May 12, 2021

Change Is the Only Constant 

By Claire Zilber, MD, DFAPA
CPS President

In this, my final President’s letter, I focus on change in several contexts: alterations in psychiatric health as a result of COVID-19, mutations in the virus itself over the course of the last 18 months, policy shifts we need to make to approach universal vaccination, and adaptations we are starting to make as we cautiously emerge from isolation.

The deleterious effect of the pandemic and of SARS-CoV-2 infection on mental health has been well documented in the medical and lay press, and in previous CPS COVID-19 emails. This retrospective EHR review of 236,379 patients who had recovered from COVID-19 found an incidence of a neurological or psychiatric diagnosis in 34% of patients, and a 13% incidence of a new neurological or psychiatric diagnosis in the aftermath of infection. These rates were higher among patients who were admitted to the ICU. Of particular concern is an almost 3% incidence of psychosis, as well as a 19% incidence of anxiety. In the population at large, even without a formal new neuropsychiatric diagnosis, few of us are thriving. Several of my patients and family members were eager to discuss this article on languishing, which explains the “blah” so many of us feel at this point in the pandemic.

Our daily “blah” is punctuated by occasional breezes of excitement, blown in by the wider range of behaviors we now allow ourselves. I hugged a friend! I’m planning a road trip! Going to the grocery store is less scary. As mask mandates are relaxed or lifted entirely in Colorado, depending on the county and setting, concern about variants leaves some people squeamish about reentry. Such anxiety may have been exacerbated by news that a variant initially identified in India has been found in Mesa County. You might assuage that fear by watching this highly scientific and reassuring 10-minute video on vaccines and variants. If you have been vaccinated, and by now I hope all CPS members have achieved this milestone, you are part of the solution.

More than two million people in Colorado have been fully vaccinated against COVID-19, which represents over a third of our population. This is consistent with overall US vaccination rates. Supply now outstrips demand, yet Black and Hispanic communities remain underrepresented among the vaccinated (click on the Demographics button at the top link in this paragraph to see the Colorado data), a result of mistrust engendered by racism in healthcare as well as remediable problems with vaccine access.

Meanwhile, as rich countries succeed at vaccinating their populations, developing countries lag far, far behind. "Nearly 900 million vaccine doses have been administered globally, but over 81% have gone to high- or upper middle-income countries, while low-income countries have received just 0.3%," WHO Director-general Tedros Adhanom Ghebreyesus said on April 23, 2021. Similarly, climate activist Greta Thunberg decried vaccine inequity as unethical. It is simultaneously thrilling and obvious that a teenager would scold the world about justice. It is imperative that the United States share our vaccine technology and stockpiled doses with developing countries whose people are suffering the most, such as India and Brazil. The BBC has an excellent global COVID map for those of you who want to dig into the disparities in cases, deaths, and vaccinations. Towards the bottom of that web page you’ll be riveted by an animated graph of the geographic spread of cases from February 2020 to the present.

Our gratitude about being fully vaccinated with highly effective mRNA vaccines may be slightly tempered by shame about our privilege, just as our relief and joy at being able to emerge from our tight pandemic bubbles may be subdued by anxiety about how far to go in relaxation of protocols. The CDC guidance allows fully vaccinated people from two separate households to remove their masks in private settings. However, the Colorado Department of Public Health and the Environment (CDPHE) continues to mandate masks in healthcare settings, including outpatient offices, even if everyone in the room is fully vaccinated. One might argue that a solo psychiatrist’s private practice office is closer to a living room in terms of exposure risk, yet even so called “limited healthcare settings” like audiology and occupational therapy practices are required to continue to conduct appointments by telehealth whenever possible and wear masks when in person.

I am aware that some of us have returned to in-person appointments when the patient and professional are both fully vaccinated. Just know that you are deviating from public health guidance when you do this unless you and your patient are both wearing masks.  A lot depends on the size of the building that houses your office, the nature of the ventilation, and the number of other people in the building. If you want to delve into engineering models of airborne risk, see this MIT analysis. For additional scientific guidance about indoor settings, this online app calculates the risk of being in a variety of spaces (ie: office, classroom, commercial airliner, etc), for a variety of minutes/hours, in a variety of conditions (ie: masks, no masks, speaking, exercising, singing). It is mostly reassuring, and it also reinforces the value of continuing to wear masks in indoor public spaces. Be sure to adjust the room specifications to fit your clinical setting and select the B.1.1.7 strain, which as of mid-April was the dominant strain in Colorado. Even if you see one patient at a time in a building with moderately good ventilation, if you see eight individual, consecutive patients in a day, you may be placing yourself and your patients at risk if you aren’t both wearing masks. Because I am a risk-averse rule follower, I continue to see my patients exclusively via telehealth, although I am moving that activity back to the office this week.

Emerging from what I hope has been the worst of the pandemic, it is natural to wonder about the impact of these terrible times on ourselves and society. This thoughtful article employs the most famous novel by my favorite author, Jose Saramago, as an allegory for COVID-19. I am optimistic that our collective ingenuity in adaptation will bring forth from the recent horrors of the pandemic and social upheaval innovations in healthcare delivery, social justice, clean energy, food and housing security, and immigration policy that will have a lasting positive change on the populace and the planet.

As I pass the gavel of responsibility for CPS leadership into the capable hands of Dr. Aaron Meng, I reflect on the experience of serving as president during the pandemic. I am grateful that I had the opportunity to be so strongly connected to my professional community, giving me a sense of purpose and collegial companionship during a year of isolation. Although the lyrics aren’t a perfect fit, the gratitude expressed in this uplifting acapella video, Change in My Life, feels like a fitting way to say farewell. 

Colorado Psychiatric Society COVID-19 Resource List

 May 12, 2021

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

April 7, 2021

This Sadistic Ultra-Marathon 

By Claire Zilber, MD, DFAPA
CPS President
April 7, 2021

Happy Spring! Last April we thought we were in a sprint, by summer we realized it was a marathon, and now, with the promise of vaccines and the peril of new variants, it looks like we’re in a sadistic ultra-marathon for which the organizers won’t disclose the length of the course. This is especially true in light of this commentary from the Lancet about a Danish study of reinfection with SARS-CoV-2. Immunity from SARS-CoV-2 infection is not as robust as immunity from vaccination, so herd immunity may not be realizable without global vaccination. In this letter I will provide updates about vaccination, consider the ethics of vaccination passports, focus our attention on two neglected populations of vulnerable individuals, and highlight new information about neuropsychiatric and psychosocial sequelae of the pandemic.

