to Social Factors Like Race More Than Preexisting Diseases (6-15-20)


ABPN - For diplomates whose specialty or subspecialty certificates would have expired in 2020, we will defer the 2020 Continuing Certification(CC)/MOC exam requirement for one year until December 31, 2021. Additional information at https://www.abpn.com/coronavirus-covid-19-updates/.


Is it okay to laugh during a pandemic?


PsychNews - Psychological Support Needs to Be Available to All COVID-19 Pandemic Responders Different types of responders and members of the media may require different approaches to helping them deal with their reactions to the pandemic. - Different types of responders and members of the media may require different approaches to helping them deal with their reactions to the pandemic and critical incident stress debriefing should be avoided (6-16-20)


KevinMD - Mental health among Asian American health care workers during the COVID-19 pandemic (6-22-20)


Psychiatric Services Editor's Choice - Resilience, Resistance: A Commentary on the Historical Origins of Resilience and Wellness Initiativesby CPS’s own Helena Winston, M.D., M.Phil., and Bruce Fage, M.D. (article rerun from 2019)


Colorado Sun - We’re dealing with a pandemic, but remember the opioid crisis? Coronavirus is likely to make it worse. (quotes CPS member Scott Simpson) (6-22-20)


Kevin MD - During this terrible pandemic, let’s make compassion go viral


NYT - Cutting-edge chatbots are thriving as a way to combat loneliness. (6-16-20)

 

 
Resources for Patients


Stay Healthy at Home Using Virtual Care - Governor Polis Telehealth Update - The state is making it easier for Coloradans to get care - visit https://healthathome.colorado.gov


Supporting Individuals with Autism Through Uncertain Times (UNC Frank Porter Graham Child Development Institute Autism Team) (download)


12 Ideas for Writing Through the Pandemic With The New York Times A dozen writing projects — including journals, poems, comics and more.


Westword - What If I Hate Masks? Top 20 COVID Covering Questions, Expert Answers (6-19-20)


Times are Strange, but Uncertainty is Nothing New: Managing COVID-19 When You or a Loved One Has OCD by CPS’s Rachel Davis (6-16-20)


Washington Post  - What to know about the coronavirus and summertime activities (6-20-20)


Kevin MD - During this terrible pandemic, let’s make compassion go viral


How COVID-19 Layoffs Broke My Confidence, and How Starting a Greenhouse Brought It Back (6-16-20)


The Atlantic - The Three Equations for a Happy Life, Even During a Pandemic “How to Build a Life” is a new column that aims to give you the tools you need to construct a life that feels whole and meaningful.


Ten Percent Happier - Free Access to Ten Percent Happier app for Warehouse Employees, Teachers, Healthcare, Grocery, and Food Delivery Workers


Feeling hopeless? There are things you can do to create and maintain hope in a post-coronavirus world (6-16-20)


Santa Cruz Public Library - Art "Quilt" for Virtual Community - Make a piece of art in any medium, 2D or 3D, and submit a square image for inclusion by July 31st.


KFF - What Options Exist If You’ve Lost Job-based Health Insurance? (Video) (6-17-20)


Virtual Narcotics Anonymous Meetings


David Sedaris, Dressed Up With Nowhere to Go - David Sedaris, the author and humorist, has been in lockdown just like the rest of us. With two books in the works but all plans on hold, the writer is pacing New York City and destroying his friends on Fitbit, the physical-activity-recording device. (6-20-20)

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page


REGION 8 HHS and FEMA COVID-19 RESOURCE DOCUMENT.pdf (download) (6-15-20) *NEW resource* (added 6-24-20)

The references and documents compiled here have been provided by members of CPS and other sources. They are offered as samples for your reference only and are not intended to represent the best or only approach to any particular issue. CPS has not attempted to evaluate any posted material. Neither CPS nor the individuals briefly reviewing the materials make any guarantee with regard to the accuracy of any document, and they assume no responsibility or liability in connection with the use or misuse of any material. Copyright in posted materials belongs to the respective owners, whether or not a copyright notice appears on the screen displaying the materials.


 

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 15th 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

Updates

CPS COVID-19 Resources for the General Public - CPS now has a webpage of COVID-19 Resources for the general public! It can be accessed from the CPS website homepage or at https://www.coloradopsychiatric.org/coronavirus. Resources are organized into the following categories: Key Resources; Self-care Resources; Colorado Specific Resources; Reopening and How to Stay Safe; Resources for Families and Children; Activities for Adults, Families and Children; Learn More about COVID-19; and Substance Use Resources. It is updated weekly so please share with your patients and anyone else who may find it helpful.

 

 
Resources for Providers


JAMA- Strategies for Digital Care of Vulnerable Patients in a COVID-19 World—Keeping in Touch


Psychiatry Online - Mental Health Policy in the Era of COVID-19- This article describes significant changes in mental health policy prompted by the COVID-19 crisis across five major areas: legislation, regulation, financing, accountability, and workforce development. (6-10-20)


KFF - Using Stories To Mentally Survive As A COVID-19 Clinician (CHL)


The Hospitalist - Human sitters in the COVID era - Data collection needed for care of suicidal hospitalized patients (6-9-20)


Doctors’ top telehealth coding questions answered - see page 2 for Providing mental health services during COVID-19 (6-8-20)


APA Releases Guidance on Admittance, Discharge of Psychiatric Patients During COVID-19 - The APA Board of Trustees last week issued guidance on how hospitals should manage patients in psychiatric inpatient settings during the COVID-19 pandemic. (6-4-20)


KEVIN MD - Feeling guilty for not being on the frontlines of the pandemic [15 minute PODCAST] June 15, 2020


HCPF - Help Us Spread the Word: Become A Health First Colorado Provider Today! Currently, the Department is offering incentives to increase provider enrollment and help provide an important public service. In an effort to increase provider enrollment, the Department is:

  • Allowing temporary enrollment for providers during the federally designated COVID-19 emergency. 
  • Waiving the application fee and fingerprinting process for applicable providers. 
  • Waiving site surveys for applicable providers.


Autoimmune effects of Covid 19 (5-29-20)


You can now listen to PsychNews Briefings on topics like Psychiatrist Transitioning to Telemedicine, Telepsychiatry During and After the COVID-19 Pandemicand more articles related and not related to the pandemic.

 

 
Resources for Patients


NYT - How to Navigate Your Community Reopening? Remember the Four C’s - Close contact, confined spaces, crowds, choices — these are the considerations to ponder now. Also see this video on the Japanese model to Prevent the Spread: Avoid “Three Cs” to prevent infection.


The Hospitalist - COVID-19: Use these strategies to help parents with and without special needs children (6-5-20)


NYT - Your 2020 Virtual Pride Guide


HuffPost -Why You’re Having Anxiety Over Lockdown Ending, And How To Cope As coronavirus restrictions lift and states begin to reopen, therapists say there are things you can do to manage your anxiety and stress about the transition. (6-10-20)


PBS - This chart can help you weigh coronavirus risks this summer


The Washington Post - Alcoholics Anonymous, struggling to reach new members during the shutdown, expects a surge (6-12-20)


NAMI COVID-19 Resource and Information Guide


NYT - 5 Rules to Live By During a Pandemic


NYT - As Playgrounds Start to Reopen, Here’s How to Keep Kids Safe (6-11-20)


NYT - Marvel at this footage of 64,000 green turtles migrating in Australia. Watch drone footage here.

 


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


Updates


Thank you for participating in the Colorado House of Medicine COVID-19 member survey, co-sponsored by CPS and others.  You can review the survey memo here (aggregated data).

 

 
Resources for Providers


Register for ACEP/APA Webinar - Taking Care of Yourself and Your Teams - Jun 23, 2020 Noon Mountain Time - Webinar on promoting peer recognition of the signs and symptoms of suicidal depression and how to build a supportive environment in team-based settings.


AACAP - Virtual Forum: Healthcare Disparities through the Lens of Diversity During the COVID-19 Pandemic - AACAP will host their second virtual forum June 13, 10am-12pm MT highlighting mental health, COVID, and other healthcare disparities related to race and ethnicity among children and adolescents of color.  Register today!


Medscape - COVID-19: Delirium first, depression, anxiety, insomnia later? (5-21-20)


MD Edge - COVID-19: New group stands up for health professionals facing retaliation (6-2-20)


Changes in patient behavior during COVID-19: What I’ve observed (download) (06-2020)


CDC - Communication Toolkit for Migrants, Refugees, and Other Limited-English-Proficient Populations


COVID-19 Emergency Reforms in Massachusetts to Support Behavioral Health Care and Reduce Mortality of People With Serious Mental Illness (6-3-20)


Grant funding for rural telemedicine available. Available to organizations like rural mental health centers, hospitals, and practices. Currently accepting applications for the Distance Learning and Telemedicine Grant Program. Application Deadline: July 13, 2020.

 

 
Resources for Patients


Virtual room of Refuge” - lots of different options offered, such as meditation, music, humor, stretches…


If you want to protest, how can you protect yourself from the coronavirus while doing so? An infectious-disease physician shares advice on how to demonstrate in crowds of thousands and do your part to limit the spread at the same time.


PsychNews - Asian American Hate Incidents: A Co-occurring Epidemic During COVID-19 (6-1-20) How to Handle an Attack or Threat - For People Who Feel at Risk and For Witnesses


CDPHE - Guidance for Coloradans on Places of worship(updated 6-4-20) and Outdoor recreation (updated 6-6-20)


Explore the Outdoors! 8 Outdoor Activities That Are Good for Your Family’s Mind and Body

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

 

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

Updates

CPS Members - Are you working on a resource that would be helpful to others during the pandemic? Are you speaking on a webinar or have you written an article on COVID-19? Please let us know by emailing [email protected] so we can help spread the word!

 

 
Resources for Providers


Q&A with CPS Member Dr. Neill Epperson, Chair of the Department of Psychiatry, including info on new podcast “Mind the Brain: Mental Health in the Time of COVID-19”. You can listen to episodes by clicking “full story” and “listen” in each written version of the podcasts. Episodes include Suicide Risk and the Global Pandemic featuring CPS member Dr. Michael Allen and Students During COVID-19 with CPS member Dr. Rachel Davis.


APA - Guidance Document: Opening Your Practice During COVID-19  (download). Also see additional resources from the AMA: Mistakes to avoid as you reopen (5-18-20)and COVID-19 screening script (5-15-20).


CDPHE - How to conduct a facility health screening.


KevinMD - I’m a physician during a pandemic. Please don’t ask me how I’m doing. - by a Colorado physician.


NEJM - A Paradigm for the Pandemic: A Covid-19 Recovery Unit (5-27-20)


MD Edge - Domestic violence amid COVID-19: Helping your patients from afar (5-27-20). For an overview of the pandemic and domestic violence, see We can't lose sight of the pandemic's hidden crisis: domestic abuse, says AMA President (5-28-20).


Judge Demands Washington Psychiatric Hospital Reopen - Western State Hospital has mostly stopped accepting jail transfers, leaving inmates with mental illness in limbo (5-12-20).

 

 
Resources for Patients


Washington Post - Is it possible to safely see friends again? How to have a judgment-free conversation about it. (5-28-20). Also see Washington Post: Four Concepts to Assess your Personal Risk as the U.S. Reopens (5-21-20), NEJM -“Is It Safe for Me to Go to Work?” Risk Stratification for Workers during the Covid-19 Pandemic (5-26-20), and CDC - People Who Are at Higher Risk for Severe Illness from COVID-19.


Denver Post - Colorado-themed coloring pages


Washington Post - Adaptability may be your most essential skill in the covid-19 world. Here's how to cultivate it. (5-26-20)


Washington Post - Poor mental health and isolation can take a toll on your immune system. (3-31-20)


PsychHub - COVID - 19 : Mental Health Provider Videos for Patients.