The CDC issued new domestic and international travel guidelines on 4/2/21 for people who are fully vaccinated. Listen to this brief, thoughtful interview with Jeanne Marrazzo, MD, Director of Infectious Disease at University of Alabama School of Medicine, focused on balancing optimism about vaccination with caution about ongoing infections. She encourages us to focus on community health rather than merely considering personal health.

Once we each have our vaccination cards in hand, what should we do with them? Are they the same thing as a vaccine passport? This piece discusses the history of vaccination cards and the possible importance of the current one. They might become linked to a vaccine passport, but that has become a highly controversial concept. This NEJM paper considers both the political and ethical implications of vaccine passports, which may confer privilege in an inequitable manner and create a “mandate” that inadvertently de-incentivizes voluntary vaccination. This nuanced PBS story goes into more depth about the concept of vaccine passports, their near certainty for international flights, concerns they raise about healthcare privacy, and their potential use as a divisive political weapon.

Colorado is doing fairly well with our vaccinations, ranking 24^th among the states in percentage of population fully vaccinated. However, as seen across the country, white Coloradans represent a disproportionate share of those vaccinated despite being at lower risk of clinically relevant infection. The ethnic group faring even better than Caucasians in vaccination rates are Native Americans. As detailed in this report, 21.8% of Indigenous Americans had received at least one dose of vaccine last week, compared to 21.3% of white Americans.  Some tribes are taking the lead on vaccinating their nations, and in South Dakota the Sioux are being vaccinated at twice the rate of other people in that state because of the efforts of the Indian Health Service (IHS). Despite historical underfunding of the IHS, it appears to be meeting the challenge of the moment. Unfortunately, Native Americans living in urban areas who are not already registered for health care services with the IHS are finding it difficult to obtain a vaccine. 

In addition to racial and ethnic minority groups, there are other populations that have received less notice in the pandemic despite the fact that they, too, have increased medical and psychosocial vulnerabilities, among them those with intellectual disabilities and the LGBTQ population. As detailed in this large population study, intellectual disability is the strongest independent risk factor for COVID-19, and confers the third highest mortality rate. This is partly because of higher medical comorbidities in this population, and because of greater exposure through group living and interaction with home care aides. People with intellectual disabilities have had their lives profoundly disrupted by the pandemic because of the loss of day programs, as detailed in The Arc’s briefing paper and the COVID-19 resource page on its website. Isolated, lonely, disoriented without their routines and regular social/therapeutic interactions, intellectually and developmentally disabled people may have more difficulty adapting to the pandemic than the rest of us. We need a better pandemic plan than “shelter at home” for these populations.

Another group that faces higher risks from COVID-19 because of a greater incidence of health comorbidities is the LGBTQ population. This MMWR report documents the higher adjusted prevalence of asthma, cancer, heart disease, COPD, hypertension, kidney disease, obesity, smoking, and stroke in sexual-minority populations than in heterosexual persons. In addition, this Kaiser Family Foundation analysis documents the disproportionate burden of job loss and mental health stress on LGBT individuals compared to non-LGBT people. Furthermore, pandemic isolation and school closures are distinct misfortunes for queer and trans youth, who already faced higher rates of mental illness before the pandemic, now exacerbated by loss of social networks and support. Especially for youth sheltering at home with unsupportive or abusive family members, the peril to their safety is tangible.

The neuropsychiatric and psychological effects of COVID continue to reveal themselves. Several possible mechanisms of brain injury from COVID are postulated, from direct invasion of the CNS by SARS-CoV-2 (for which there is not yet definitive evidence); to neurotoxicity from inflammatory cytokines, increased glutamate, and upregulation of NDMA receptors; to micro-strokes from endothelial damage. An internet-based survey identified an association between severity of acute COVID symptoms, especially headache, with later symptoms of depression. An alarming 52% of the 3900 respondents reported current symptoms of major depression, on average four months after being ill with COVID.

As described in previous COVID emails, there are consistent reports of increased anxiety and depression among people who have not developed COVID. In my practice, I have seen two cases of new onset agoraphobia as a result of the pandemic. One developed in a patient with preexisting generalized anxiety disorder who had his first-ever panic attack in a grocery store last spring, after which he has experienced enduring agoraphobia. The other patient has a preexisting diagnosis of post-traumatic stress disorder and had not been agoraphobic until the pandemic. In both patients, catastrophic cognitions lead to avoidance behaviors. This study validates a new research tool to assess catastrophic cognitions about SARS-CoV-2. A European study of the impact of the pandemic across psychiatric disorders compared with healthy controls found increased symptom severity in subjects with depression, body dysmorphic disorder, illness anxiety disorder, and generalized anxiety disorder. A CDC study identified increases in anxiety and depression throughout the course of the pandemic, especially among young adults and those with less than a high school education.

Even for people without underlying mental health disorders, the pandemic has had a profound effect on stress and behavior. I notice myself yearning to hug friends, fly to visit family members, and eat in a restaurant again while simultaneously avoiding planning any of those activities, even for a time after I receive my second dose of vaccine. In that context, I appreciate this article about how pandemic fatigue has made us withdraw from others, and the author’s encouragement to reach back out again when we feel ready while also honoring our need for “aloneness.” ​Even if you don’t want to read the whole article, read the poem by Donna Ashworth. The permission to feel what we feel and the sense that we are not alone in these feelings is supremely soothing.

Colorado Psychiatric Society COVID-19 Resource List

 April 7, 2021

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

March 10, 2021

Pandemic Equipoise 

By Claire Zilber, MD, DFAPA
CPS President
March 10, 2021

We are at a point of equipoise, balancing precariously between opposing forces. Global COVID cases are rising after having fallen for six weeks. We have three amazing vaccines, yet a mere 10% of the population has been fully vaccinated. ICUs are no longer overwhelmed, but long-term consequences of COVID are becoming more apparent. This email will focus on maintaining safe behaviors while the vaccination effort continues, offer updates about delirium in COVID and post-COVID syndrome, and consider loneliness and forgiveness as crucial experiences in the pandemic.

As some states lift mask mandates and bar & restaurant restrictions, we can expect to see a fourth surge in the US. In contrast to some governors, the CDC advises us to double mask, wearing a cloth mask over a medical procedure mask, to reduce the spread of SARS-CoV-2. This MMWR report has an instructive graphic. I don’t feel the need to do this while walking my dog, but I’ve started double masking when I go to the store or any indoor appointment. The CDC has also issued guidelines for those who have been fully vaccinated, distinguishing the situations in which being indoors unmasked may be safe from those where masking and social distancing is still advised. Here is the science brief behind the new guidelines. Before gathering with others, especially if you plan to be unmasked, consider self-administering an at-home molecular SARS-CoV-2 test. The first FDA approved home test kit uses a nasal swab, cartridge reader and mobile app, and delivers results in about 20 minutes.

Vaccines are here and, as of March 7, 1,054,537 Coloradans have received at least one dose and 612,538 have been fully vaccinated. Our state has an estimated population of 5.94 million, which means around 10.3% of Coloradans are fully vaccinated. In my last COVID-19 email, I discussed inequities in vaccine access and advocated for vaccination clinics in community mental health centers (MHC) to reach our vulnerable patients with serious and persistent mental illness. A convenience survey of three Denver metro area MHC leaders revealed that this had already begun. MHCD (Denver), Jefferson Center for Mental Health, and Community Reach Center (Adams County) each have an onsite vaccination clinic for eligible age and comorbidity groups managed by their pharmacies. (If someone has time on their hands, a survey of all the other county MHCs would be enlightening.)

Case rates and hospitalizations are down, but they are not over. Even when the virus is contained, there will still be a need for a healthcare response to the COVID-related fallout.

As psychiatrists, we know the pandemic of PTSD and other psychiatric disorders unleashed by COVID is only just beginning. According to an Italian study, delirium is a risk factor for developing PTSD, as are female gender and the presence of psychiatric comorbidities. The prevalence of PTSD in this sample of 381 consecutive patients was a shocking 30.2%. An international study of over 2000 patients in ICUs with COVID-19 found that almost 55% had delirium lasting a median of 3 days. Mechanical ventilation; use of restraints; infusions of benzodiazepines, opioids, and vasopressors; and antipsychotics were each associated with a higher risk of delirium, whereas in person or virtual contact with family members was associated with a lower risk of delirium. With this knowledge, C/L psychiatrists may have the opportunity to avert PTSD by avoiding or reducing delirium.

Even in patients with mild or asymptomatic infection, long term sequelae are common. A study of adults six months after COVID infection found that over a quarter of patients reported persistent symptoms, with fatigue, loss of smell or taste, and brain fog as common complaints. It is easy to imagine the negative impact of these long-term symptoms on one’s quality of life and sense of wellbeing. Another study examined post-COVID symptoms exclusively in patients who had been asymptomatic with their acute infection, and found that nearly a third of patients across all age groups developed chronic symptoms. Although scientists cracked the code of the viral genome and developed vaccines in record time, we still have so much more to learn about this virus, its effect on the body, and how to help people recover.

The COVID-19 pandemic has created a second, mental health pandemic that may outstrip our traditional treatment resources. In addition to PTSD, anxiety disorders, depressive disorder and substance use disorders, the last year of social distancing has uncovered a preexisting epidemic of loneliness. I am intrigued by this report on training laypeople to provide empathetic phone calls to homebound older adults. This is a low-cost, scalable option that seems to be beneficial. Might this be an innovation for our overtaxed mental health resources even after the pandemic? What if we launched a public health campaign that taught kindness, compassion and outreach to citizens? The UK has a Minister of Loneliness. Shortly before the pandemic, a US survey found that three in five people here are lonely. Does the US need a similar person or office to respond to the public health implications of so many lonely, fatigued, traumatized people?

Colorado has recorded 5,995 deaths from COVID, or one tenth of one percent of the population. It is likely we each have lost someone, a patient or family member or friend overcome by this virus. While dealing with our own grief, we have helped our patients cope with cascading losses. I have noticed the disparate ways my patients talk about COVID transmission within families. One person steadfastly avoids casting any blame on a sibling for infecting their elderly parents, one of whom died. This person focuses instead on gratitude that the sibling was present to take care of the parents. Another patient is contorted with rage directed at the spouse of an acquaintance. The spouse was careless in masking and distancing and brought infection home to their partner, who had been cautious because of medical comorbidities. The dialectic between blame and forgiveness is movingly captured in this insightful viewpoint titled, “It’s Not Your Fault.” I especially appreciate the closing sentences: “We must find our way quickly to forgiveness, for each other and for ourselves. This story cannot be about shame and guilt.”

Colorado Psychiatric Society COVID-19 Resource List

 March 10, 2021

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

We are at a difficult and dangerous phase of the pandemic. With vaccines available to some but not most, there is a risk that people will relax the stringency of their safety behaviors, wear masks less consistently, take more liberties with social exposure, and generally behave like the peril has passed. This letter will describe the state of Colorado’s vaccination effort, provide the most recent information about vaccine availability, discuss vaccine reluctance and how to work with people who have fears about its safety, and illuminate the human vulnerability to conspiracy theories that have tainted the vaccine effort.

CMS held a Town Hall on vaccines on Wednesday, January 13, with presentations by Dr. Eric France (CMO of CDPHE), Dr. Mark Johnson (CMO of Jeffco Public Health) and Dr. Darlene Tad-y (VP of clinical affairs for Colorado Hospital Association). Colorado has 5.8 million residents, which represents 1.69% of the US population. We receive a proportionate number of vaccine doses from the US supply. Although we have the capacity to deliver more doses per week than are currently being administered, we don’t have more doses. We were told in the Town Hall that this would change this week or next, as the administration releases the vaccines that are being held in reserve for second doses. However, last Friday we learned that the federal government has no vaccines in reserve. As of last week, Colorado has received approximately 500,000 doses of the vaccine, and has immunized 209,000 people with one dose and 44,000 with two. At his press conference yesterday, Governor Polis announced that 5% of the state’s population will have received a first dose by the end of this week, including 20% of people over 70.

The Town Hall addressed the somewhat disorganized process of moving from 1a to 1b categories (scroll down to chart of Phases) for vaccination, shifting from hospital-based to community-based vaccinations, which Dr. Tad-y framed as “building the plane after it’s already taken off.” It is reasonable to move away from hospitals as the primary location for vaccination, as hospitals are struggling to staff vaccination clinics while in the midst of a COVID surge. Furthermore, in rural counties there are practical geographic reasons to use pharmacies rather than hospitals for vaccination.

The information about which sites are open for vaccination is changing weekly, sometimes daily, so practicing patience will help us contend with the resulting frustrations. Depending on the county in which a person resides, there are different places administering the vaccine. This webpage lists those places by county. For people who are unable or unwilling to go online, COHELP is a phone line that answers vaccine questions in multiple languages: 1-877-462-2911. A person may sign up through the patient portal of each system in their county and then wait for an invitation to schedule. There is an option to sign up by phone, but wait times can be as long as three hours. Anyone who gets a first dose is automatically scheduled for a second dose at the same location. Kaiser, UCHEALTH, Centura, and all the other major health systems are administering vaccines to 1a and the first half of the 1b list (above the dotted line on the chart) which includes seniors over 70, HCPs who work in person with patients who are not known to be COVID positive, firefighters, police, correctional workers and funeral workers. In addition, two major pharmacy chains that have outlets throughout the state (Safeway is one; the second may be King Soopers but they weren’t named at the time of this writing), will begin administering vaccines to people 70 and older.