J.K. Rowling is publishing a free fairy tale for children online, called “The Ickabog.”


American Industrial Hygiene Association (AIHA). Back to Work Safely guidance for retail stores, restaurants, hair and nail salons, construction sites, small offices, gyms and workout facilities, in home services, and ride shares.


NYT’s Modern Love - Why Are All the Exes Texting? Not since The New York Post said I was dead have so many friends and lovers checked in on me.

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

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

Updates

Register here for CPS Event (free CME) - PsychSummit: COVID-19, Climate Change and Mental Health is TODAY! Wednesday, May 27, 2020 at 11am MT (1pm ET) OR 6pm MT (8pm ET). Open to anyone.

This PsychSummit event will focus on climate change and mental health and open with comments on COVID-19 and climate change by David Pollack, MD. Then join our panel to discuss clinical examples and experiences, the role psychiatrists can play in advocacy and preparedness, and the ways we can best educate about the effects of climate change on mental health. The APA has designated this FREE live activity for a maximum of one AMA PRA Category 1 Credit ™.* More information and registration here.

*Accreditation 
This PsychSummit: Climate Change activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Psychiatric Association (APA) and the New York County Psychiatric Society. The APA is accredited by the ACCME to provide continuing medical education for physicians. 

Designation The APA designates this live activity for a maximum of 1 AMA PRA Category 1 Credits (TM). Physicians should claim only the credit commensurate with the extent of their participation in the activity.
 


In case you missed it, you can still register to watch a recording of the CPS Spring Meeting HERE.

COVID-19, Physician Leadership, and the Urgency of the Moment in Medicine
Speakers: AMA President Patrice Harris, MD, MA; New York Times Op-Editor Dr. Richard A. Friedman; comedian Gary Gulman of HBO's The Great Depresh.

 

 
Resources for Providers


APA Survey - The Department of Health and Human Services has asked if psychiatrists are having trouble receiving funding from the (1) CARES Act and the (2) Paycheck Protection Program and Health Care Enhancement Act. If you are having trouble accessing funds, we would like to know in order to identify ways to help.


JAMA - Prioritizing Physician Mental Health as COVID-19 Marches On
(5-20-20)


Professional Quality of Life Measure (ProQOL)
- Measure of both negative and positive effects on professionals from helping others who experience suffering and trauma. Available in 27 languages, or download the “Provider Resilience” app for iOS or Android. The ProQoL is included in this set of quick, evidence-based tools to gauge your stress as well as your compassion satisfaction. Give yourself a regular “checkup” – the app will help you track your responses over time (select the self score version for instructions on scoring).


Colorado Pediatric Provider Toolkit - contains templates for pediatrics, but they could be adapted for psychiatry practices (May 2020) (download)


Johns Hopkins - Assessing Capacity for Medical Decisions in the Covid-19 Context (download) (5-4-20)


CMS webinar: Ethics and COVID-19 - Watch recorded webinar Ethical issues related to COVID are complex and challenging. This webinar will bring experts to talk about the ethical aspects of COVID-19, including equity and prioritizing access to health care workers in triage. Confirmed panelists: CPS Member Jeremy Lazarus, MD, and Matthew DeCamp, MD, PhD, Moderated by CMS President-elect Sami Diab, MD.


Washington Post - The surprising intimacy of online therapy sessions during the pandemic (5-18-20)

 

 
Resources for Patients


NPR - Is It Safe To Go To The Beach? Camp? Eat Out? Here's How To Evaluate The Risks (5-23-2020)


Will the Pandemic Have a Lasting Effect on My Kids? - Research on wars, natural disasters, and other crises reveals how to protect our children’s mental health (5-18-2020)


The Smithsonian, in collaboration with Science for Global Goals, is providing a resource on COVID-19 to help young people understand the disease and how to keep safe, and it will address mental health concerns possibly caused by the pandemic. There are different versions for grade levels 3-8 and it is available in over 15 languages.


NYT - When can I see my grandkids (or, for that matter, my grandparents or aging parents)? (5-20-20)


NYT - Tired of WFH neck or back pain? These three stretches may help.


Washington Post - 5 pieces of advice to help manage postpartum depression during coronavirus (5-25-20)


NIDA - How is COVID-19 impacting people in recovery or with a substance use disorder? Watch a short animation from the National Institute on Drug Abuse.


My Pandemic Story – A Guided Activity Workbook for the World’s Children, Families, Teachers and Caregivers (download)


Right Now I am Fine – coping coloring book for kids

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

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

Updates


PsychSummit: Climate Change and Mental Health with comments on COVID-19 and climate change -
Wednesday, May 27, 2020 at
1pm MT (3pm ET) OR 6pm MT (8pm ET). Virtual- attend from anywhere!  

This PsychSummit event will focus on climate change and mental health and open with comments on COVID-19 and climate change by David Pollack, MD.

Next, join our panel to discuss clinical examples and experiences, the role psychiatrists can play in advocacy and preparedness, and the ways we can best educate our patients and the public about the effects of climate change on mental health. The APA has designated this FREE live activity for a maximum of one AMA PRA Category 1 Credit ™.* More information and registration here.

*Accreditation 
This PsychSummit: Climate Change activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Psychiatric Association (APA) and the New York County Psychiatric Society. The APA is accredited by the ACCME to provide continuing medical education for physicians. 

Designation The APA designates this live activity for a maximum of 1 AMA PRA Category 1 Credits (TM). Physicians should claim only the credit commensurate with the extent of their participation in the activity.
 