Counties are allocated doses of vaccine based on their population. It is disruptive to the fairness of the distribution process if a person with a second home in a different county gets their vaccine in the county of their second home. Please discourage this behavior.

The state’s goal is to complete the vaccination of people aged 70+ by the end of February. Everyone appreciates that this vaccine is a precious resource and doses are not being wasted. If someone doesn’t show for their vaccine appointment, the remaining dose is put into someone else’s arm even if that person is not in the 1b category.

Currently, the state is receiving the Pfizer/BioNTech and Moderna vaccines, both of which require two doses. Additional vaccines by Johnson&Johnson, AstraZenica and Novavax are in Stage 2-3 clinical trials. The first two will be single-dose vaccines, while the Novavax will likely require two doses.

Although we are currently focused on getting the vaccine to people who desperately want it, we must also focus on those who are more reluctant, particularly people whose communities are most hard-hit by COVID. This study found that the proportion of adults who said they were somewhat or very likely to get the vaccine was 56% six weeks ago, down from 74% in early April. They also found that only 38% of Black individuals surveyed are likely to get the vaccine. We will need to vaccinate a higher proportion of the population to achieve herd immunity, but the exact number to target is elusive, as described in this excellent report from the Colorado Sun.

Like me, you may have patients in your practice who are reluctant or completely unwilling to receive the vaccine. Dr. Joshua Morganstein, Chair of the APA Committee on Psychiatric Dimensions of Disasters, offers useful advice for discussing vaccination with reluctant patients. Although it is a public health goal to vaccinate the majority of the population, we must be prudent in our approach to this goal. Any heavy-handed policy is likely to backfire given the current political divisions in our country and risks further politicizing the vaccine. Although it is conceivable that eventually some workplaces, such as nursing homes or hospitals, may mandate vaccination for their employees, the legal and ethical implications of such mandates must be considered. Last week, the CDC announced that proof of a negative COVID test or recovery from COVID illness is required for international airline passengers arriving in the US. It is possible that airlines may require proof of vaccination, a so-called “vaccine passport” for air travel, but this is not necessarily going to occur and certainly not until the general public has had a chance to get vaccinated.

One reason some people are refusing to consider the vaccine is the conspiracy theory that Bill Gates has inserted a microchip into the vaccine, which will be used to track the population. A YahooNews/YouGov poll from May 2020 found that 44% of Republicans believe this false claim. I was unable to find a more recent poll, but at least one of my patients continues to fear that this is true. This interview with a social science researcher offers useful advice about how to discuss misinformation with patients, including to not shame the patient either verbally or through your body language, to listen with humility to the patient’s concerns, and to consider this an ongoing conversation over several visits rather than a one-shot (no pun intended) effort to change someone’s mind.

Although it may be tempting to silently or not-so-silently scoff at conspiracy theories, it is more beneficial for us to consider the human tendency to look for patterns or meaning where none exists. This article discusses the evolutionary advantage of slightly suspicious thinking, which both helps us anticipate real threats and makes us vulnerable to conspiracy theories.

Finally, on the topic of vaccines and their funding, this paper describes the effort to create a fentanyl vaccine to protect against overdose.  The fentanyl vaccine induces antifentanyl antibodies which bind to any fentanyl that might be used later and prevent it from getting out of the bloodstream and into the brain. The vaccines reduce brain fentanyl levels by 50% to 80%, depending on the dose of fentanyl taken. The fentanyl vaccine effort is funded at a fraction of that for COVID-19, a reflection of stigma by the pharmaceutical industry and the government about the value of investing to save the lives of people addicted to opiates. In the meantime, HHS has made it easier for physicians to prescribe buprenorphine, which isn’t as effective against fentanyl as it is for other opiates but is still saving lives. Any physician with a DEA license may prescribe buprenorphine to up to 30 patients without applying for a separate waiver.

We have two innovative vaccines against COVID-19, and some of us have even received a dose or two, but we are not out of the woods. The more virulent new strain of COVID-19 is present in Colorado and at least 9 other states, and will be the predominant strain by March. I particularly appreciate the boxed comment at the end of this post by my favorite infectious disease blogger. There are many more months to go before it will be safe to relax our diligence. As they say in AA, take it one day at a time.

Stay healthy,

Claire

Colorado Psychiatric Society COVID-19 Resource List

 January 20, 2021

Updates

Vaccines - Both CPS and the APA are advocating to ensure our members who need it have access to the vaccines. CPS is in contact with CDPHE and other organizations and is actively monitoring information on the logistics of vaccinations for psychiatrists not affiliated with a facility. If you are category 1B and are having trouble accessing a vaccine, please contact CPS and we will do our best to assist you. See https://covid19.colorado.gov/vaccine for a vaccine distribution flowchart. Additional information at https://covid19.colorado.gov/for-coloradans/vaccine/vaccine-for-coloradans. Also see CMS - Physician Town Hall: COVID-19 Vaccine Update (Webinar, 1 hr 29 mins) (1-14-2021)

APA - Quick Guide to 2021 Office/Outpatient E/M services (99202-99215) Coding Changes (login required). Also see the APA’s Coding and Reimbursement site.

 

Resources for Providers

Psychiatric Times - After COVID-19 and Beyond the Opioid Wave Lessons from the opioid epidemic should be applied to cases of methamphetamine abuse -  by CPS Disaster Liaison Scott Simpson, MD, MPH and CPS members Chelsea Wolf, MD and Melanie Rylander, MD, and Alia Al-Tayyib, PhD (12-28-21)

JAMA - The Hidden Epidemic of Opioid Overdoses During the Coronavirus Disease 2019 Pandemic (12-30-2020)

HHS - Renewal of Determination That A Public Health Emergency Exists - effective January 21, 2021 through April 20, 2021

NYT - Isolation Helps Homeless Population Escape Worst of Virus Despite outbreaks in shelters and the prospect of more, the rates of infection among homeless populations are lower than feared (12-23-2020)

APA - January Course of the Month –The Effects of Loneliness and Social Support on Mental, Cognitive, and Physical Health (free to APA members for the month of January, .75 CME)

NPR - How COVID-19 Attacks The Brain And May Cause Lasting Damage (1-5-2021)

KHN - Children’s Hospitals Grapple With Wave of Mental Illness (1-6-2021). Also see NPR - 'I've Tried Everything': Pandemic Worsens Child Mental Health Crisis (6 min listen and article) (1-18-2021)

Our World in Data - Coronavirus (COVID-19) Vaccinations - A map that shows global vaccination rates.

 

Resources for Patients

Huffpost - 10 Ways Therapists Are Practicing Self-Care In 2021 Here's how mental health experts are staying healthy, reducing stress and anxiety, and prioritizing themselves after the hell of 2020 (1-7-2021)

Vox - How to make this winter not totally suck, according to psychologists This one idea may help you conquer pandemic winter (12-21-20)

Colorado Mental Wellness Network - #IsolationHacks - very brief videos (under 30 seconds) posted daily with tips and examples of how to practice self care

USA Today - That feeling you can't name? It's called emotional exhaustion - The second part of the article includes useful suggestions for setting boundaries and replenishing your “tank.” (1-12-2021)

CNN - Millions have a real fear of needles. Overcoming that is critical for the vaccine rollout  (1-13-2021)

Our World in Data - Coronavirus (COVID-19) Vaccinations - A map that shows global vaccination rates.

Yahoo - How the pandemic may have changed AA and recovery culture — in surprisingly hopeful ways — forever (1-12-2021)

 

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.

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December 23, 2020

Our Balancing Act

By Claire Zilber, MD, DFAPA
CPS President

When I was a child, I was drawn to all manner of activities that involved exercising my balance. One of my favorites was standing on the exact center of a see-saw, one leg on either side of the central pivot point, attempting to keep the see-saw perfectly parallel to the ground. This is the image I hold now as I work to find equilibrium between despair at the ongoing deaths from COVID (320,000 in the US and 4,432 in Colorado as of December 22) plus concern about the long-term neuropsychiatric sequelae of infection, and excited optimism that the Moderna and Pfizer vaccines herald an end to the pandemic.

The neurologic manifestations of COVID are common, varied, and persistent. A small German study found post-mortem evidence that SARS-CoV-2 enters the brain by crossing the neural–mucosal interface in olfactory mucosa. A study of hospitalized COVID-19 patients found that one in seven had neurologic complications, which the study authors believed to be the result of hypoxia.  An older study notes cases of encephalitis and Guillain-Barré syndrome, while this recent Spanish case report describes the successful treatment of a 39-year-old man with SARS-CoV-2 encephalitis with interferon and tocilizumab. A study of 29 patients who had recovered from COVID-19 revealed persistent cognitive dysfunction, hypothesized to be due to the inflammatory process. A large analysis of the medical records of 62,354 recovered COVID patients in the US showed that 18% had a psychiatric diagnosis within 90 days of recovery, most often for an anxiety disorder, insomnia or dementia.

Of equal concern are the reports of lingering “brain fog.” This NYT story includes reporting on a nurse practitioner who admits that she’s working in an impaired state. What if she inadvertently harms a patient? What if her licensing board sees this confession? The brain fog is one of the most confusing symptoms among so-called “long-haulers,” those who experience lingering disabilities long after their acute illness has abated. We have all been counting on this nightmare ending, but what about those who develop a chronic illness that persists beyond the pandemic, whose nightmare has no conclusion?

It’s possible that even before we’ve all been vaccinated, we’ll have access to at-home testing to ensure it’s safe to go to work, to school, or on a social visit. The first at-home, 20-minute Coronavirus test received FDA approval last week, and the developer anticipates the availability of three million tests in January 2021. Of course, we’ll need a hundred times that monthly number if we’re going to use frequent testing to open up society before we have all been vaccinated, but more tests are on the way. 

Which brings me to another important duty of psychiatrists at this crucial time in the pandemic: we must find ways to fortify our patients’ (and families’ and neighbors’) commitment to pandemic safety while we wait for herd immunity. That workers in ERs and ICUs will be vaccinated by next month protects our healthcare workforce, but doesn’t resolve the problem of maskless people in public. To get people to follow COVID guidelines, it may be helpful to appeal to their care for others. This Harvard study from early in the pandemic found that public health messages focused on protecting others were more likely to inspire compliance with health guidelines than messages focused on the need to protect oneself. If you want to read more about prosocial behaviors, go to The Top 10 Insights from the Science of a Meaningful Life.

I have found nothing motivates my compliance with regulations more than the stories I hear from patients, friends, and the media about the intense suffering of people dying in ICUs, healthcare workers crumbling from exhaustion, families agonizing that they cannot be with their loved ones at the end. Hearing this testimony, I cannot harbor the possibility that my behavior might transmit the virus and disrupt or end another’s life. This JAMA article should be mandatory reading for everyone not on the frontlines. We have included it in our COVID-19 Resources for the Public this week, so feel free to direct people there if they are expressing reluctance to maintain safe behaviors.

Compliance with public health regulations doesn’t mean we are doomed to a gloomy Christmas and New Year devoid of celebrations and diversions. I hope each one of you has a few extra days off in the next couple of weeks, time to slow down the stressful pace, reboot your exercise regimen, connect meaningfully with people you love, and find some frivolous fun.

Do you have a Christmas movie tradition? You can watch the latest blockbuster movies from home. My mother’s childhood family holiday tradition was to travel to New York City to catch a Broadway theatre performance. You can too! Here are some free ones; and here are a collection of Broadway Christmas plays, ballets and concerts. Those of us from the West Coast have other traditions: check out the Christmas concerts and sing-alongs from San Francisco’s Grace Cathedral. Unless you were wealthy enough to fly on the Concorde, never before have you been able to take in a show in New York and join a concert in San Francisco on the same day! A pandemic silver lining, for sure.

If playing games with the clan after opening gifts was your family tradition, that’s still possible. Here are six classic games you can share on Zoom,  and another 21 collected here. In case you didn’t know, that activity is called a “covideo party.” Satisfy your word nerd urge with other novel coronavirus neologisms in this amusing article. Go play!

We must remain steadfast in our mask wearing and social distancing until the CDC signals that enough of the population has been vaccinated for us all to be safe. We must balance our optimism and excitement with caution and diligence. Which reminds me of another lesson I have learned from a variety of physical activities. Whether shooting a basketball, serving at tennis, swinging a golf club, or holding an arabesque, the same principle applies: you must maintain your focus and follow through with the physical gesture all the way to the end of the motion in order to achieve success.

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 December 23, 2020

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

December 9, 2020

Lighting the Candles of Resilience   

By Claire Zilber, MD, DFAPA
CPS President

Chanukah begins Thursday at sundown, celebrating a miracle. A vial of sacred oil, only enough to keep the everlasting light illuminated for one night, lasted eight nights, long enough for the community to acquire a fresh supply. This year, that story feels particularly relevant. We know relief in the form of a vaccine is on its way to us, but we are not the first in line for it, and it will be a while before our communities are safe. As we witnessed over Thanksgiving, many people are so exhausted by the pandemic restrictions, so in need of connection, that they threw caution to the wind. The case rates reflect the result, yet the anticipated spike from Thanksgiving gatherings won’t show up until later this week. We must double down on safety over the winter holidays, or we will have a nightmarish January. What oil can we find to sustain our hope and renew our diligence? After reviewing some information about the exhaustion and depletion that are real for all of us, I’ll bring you some good news and suggestions.