Survey Results - APA - Psychiatrists Express Concerns Over MH Care During Pandemic - CPS Disaster Representative Scott Simpson, M.D., M.P.H., medical director of psychiatric emergency services at Denver Health and an associate professor of psychiatry at the University of Colorado Anschutz Medical Campus, and colleagues surveyed psychiatrists from March 19 to 30 and received responses from 101 psychiatrists in 29 states. Thank you to those of you who completed the survey! (5-7-20)

 

 
Resources for Providers

Telepsychiatry and the Coronavirus Disease 2019 Pandemic—Current and Future Outcomes of the Rapid Virtualization of Psychiatric Care by CPS Members Jay Shore and Chris Schneck and Matthew C. Mishkind, PhD

Psychiatric Times Webinar - Telepsychiatry: Ready Your Practice for COVID and Beyond featuring CPS member Jay Shore - available on demand upon registration

CDHS sponsored Channel 9News/Facebook Live event on Frontline Mental Healthcare workers- CPS Member Kim Nordstrom is a co-panelist with CCAPS member Dr. Christian Thurstone, Director for Behavioral Health (DHMC) and Renee Marquardt, Chief Medical Officer at CDHS. Scroll down to see event video.

NEJM - Preventing a Parallel Pandemic — A National Strategy to Protect Clinicians’ Well-Being (5-13-20)

COVID-19 Care Line for Physicians 720-810-9131
If you are a physician who needs support and assistance with acute stress during this challenging time you may call the COVID-19 Care Line for Physicians (Care Line) at 720-810-9131. The Care Line is a special peer support offering by the Colorado Physician Health Program (CPHP) in response to the COVID-19 pandemic. Call to speak with someone or go here for further information. The Colorado Psychiatric Society, Colorado Medical Society, COPIC, and Colorado Hospital Association endorse the Care Line to assist vital medical community providers.

Washington Post -  Losing your motivation to exercise as the pandemic drags on? Here’s how to get it back (5/12/20)

APA Practice Guidance  (updated 5-11-20)
-Receiving funds from CARES Act
-FDA guidance on relaxing rules for REMS medications such as Clozaril, when clinically appropriate
-CMS guidance as of April 30 regarding billing for audio only telepsychiatry visits
-SAMSHA and DEA guidance waiving requirement for initial in-person evaluation to prescribe buprenorphine to new and existing patients by telephone, during this public health emergency
-And numerous other items

CMS Webinar - Social Determinants of Health and their Effects on COVID-19 Outcomes - Friday, May 29, 12-1 p.m. Registration and full accreditation statement here.

APA, Inc - Returning to Work During COVID-19 Recovery (download)

Redeployment to COVID-19 Care Is Like Treading Water but Deeply Gratifying(5-11-20)

 

 
Resources for Patients

Consider these ways to reframe COVID-19 to speak with youth and manage stress and anxiety - short article by CCAPS member Chris Thurstone

The New Yorker - Advice for the workplace - Atul Gawande explains how businesses can minimize the virus’s spread when they reopen by copying what hospitals are doing with their employees.

Vanity Fair: If 80% of Americans Wore Masks, COVID-19 Infections Would Plummet, New Study Says

Washington Post - Your questions, answered - My father was a healthy, 96-year-old senior with a robust social life at his assisted-living home. Now, after 60 days of total isolation, he is a depressed, run-down, lonely shell of his former self with no quality of life and no end in sight. Is this really the best way to handle this pandemic in our senior communities? How can people help?Lynn (5/12/20)

Washington Post -  Losing your motivation to exercise as the pandemic drags on? Here’s how to get it back (5/12/20)

Headspace - Headspace Plus is now FREE for every unemployed person in the US. An app for users to discover meditation and mindfulness tools to help feel less stressed, more resilient, and kinder to yourself.

The Centers for Disease Control and Prevention (CDC) has released six "decision trees" to help businesses, workplaces, schools, camps, transit, and other communities decide whether it is safe to reopen

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

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
 

Updates


CPS Virtual Event - This Saturday, May 16, 2020 5:00pm MT - Reserve your spot to hear AMA President and psychiatrist Patrice Harris discuss specific ways of responding to the mental health needs of physicians and the public during the COVID-19 pandemic. The evening will begin with an interview between New York Times Op-Editor Dr. Richard A. Friedman and comedian Gary Gulman of HBO's The Great Depresh.

REGISTER HERE! Non-members welcome!


APA Telehealth Survey
- Many telehealth regulations have been temporarily lifted due to the COVID-19 pandemic. To help APA understand the implications on your practice and access to care for your patients, please fill out a short survey. APA will use the answers to develop member resources and for our advocacy initiatives.

 

 
Resources for Providers


30 minute guided meditation for mental health providers to reset while treating patients during COVID-19

 
MD Edge - COVID-19, anxiety, and CBT with Dr. Lynne Gots (podcast) (5-22-20)


U.S. ‘deaths of despair’ from COVID-19 - Report from Well Being Trust (WBT) and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care (5-8-20) (download)


NYT - There Is No Vaccine for Teenage Despair: Being shut in has a way of bringing out our dark thoughts. But it’s also a chance for honest conversation. (5-7-20) by 17 year old Tali Rosen.
The admonition to worry about the kids we don't think we need to worry about feels important. Probably true about adults, too.


CDPHE - ConnectToCareJobs.com provides facilities and job seekers with an easy way to connect. The online tool pairs licensed and/or trained health care workers with facilities that need their specific skills.


PBS - The ominous consequences of COVID-19 for American mental health - Amna Nawaz talks to Dr. Joshua Gordon of the National Institute of Mental Health and former Rep. Patrick Kennedy of the Kennedy Forum.


Have Ethical Questions Regarding COVID-19? APA's Ethics Committee invites members to seek advice on ethical dilemmas they are facing during the COVID-19 pandemic. Submit questions to [email protected], and a committee member will respond to you directly.

 
JAMA - Religious Service Attendance and Despair Among Health Professionals—A Catalyst for New Avenues of Inquiry
The most significant finding of note was that religious service attendance was inversely associated with deaths from suicide for nurses and physicians in the study. The suicide rate for health professionals is more than double the corresponding rate in the general population, and results from this studysuggest that religious service attendance may be an antidote for or provide substantial relief from overwhelming social, economic, or occupational environments, although such a potential causal link can only be viewed as speculative in an association study.


JAMA - Managing Virtual Hybrid Psychiatrist-Patient Relationships in a Digital World Jay H. Shore, MD, MPH


Colorado Health Institute Provides Guide for Colorado’s Telemedicine Future (5-11-20)


NEJM - Pandemic and Persona (5-6-20)


PRMS FAQs (updated 5-11-20) and Practice Survey- changes to state licensure waivers, resources for re-opening a practice, resource for patients new to telemedicine, contingency / disaster planning, closing a practice on short notice, and a reminder to not forget the basics when treating patients remotely – assess for suicidality, check the Prescription Monitoring Program, if possible – and do not apologize for any adverse outcome without calling your risk manager first.  


PsychNews: C-L Psychiatrists Provide Overview of Response to COVID-19 Pandemic and Patient Management (4-29-20)


COVID-19: Eight steps for getting ready to see patients again (5-7-20)

 

 
Resources for Patients


The Risks - Know Them - Avoid Them


Let Daniel Radcliffe read you (or your kids) a chapter from the first “Harry Potter” book.


Take a Self-Compassion Break


COVID-19 Quiz Social distancing. Herd immunity. Flattening the curve. With so much information coming out daily about the coronavirus and COVID-19, it’s hard to keep up, but important to know the facts. Test your knowledge, and share this quiz with family, friends and colleagues.


Webinar - Colorado House Public Healthcare and Human Services Committee and several behavioral health experts from across the state discuss why behavioral health is so critical during COVID-19 and what this pandemic means for our state moving forward. Hosted by Colorado Representative Dafna Michaelson Jenet. 


CDC - Protect Yourself When Running Errands


NYT - Take a walk through nature with photographers at One Foot in Front of the Other - How A Daily Walk Helps Us Cope or tour the Brooklyn Bridge with the NYT architecture critic.


VA - New FREE COVID Coach app available - If you’re feeling worried or anxious about your health, safety, loved ones, finances or uncertainty about the future, you are not alone. The new COVID Coach app can help you learn about self-care and improve your mental health during this difficult time.

 
NAMI COVID-19 Resource and Information Guide (La Guía COVID-19) (download)

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

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.

                    
           


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.

 

 
Resources for Providers


APA/SAMHSA Webinar -  "Implementation of Digital Mental Health for SMI: Opportunities and Barriers" Thursday, May 7, from 1 pm to 2 pm MT


Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic
(download)


The Pandemic's Future - Researchers with the Center for Infectious Disease Research and Policy (CIDRAP) used data from influenza pandemics to predict the future course of the COVID-19 outbreak.


MD Edge -
COVID-19: Employers cut doc pay and bonuses: What’s your recourse? (4-29-2020)


COVID-19: An opportunity, challenge for addiction treatment, NIDA boss says (4-30-2020)


Register here for the next CMS Physicians' Town Hall on COVID-19, co-sponsored by CPS - impacts and practicalities of re-opening offices to procedures - Wednesday, May 6, 6 - 7 pm


COVID-19 Initiative to Stem the Tide of Suicide and Mental Illness - Several federal agencies and private sector groups have launched a national initiative that aims to prevent suicide and mental illness resulting from the COVID-19 pandemic.


Webinar focused on the critical needs, priorities, and emerging strategies to support the well-being of clinicians - May 7th 11:30am - 1pm MT


Colorado Behavioral Health Task Force - Governor Polis has directed the creation of a new special assignment committee that will focus on the impacts of COVID-19 on behavioral health in Colorado.


The Office of eHealth Innovation (OeHI) and the Innovation Response Team are interested in learning about efforts to serve vulnerable populations with telehealth. Behavioral health providers are encouraged to fill out this form to potentially receive technical assistance, education, and clinical volunteer support as they implement telehealth projects.


MD Edge - Reproductive psychiatry during the COVID-19 pandemic (4-29-2020)

 

Resources for Patients


Four tips for parents and caregivers when talking to their children - video by COACT Colorado (a program of OBH, in collaboration with Children’s Hospital Colorado, Partners for Children’s Mental Health and the Kempe Center) on how to better understand what children are feeling during the pandemic and ways parents and caregivers can teach valuable coping skills during the crisis.


Rad Resilience - Nikita Gupta Workshop Self-Care Toolkit (download)


S.AF.E. Virtual Music Festival on May 8th - SAFE is a Colorado-based recovery community organization committed to showing people how to be healthy and mentally strong. S.AF.E. provides sober sections and sober tailgates at events that are not traditionally sober. You can also enjoy a 76 songs playlist.


Get your art fix by perusing over 400 art pieces at Denver Public Art, exploring Denver Art Museum's online archives or taking a virtual tour of the 2019 Natura Obscura exhibit at the Museum of Outdoor Arts.


Denver Public Library’s 2020 Maker Challenge - Share what you're making at home with us and automatically enter to win a $50 gift card to an awesome local business! From April 3- August 8, a winner from each Denver Public Library branch will be randomly selected and notified at the end of each month.


Send a free recovery greeting card (part of OBH’s Lift The Label opioid anti-stigma campaign).


Working Remotely During COVID-19: Your Mental Health & Well-Being - The Center for Workplace Mental Health, an APA Foundation initiative, has a new employer resource on maintaining your mental health and well-being while working remotely, what to do if you have a mental health condition, and tips for managers and HR professionals on staying connected and supporting employees during this challenging time.


Bingo Card 1 and Bingo Card 2 for Youth - To encourage youth to do their part, CDPHE has put together stay-at-home BINGO cards to fill out and post in Instagram or Facebook Stories, using the hashtags #DoingMYPARTCO and #InActionHero.

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

 

 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)

4 Life Skills Parents Can Teach Kids Amid The Coronavirus Pandemic

Colorado Psychiatric Society COVID-19 Resource List

April 29, 2020

 
Resources for Providers


The Atlantic - Why Some People Get Sicker Than Others: COVID-19 is proving to be a disease of the immune system. This could, in theory, be controlled. (4-21-2020)


JAMA - Mental Health Status Among Children in Home Confinement During the Coronavirus Disease 2019 Outbreak in Hubei Province, China (April 24, 2020)


KFF - The Implications of COVID-19 for Mental Health and Substance Use A new issue brief explores mental health and substance use in light of the spread of coronavirus, including the implications of social distancing practices and the current financial crisis on mental health, as well as challenges to accessing mental health or substance use services.