Holidays are hard in a pandemic, especially in the tenth month of social restrictions. Our colleague and former CPS President Peter Mayerson coined the term “sequesteritis.” I want to see my friends’ unmasked smiles. I yearn to give them hugs. I long to visit my mother. I’m only one of 7.8 billion people on this planet who share these feelings. Our Brains Explain the Season’s Sadness reports on why we all are so depleted. According to the neuroscientist interviewed for the story, our prefrontal cortex is working overtime to keep an eye out for all the threats we face. Remaining vigilant about the coronavirus, civil unrest, political turmoil, job insecurity, the wellbeing and education of our children, wildfires, hurricanes, and separation from family takes a lot of energy. Add to that the extra focus required to work and socialize on a screen, or to work in PPE, and you’ve got one very tired brain. Although the phrase “deaths of despair” predates the pandemic, it is especially fitting now as preliminary data suggests deaths from drug overdoses have doubled. 

Like a lotus emerging from mud, there are glimmers of good news arising from the nightmare of the pandemic. Researchers observe a decline in youth vaping in the pandemic, and this commentary includes suggestions for ways to intervene to maintain this trend after pandemic restrictions are lifted. Since youth vaping is linked to marijuana use, a reduction in the former may have a significant impact on the pathway to addiction.

Another measure of good news oil is that the pandemic has increased our access to online material that we can use in our work. Take, for example, this stigma-busting video discussion between two women in the publishing industry, one with dyslexia and the other with bipolar disorder. It includes reflection on how the pandemic has added further complexity to managing their neurodiversities, as well as valuable information about combatting shame, and advice to managers who supervise people with neurodiverse qualities. We have dropped this into the COVID-19 Resources for the Public page on the CPS website, so you can share it with your patients.

One of the conversation starters at CPS' Monday evening cranberry-margarita-infused Winter Party was to identify a way each of us has grown during the pandemic. Albert Einstein wrote that “Adversity introduces a man to himself.” The pandemic provides an opportunity to dig more deeply into ourselves for the strength to endure; we will be changed. As psychiatrists, we have the privilege to help others who might otherwise break under this pressure, help them find their resilience and emerge from the storm. In my work these last few months, I find that empathetic humor is especially helpful in those moments when someone is describing their latest personal calamity piled upon this collective disaster. Something about the release of laughter eases the tension on the soul, and we find we can bend a little further after all. In that spirit, I was delighted to read JAMA’s best of 2020 Graphic Medicine. If you don’t have time to click on all the links inside that review, here are two highlights. This comic by Gemma Correll, Creativity in Captivity, pokes fun at what she plans to do during the shelter-in-place order vs. what she actually does. Another gem in the JAMA review was the revelation that there’s an annual conference on graphic medicine, and that they have created a free, monthly virtual meet-up during the pandemic called Drawing Together. Free art therapy for us!

Good news, humor and art therapy are some of the extra oil we need to keep our lanterns lit, to help us find the will to stay safe for a few more months as we wait our turn for the vaccine and then wait a little longer for enough of the population to be immunized so that we all can be safe. The CDC’s recent revision of quarantine guidelines applies a scientific lens to choosing a length of quarantine based on risk. I find the graph especially helpful in illuminating the difference between 7, 10 and 14 days of quarantine, and the table below it clarifies how adding a negative PCR or antigen test may increase confidence about reducing quarantine from 14 to 10 days. I also was reassured to see what precautions epidemiologists are taking in their personal lives; apparently, that I do not place my mail in quarantine does not make me a daredevil. Whew! When a physician friend told me that he is only doing the top four activities on the chart, I felt a competitive zing because I’m only doing the top three. Hey, if friendly competition is what it takes to keep me safe, I’m all in. In the end, I’d rather have sequesteritis than coronavirus. 

Although I didn’t set out to include eight positive links in this letter, to correspond to the eight nights of Chanukah, it worked out that way. There is your oil. Now light your candles and those of your patients so that we all retain the fortitude to manage our behavior, reduce our risk of acquiring and transmitting the virus, and further develop our capacities for endurance and resilience.

Stay healthy,

Claire

Colorado Psychiatric Society COVID-19 Resource List

 December 9, 2020 

November 25, 2020
Suffering and Hope: The Pandemic Thanks Giving

By Claire Zilber, MD, DFAPA
CPS President

Psychiatrists are a strange and wonderful breed. Whether through training or natural inclination, we develop our unique superpower: the capacity to hold the suffering of others while radiating hope. As we descend into the pandemic winter, the dialectic of suffering and hope will persist.

Let’s begin by witnessing the suffering. The US has had over 12,422,000 COVID cases, and 257,700 deaths. Colorado has had over 203,600 cases and 2,820 deaths. Mesa County, a model of public health preparedness early in the pandemic, has run out of hospital beds, and hospitals across the state are struggling with ICU capacity, non-ICU capacity and staff capacity. Frontline healthcare workers are under severe strain, as are just about everyone else.

According to the Pan-American Health Organization, only 2 of the 29 countries in the Americas have an adequately funded mental health plan for the pandemic. Their report doesn’t name names, but I’ll venture that the US is not one of the lucky two. A recently published survey of mental health across the United States, Canada and Europe showed increased levels of anxiety and depression, but the data was collected in March and April, so it doesn’t inform us about the current state of population mental health. We know that pediatric ER visits for emotional distress rose after March 2020, as described in this CDC report. What is not yet captured in published data but is plainly evident is the further increase in distress in the last two months. The election set us on edge. Everyone has grown weary of pandemic precautions. We tire from lack of a good vacation, from missing distant family, from deprivation of singular pleasures like fine dining and heartfelt hugs from friends. Psychiatrists don’t need data to know this because we hear it first hand: our patients are more distressed and they have exhausted their coping reserve.

Without a doubt, Colorado does not have an adequately funded mental health system. Mental Health America ranks our state 33^rd based on prevalence of mental illness and low access to treatment. We have the seventh highest suicide rate of all the states, according to the CDC. Governor Polis has taken steps to improve mental health and substance abuse treatment services in the state, and you can learn much more about those efforts from the Putting People First report. Governor Polis established the Behavioral Health Task Force (BHTF) to reimagine the behavioral health system in Colorado. CPS member Dr. C. Neill Epperson served on the main BHTF and the following CPS members served on subcommittees of the Task Force: Drs. Richard Martinez, Alexis Giese, Sasha Rai, and Kimberly Nordstrom. The Blueprint for Reform has 3 phases. The first step is creating a Behavioral Health Administration to coordinate a centralized response to our mental health crisis. The second step will be increasing access to services for crisis support and ongoing treatment. The final phase will focus on assessing and implementing remaining recommendations. This is vital work, but it is also woefully overdue and of no help to the many people who are suffering right now.