Yale Dept of Psychiatry - Alternatives to Parenteral Lorazepam in Face of Possible Shortage (4-10-20) (download)


University of Toronto - University Health Network Centre for Mental Health COVID-19 Screening and Isolation Algorithm (4-16-20) (download) 


University of Pittsburgh Medical Center Consultation Liaison Psychiatry COVID-19 Service Manual (3-26-20) (download)


Gov. Polis Executive Order - Colorado essential workers and government employees are required to cover their faces when close to colleagues or the public


PsychNews: How to Prevent Psychiatric Crises During a Pandemic - CPS Disaster Rep Scott Simpson, MD, discusses issues surrounding transitions of care and psychiatric boarding in the ER during a pandemic. CPS Member Kim Nordstrom, MD, JD, is also quoted on the role of outpatient care in preventing the need for crisis services.


NEJM Resident - COVID-19 Primer: Virtual Patient Simulation An interactive case provides a primer for the general management and clinical considerations in managing patients with possible Covid-19 infection.


NEJM - Rural Matters — Coronavirus and the Navajo Nation


Volunteer Opportunity: CMS is compiling a list of interested volunteers to share with the state as soon as the Contact Tracing system is up and running. They will be looking for Contact Tracers as well as COVID Navigators to support individuals in self-isolation. If you would like to be included on this list, please fill out the CMS Contact Tracing Volunteers Form.


CDPHE - The National COVID-Ready Caregiver Certificate Training Program for Frontline Staff - Training topics include infection control practices, personal protective equipment, changes to health and safety practices and tips for managing stress and anxiety. Available through May 2 for only $5 per frontline staff member: covidcert.nextstep.careers. Use code COCOVID5 (select 'Click here to enter discount code' on the enrollment page). If you are unable to afford the training fee, please send an email to [email protected].

 

 
Resources for Patients


Stuck at Home? How to Find Awe and Beauty Indoors - During quarantine, you can gain a sense of perspective by discovering what's wondrous in the clutter of your home.


CDPHE - NEW Statewide Resource: OnwardCO - One-stop resource for the people of Colorado impacted by job loss during the COVID-19 pandemic.


Depression Center: Parent Support Through the Corona Virus – Thursday evenings 8 pm – 9:15 pm via zoom - An online parenting support group to help parents in our community as they cope with the pandemic, home schooling, and other causes of anxiety.


Project Gutenberg is a library of over 60,000 free eBooks. Choose among free epub and Kindle eBooks, download them or read them online. You will find the world's great literature here, with focus on older works for which U.S. copyright has expired.


4 Life Skills Parents Can Teach Kids Amid The Coronavirus Pandemic
Yes, kids are missing out on so much right now. But they're also learning some pretty big life lessons during lockdown (04/23/2020)


Video
using black paint to illustrate good handwashing

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

 

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

Updates


Did you miss our PsychSummit: COVID-19 event on Sunday evening? Not to worry, you can view Part 1 of the free event here! The video 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 as well as glimpses into the lives of NYC 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. We held a last-minute special COVID-19 edition on Sunday April 19th and are thrilled that almost 670 people registered in less than a week!

 

 
Resources for Providers


Getting Paid in a Pandemic by Claire Zilber


Physician Support Line
(1 (888) 409-0141) - is a free peer support line run by volunteer psychiatrists for their physician colleagues all over the U.S. on the frontlines of COVID-19 (not accepting new volunteers at this time)


Study identifies 275 ways to reduce spread of coronavirus following lockdown


Coronavirus in a psychiatric hospital: 'It's the worst of all worlds'


AMA – Physician Practice Financial Relief Guide (download) 4-8-2020 - Note - SBA loans have maxed out but additional funds may be added


APA Spring Meeting - A free virtual two-day conference Apr. 25-26 with top psychiatric experts


Social Distancing Is Harder in Some Colorado Neighborhoods - a new interactive map and analysis identifies the places in Colorado where people are likely to have the hardest time staying isolated


Neurological effects with Covid - News summary and JAMA article April 10, 2020            


New Yorker - Why Psychiatric Wards Are Uniquely Vulnerable to the Coronavirus


PRMS - FAQs - updated 4-17-2020


Keeping the Coronavirus from Infecting Health-Care Workers
by Atul Gawande 3-21-2020

 

 
Resources for Patients


New video from CCAPS and Smart CO: Tips for Parents about Healthy Behavior Modeling in Challenging Times -  In response to a surge in marijuana sales, the Colorado Child & Adolescent Psychiatry Society partnered with Smart Colorado to create a video with helpful tips for parents. See the interview with CAP Fellow Steven Solomon here.


That Discomfort You’re Feeling Is Grief


AACAP - How to Prepare for a Video Appointment with Your Mental Health Clinician (download)


Alcoholics Anonymous is hosting online meetings


3-D simulation
helps show why distancing is so important

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

 

 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

Updates


CPS COVID-19 Event this Sun 4/19 @ 5pm - Register here

On Sunday, April 19th, join us for a special edition of PsychSummit focused on COVID-19. This virtual, interactive conference will allow psychiatrists from across the country to share ideas and solutions relating to the pandemic. A portion of the event will contain presentations from NYC psychiatrists on their experiences on the ground and lessons learned. Attendees will also come together in dedicated rooms to discuss issues facing doctors in private practice, administration, palliative COVID care, and more.

Dedicated discussion rooms will include:
  • Hospital-based psychiatry
  • Private practice
  • Corrections
  • Community Mental Health 
  • Child & Adolescent psychiatry 
This event is FREE for all psychiatrists and trainees! Register now at: www.psychsummit.org

 

 
Resources for Providers

Contingency Planning for a Pandemic by Claire Zilber, MD, DFAPA (download)

COVID-19 Testing for healthcare workers

CDPHE is currently partnering with Kaiser Permanente to help provide COVID-19 testing to symptomatic health care workers and first responders, including those who are not Kaiser members, who do not have access to testing through their employer. Testing is available at eight locations between Loveland and Pueblo. To schedule an appointment, contact CDPHE at 303-692-2700 and ask to speak with a clinical consultant about Kaiser testing. 

Self-Care Advice for Health-Care Providers During COVID-19 by CPS’ Rachel Davis, MD; CCAPS’ Steve Berkowitz, MD and Helen Coons, PhD

Health First CO Medication Prior Authorization Deferments - 4/7/2020 (download)

Highlights:

Prior Authorization (PA) requirements for Health First Colorado (Colorado's Medicaid Program) members on all medications for which there is an existing 12-month PA approval in place are being deferred. Each PA may be extended one time for 90 days. These extensions will be handled on a case-by-case basis by the Magellan Rx Management Pharmacy Call Center (1-800-424-5725 for a one-time PA deferment). New PAs and existing PA approvals that are less than 12 months are not eligible for deferment.

Telepsychiatry in the age of COVID-19 with CPS Member Dr. Jay Shore (podcast) - Dr. Jay H. Shore discusses telepsychiatry in a regulatory environment that is quickly changing because of the physical distancing forced by the COVID-19 pandemic

Register for the Physicians' town hall on COVID-19: Wednesday, April 15, 6 - 7 p.m. Speakers are Rep Caraveo (Legislator and Pediatrician) and Eric France (CDPHE CMO)

Virtual visit tools - Israeli hospital treats Coronavirus patients virtually in their homes (video)

Electroconvulsive Therapy ECT as an Urgent Procedure 

Restarting America will put human lives at risk - The Times Magazine talked to five experts on the ethics of the decision

DEA decision tree (download)
PRMS note: Keep in mind that states can have their own requirements for and restrictions on prescribing controlled substances

 

 

Resources for Patients

A Colorado Tenant’s Guide to COVID-19

Mental Health Colorado - FREE resources for self-care

Wall Street Journal - What to Put in a Covid-19 Emergency Home-Care Kit

HealthFlix - a series of free online classes from international leaders in health, wellbeing, psychology and lifestyle, designed to help us all cope in this time of global crisis and beyond.

 

 

Key Resources

CDC Website on COVID-19

Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)

Governor’s Facebook Page

 
 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

Updates

 
Register here for the next House of Medicine topic-specific webinar: Physicians - Staying Well Amidst the Crisis, Friday, April 10, 12 - 1 p.m. Co-hosted by the Colorado Psychiatric Society and the CMS Committee on Physician Wellbeing (free CME).

Plan to join CPS, CMS and others in the House of Medicine on Friday, April 10, 12 - 1 p.m. Speakers from the Colorado Psychiatric Society, Colorado Physician Health Program and the CMS Committee on Physician Wellbeing will lead a discussion on stress in these incredibly trying times and tips for wellness.


CDPHE Emergency Regulation 20-E-05 - Concerning Coverage and Reimbursement for Telehealth Services During the COVID-19 Disaster Emergency

Highlights: The purpose of this emergency regulation is to require carriers to reimburse providers for provision of telehealth services using non-public facing audio or video communication products during the COVID-19 nationwide public health emergency.

 

 
Resources for Providers

 
APA webinar (free CME) COVID‐19 AND MENTAL HEALTH: Caring for the Public & Ourselves


COVID Staffing online resources - helps hospitals understand and manage their staffing needs during the COVID-19 pandemic, includes staffing and PPE calculators and other tools.

 
NEJM - Harnessing Our Humanity — How Washington’s Health Care Workers Have Risen to the Pandemic Challenge Lisa Rosenbaum, M.D.


Small Business Administration Loan Application - In response to the Coronavirus (COVID-19) pandemic, small business owners are eligible to apply for an Economic Injury Disaster Loan advance of up to $10,000. This loan advance will not have to be repaid.


CPR - Fear, Avoidance, Being Told To Go Back To Their Country: What It's Like To Be Asian In Colorado In The Time Of Coronavirus


Centennial Peaks Hospital Opens a Dedicated Unit to Treat COVID-19 Patients. The hospital has opened a unit that is dedicated to serving medically ill and/or COVID-19 symptom patients who are also struggling with behavioral health or substance use disorder at this time. The unit is open, and accepting adult patients 18 years and older for treatment. Contact the intake department at 303.666.2088 to schedule a level of care assessment.


HIPAA and Payment - Some CPS members have been cautioned about using alternative payment methods such as Venmo instead of checks and credit cards. Call your risk management carrier if you are concerned about HIPAA compliance and payment methods. Stay tuned for more information in the next CPS COVID-19 Resource email!


CDPHE COVID-19 Guidance for Prescribers and Telemedicine FAQs for Health First Colorado (updated)


Thoughts from fellow psychiatrists:

 

 
Resources for Patients


CDC - Use of Cloth Face Coverings to Help Slow the Spread of COVID-19


No-Sew Pleated Face Mask with Handkerchief and Hair Tie


Food pantry schedule - A listing (download) of over 30 Denver food pantries with hours and contact information. Call 211 to locate additional resources or to confirm information is current.


PATIENTS - COVID-19 Updates & Resources
(download) - Comprehensive list of resources, including general information, healthcare resources, information on community mental health centers, crisis services, mental health/substance use online support groups, low-income technology resources, food/housing/financial assistance and more.


While the stay-at-home order is critical for fighting COVID-19, it also can make an already unsafe situation even more volatile. The National Domestic Violence Hotline is available 24 hours a day in more than 200 languages at 1-800-799-SAFE or text LOVEIS to 22522. This national hotline will connect you to local resources. They can help you plan to stay safe no matter what your situation is, even if you can't leave. Also see Violence Free Colorado list of Domestic Violence Programs in Colorado.