How do we infuse hope into our pandemic-weary patients and selves given our resource-poor mental health environment? Christina Figueres suggests relentless optimism. In her TED Talk, she discusses the optimism required to achieve a global accord on combatting climate change, but her points apply equally well to every other pressing national and global issue, including the pandemic. She defines optimism as a conglomerate of courage, hope, trust and solidarity. Is it worth 15 minutes of your time to watch this TED Talk? Only if you want to be uplifted by admiration and inspired to your own internal shift away from cynicism.

Relentless optimism reminds me of the DBT skill of radical acceptance, which in turn inspires “radical gratitude” about Operation Warp Speed. Despite the many blunders and general incompetency of our federal response to the pandemic, Operation Warp Speed appears to have yielded impressive results, for which we may all be unreservedly grateful. This Lancet article expresses optimism and simultaneous reservation about the three vaccine announcements (including Russia’s) in the last two weeks. The manufacture and distribution of vaccines in an equitable manner both nationally and globally raises difficult logistical and ethical problems. But how exciting to have arrived at the opportunity to address these problems!

This CDC communication inspires optimism that they might counter vaccine skepticism with reassurance about safety and efficacy monitoring, and the extent of CDC coordination with other government agencies. Further hope rests on the knowledge that many other vaccines as well as alternate, creative medical approaches are under development, such as inhaled interferon to protect pulmonary tissues from infection.

Last weekend, the FDA issued an emergency use authorization (EUA) for a combination monoclonal antibody treatment, casirivimab plus imdevimab, for patients with mild-to-moderate COVID-19 who are at high risk for developing severe disease (for example, adults aged 65 and older). This is the same treatment given to President Trump. The EUA was issued based on findings from a randomized placebo-controlled trial of 800 outpatients with mild-to-moderate COVID-19. Patients who received the active treatment were less likely to be hospitalized or visit the emergency department within 28 days.

Late last week the FDA also issued an EUA for the combination of baricitinib (an oral janus kinase inhibitor) and remdesivir to treat hospitalized COVID-19 patients who require supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation. In a randomized placebo-controlled trial of 1000 patients, those given remdesivir plus baricitinib, versus remdesivir plus placebo, had a shorter time to recovery and were less likely to die or need mechanical ventilation within 29 days of treatment.

In research news that may be especially exciting to psychiatrists, two weeks ago a randomized placebo-controlled trial found that the antidepressant fluvoxamine may have a role in treating novel coronavirus infection. In addition to being an SSRI, fluvoxamine is also a strong S1R agonist. The S1R is an endoplasmic reticulum chaperone protein with various cellular functions, including regulation of cytokine production. Previous studies have shown that fluvoxamine reduced damaging aspects of the inflammatory response during sepsis through the S1R-IRE1 pathway. In this preliminary study of 152 adult outpatients with symptomatic COVID-19, patients treated with fluvoxamine (100mg TID) had a lower likelihood of clinical deterioration over 15 days. Psychiatrists may actually be able to prescribe something within our scope of practice to actively treat symptomatic patients!

Although Christina Figueres doesn’t include gratitude in her list of optimism-inducing traits, I believe that gratitude is a powerful prompt to a more positive mindset. By focusing on what is good, our outlook about our circumstances shifts. I am grateful for all I am learning with my patients. As we struggle together to navigate and endure the many difficulties encountered this year, I strengthen and broaden my own coping skills. I’m grateful to have a purposeful focus each day, whether that’s direct patient care, practice administration, continuing education, teaching, or CPS activities. I am grateful for technology, which has helped us adapt in all our work and social environments. Nine months ago, I never imagined I would be facile with telehealth, teaching by Zoom, electronic prescribing, electronic lab orders, even electronic file sharing through the telehealth portal! I am grateful for all the hospital workers who are putting in extra hours, isolating from their families, risking their lives, stressed to the max yet still trying to provide comfort to dying patients. And I am grateful for all the other essential workers who put themselves at risk to keep society somewhat functional.

Suffering, hope, gratitude. We cannot transmit hope to our patients without first witnessing their suffering. We cannot bear to absorb their suffering without holding on to hope. We cannot reach for hope without awareness of what remains in the world that is good, and give thanks for all of it.

Stay healthy,

Claire

(Gratitude to Dr. Jenny Kennedy for bringing to my attention the TED talk on optimism.)

Colorado Psychiatric Society COVID-19 Resource List

 November 25, 2020

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

November 11, 2020
Inpatient Psychiatry in the Pandemic

By Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 November 11, 2020

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

October 28, 2020
More Tricks than Treats: Psychiatric Sequela of the Pandemic

All but one of my patients on Monday was dispirited about making it through this winter. Worn down by almost eight months of health anxiety, social restrictions, inability to visit far-flung relatives, and political angst, the frigid conditions early in the week seemed to knock the wind out of almost everyone. The alarming surge in cases in Colorado, with over 2100 new cases reported on Sunday and a new case rate of 24.3 per 100K residents, is a great concern, dwarfed only by the reality that every single one of our neighboring states is faring even worse, according to Johns Hopkins University.  In this letter, I offer an update about psychiatric sequelae of COVID-19 infection itself, managing chronic mental illness during this pandemic, and coping with depression. Lest this leave you hollowed out in despair, I promise levity at the end.

Psychiatric Conditions Associated with COVID-19

There appear to be several different biological pathways to psychiatric syndromes as a result of COVID infection. Acute syndromes include delirium, and symptoms related to acute stroke caused by the vascular manifestations of infection. Later psychiatric symptoms may be the result of immunologic responses to infection, and perhaps from the ongoing presence of the virus within the CNS (within endothelial cells, macrophages or monocytes). There is so much more to learn about this virus. To the extent that the CNS may serve as a reservoir for infection, as it does for HIV, we may find long-term psychiatric sequelae emerging months or years after initial infection. For now, we must content ourselves with hypotheses about mechanisms of illness, and small studies, which were recently reviewed in this paper. The reviewers found only two studies of psychiatric conditions in patients with COVID-19, which showed high rates of PTSD and depression in those patients. The remaining studies examined the indirect effect of the pandemic on wellbeing among patients with chronical mental illness (CMI), the general public, and the healthcare workforce.