 

 
Volunteer Opportunities


See CPS Volunteer Opportunities email sent 4/7/2020 or visit https://www.coloradopsychiatric.org/COVID19 and look for Volunteer Opportunities.

 

 

Key Resources


CDC Website on COVID-19


Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)


Governor’s Facebook Page

 
 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

 
Volunteer Opportunities


Help Colorado Now - Health Care Response Volunteer Sign Up

State of Colorado COVID-19 Response - We are looking for volunteers to help at-risk individuals across our state get through the COVID-19 crisis. Complete the physician form to be matched with the needs of hospitals, testing sites, or care facilities.


Volunteer to provide free telehealth visits

In the coming days, the Colorado COVID-19 Innovation Response Team -- organized by Gov. Jared Polis -- will introduce a telehealth/telemedicine service providing support to ~800,000 uninsured and under-served Coloradans. Their goal is to provide health services while reducing strain on Colorado health care facilities, leaving hospital beds open to the most severely ill.

Medical Professionals for Covid-19 Telehealth Response in Colorado - Complete the form if you are interested in volunteering for clinical, triage, or administrative efforts in Colorado. *ALL VOLUNTEER WORK WILL BE REMOTE FROM HOME*. They will reach out to introduce you to the project, and if you are interested in moving forward, will onboard you with a local free clinic so that you are covered by their malpractice insurance. They urgently need medical professionals and administrators to donate their time to provide these free telehealth visits. This work will be performed entirely from home, primarily via telephone and/or video calls. Callers will provide their symptoms over the phone, and those who need medical attention will be triaged to a queue for telephone-based care. More information here.


Want to help in another way?

CPS has additional opportunities--such as reviewing materials for the CPS COVID-19 Resource Emails--available. Email [email protected] if you are interested in serving in a non-clinical role or if you have another idea for supporting members.

 

 
Resources for volunteer FAQs


Contact your professional liability insurance carrier to confirm if they cover you for the rendering of psychiatric services as a volunteer in the state where you are licensed.


DORA COVID-19 FAQ for Healthcare Professionals

Highlights:

Question: Do I still need to contact DORA to obtain some type of provisional license, or can I just start volunteering at healthcare facilities without a Colorado license if I fit the exemptions or suspended rules/statutes?

Answer: Under the emergency measures taken by the Division of Professions and Occupations, health care professionals wanting to re-enter the workforce do not need to contact the division or obtain a provisional license provided the following conditions are met:

  1. The individual holds a license as a physician, nurse, pharmacist, or respiratory therapist, and that license is in good standing (meaning not revoked, suspended, or on probation) in another country or U.S. state OR
  2. The individual has an inactive or expired license as a physician, nurse, pharmacist, or respiratory therapist that, when active, was in good standing (meaning not revoked, suspended, or on probation); 
  3. The individual does not hold himself/herself out to be a licensed practitioner, but is transparent about the current status of his/her license; 
  4. The services are performed on a voluntary basis; and
  5. The individual ceases working in the healthcare field and either resumes inactive/expired status or pursues licensure through the proper channels once the state of emergency has been declared over in Colorado.


DORA Emergency Guidance for Physicians - Specific details and guidance for physicians on re-entering the workforce during  the COVID-19 pandemic in Colorado.

Highlights:

Q: How can I check if my license is up to date?

A: You can verify your licensure status here. However, the State of Colorado issued a release that announced emergency measures for licensure, that allows for individuals with licenses in other states in good standing and retired individuals with current inactive status to be able to practice in the State of Colorado. These updates will not be reflected in the portal.


Many malpractice companies are offering no-cost coverage for former clients who have retired.

 



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

Updates

COVID-19 Care Line for Physicians 720-810-9131

If you are a physician or physician assistant who needs support and assistance with acute stress during this challenging time you may call the COVID-19 Care Line for Physicians (Care Line) at 720-810-9131. The Care Line is a special peer support offering by the Colorado Physician Health Program (CPHP) in response to the COVID-19 pandemic. Call to speak with someone or go here for further information. The Colorado Psychiatric Society, Colorado Medical Society, COPIC, and Colorado Hospital Association endorse the Care Line to assist vital medical community providers.

Callers will be linked with a physician peer who will listen and discuss stresses associated with the COVID-19 crisis, and caring for those suffering from the disease. Calls to the Care Line are free of charge. The Care Line is not treatment, but rather an opportunity for peer support in a confidential environment. Information provided by users will be kept confidential to the extent allowed by law. The Care Line is available Monday through Friday from 8:30am to 4:30pm, and additional support phone calls (or video chats) can be scheduled after hours. If you are experiencing a medical or psychiatric emergency, you should contact 911.

Register here for the Physicians' town hall on COVID-19: Wednesday, April 1, 6 - 7 p.m. with special guest speakers U.S. Sens. Michael Bennet and Cory Gardner

DEA, FTC Issue Warning: Beware of Scammers Be aware: Scammers posing as representatives from the Drug Enforcement Administration (DEA) and officials from other agencies are targeting physicians. It was recently brought to the attention of the Massachusetts Board of Medicine that Massachusetts licensees have been receiving scam calls from individuals posing as investigators of the Massachusetts Board of Medicine of the DEA. In these cases, the impersonator falsely stated that the licensee is under investigation and that their medical license is in jeopardy or has been suspended. Impersonators may demand money and/or seek additional information about the licensee’s DEA registration number and financial information. Physicians from other states received similar scam calls from individuals purporting to be FBI and DEA. The DEA webpage includes information for reporting the threat online.

 

 

Key Resources

CDC Website on COVID-19

Colorado Department of Public Health & Environment COVID-19

      (including Resources for local public health agencies and health care providers)

Governor’s Facebook Page

 

Resources for Providers

APA and SAMHSA - Request a Free Clinician-to-Clinician Consult - Mental health professionals can submit questions about COVID-19 and bipolar disorder, major depression, and schizophrenia and receive evidence-based guidance from S