Coping with CMI in the Pandemic

For patients with CMI, the pandemic has added new burdens to an already overburdened and under-resourced population. With most outpatient clinics operating via telemedicine, patients without reliable access to the internet or whose paranoia interferes with their willingness to use telehealth are less able to engage in treatment. As discussed in this Kaiser Health News article, acute treatment settings like ERs, inpatient units, detox centers, and residential treatment facilities are now even more difficult to get into than usual because beds have been reduced to keep patients and staff safe during the pandemic.  Furthermore, patients with CMI have more medical comorbidities than the average person, yet they have less access to medical care, a problem likely to be exacerbated in the pandemic. The Canadian authors of this article suggest mitigation strategies that are equally applicable in the US, such as increasing access to low-cost technology so that patients can access telehealth regardless of their economic means, as well as bolstering resources to support collaboration between primary care and psychiatry. Another unique intersection between COVID-19 and patients with psychosis is highlighted by this case report of a patient on clozapine who was hospitalized for COVID-19 in the UK. The patient developed toxic levels of clozapine, presumably because cytokine release associated with COVID-19 infection downregulates CYP 1A2, thereby slowing the metabolism of clozapine.

Coping with Depression in the Pandemic

By now, it has been well documented that rates of depression have soared as a result of pandemic related stresses including grief over the deaths of loved ones, hardship because of loss of employment, job/food/housing insecurity, isolation because of physical distancing restrictions, and a surge in domestic violence. Because the pandemic has required massive adaptation for almost all of us, any form of psychotherapy focused on navigating the many changes and stressors in our environments is key to effective treatment.  Some authors advocate specifically for Interpersonal Psychotherapy for patients and families, while others recommend Cognitive Behavior Therapy for frontline workers. The impact of grief on family members of COVID-19 victims and healthcare professionals on the frontlines who are experiencing multiple deaths on their watch is of particular concern. We know from previous research that sudden and traumatic loss, as well as multiple sequential losses, are more likely to result in prolonged grief disorder. This article addresses the potential scope of grief as a result of the pandemic, and offers a public health/community strategy for managing a grieving population, including more training for primary care providers and referral to mental health for the more complicated cases, such as those involving psychosis or suicidal ideation. In this PsychNews story on suicide prevention strategies for the pandemic, I followed the link to a free training on CALM: Counseling on Access to Lethal Means. It takes around two hours to complete the training. While much of the information is familiar to psychiatrists, this may be an important time for us to refresh our suicide prevention counseling skills. There are additional articles in this week’s Resources for Providers about depression and suicide in the pandemic.

Enough Tricks, Time for Treats

I admit to my own trepidation last weekend: how will I be able to help all my patients keep their heads above water if I don’t stay well myself? I was bolstered by this NYT story on What Scandinavians Can Teach Us About Embracing Winter. We include this in our Resources for the Public page, so please remember to direct your patients and others to that page. It helped me reframe my dread by reminding me of all the treats that come with cold weather: hot beverages, cozy sweaters, improved sleep on crisp nights, opportunities to invent new favorite soups, “owning the park” when I walk my dog on mornings too cold for others to venture out, snowshoe day-trips with friends, and so much more. In addition to leaning on old favorites, I intend to create new traditions. For example, with the Blue Moon on Halloween, I plan to drink a Blue Moon beer, listen to all the different covers of Rodgers and Hart’s Blue Moon, and gaze at our beautiful satellite. For those of you adapting the holiday for children, I appreciate the tips at the end of the CDC’s Guidance for Halloween, especially the inspiration to hold a treasure hunt at home in lieu of trick-or-treating in the neighborhood. I love treasure hunts! If all else fails, and the winter doldrums suck the life out of you, try Yoga for When You Feel Dead Inside.

Colorado Psychiatric Society COVID-19 Resource List

 October 28, 2020

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

October 14, 2020
Ethical Dilemmas in the Pandemic

The pandemic has prompted unprecedented changes in healthcare, including psychiatric practice. Telemedicine is suddenly mainstream and is changing norms before we can consider their ethical implications. Discussions about rationing care, a very taboo notion in the US, were widespread in the spring when hospital beds and ventilators were scarce in Italy, Spain, England, New York, and other hotspots. Decision-making algorithms for access to ICU beds and ventilators  and for administration of vaccines are covered in the medical literature and lay media. Concerns about the ethical implications of rushing a vaccine through the regulatory process have become a touchy political issue, and medical editors are issuing political opinions in advance of the presidential election. This is more fodder for ethical analysis than can be managed in this space, so I will focus on three areas most relevant to psychiatrists: boundaries within telehealth, C/L psychiatry and COVID-19 ethics, and an ethical approach to public health policy.

In May 2020, the APA conducted a member survey about their use of telehealth before and after the public health emergency caused by SARS CoV-2. Whereas before the pandemic 64% of respondents used no telehealth in any of their patient encounters, a mere two months later 85% were using telehealth for 76-100% of their clinical work. Initially, we were mostly focused on getting the technology to work for us and our patients, paying attention to only the most obvious ethical issues, like privacy and confidentiality in clinician and patient environments. The APA’s Best Practices in Videoconferencing-Based Telemental Health states, “During a telemental health session, both locations shall be considered a patient examination room regardless of a room’s intended use.” We fretted about how to ensure the patient’s room is private if we can’t see the entire space. Eventually, other concerns surfaced, like hidden obstacles to confidentiality in the form of eavesdropping or recording devices. If the psychiatrist or the patient has an Alexa or Echo device within earshot, might it start recording or even speaking in response to what it hears? Might the patient intentionally record the session without the psychiatrist’s knowledge or consent? Might the psychiatrist do so without the patient’s consent?

Telepsychiatry has provoked a loosening of boundaries. A previous article on boundaries written in April feels quaint six months later. Then, it felt awkward that patients could see one wall of my home. Now, many of them ask to see my dog if they hear him bark or squeak a toy. To deny that request would seem cruelly withholding. Only recently have I considered that my dog could be in a different room when I have patient appointments, reducing the temptation to cross this boundary. This opinion piece by Lori Gottlieb, author of Maybe You Should Talk to Someone, reveals several ways in which the loosening of boundaries because of seeing patients in their homes (or cars, backyards, front porches, sidewalks… ) enhances the therapy. On the other hand, I’m disconcerted that she admits to downgrading her wardrobe. I believe it is more professional and respectful to dress as we would if we were in our offices.

Just as outpatient psychiatrists are faced with a variety of new ethical dilemmas, C/L psychiatrists are encountering new challenges, too. When should they see a patient in person, using up precious PPE, and when is it better to do an evaluation via telehealth? Is the decision to use telehealth a convenient rationalization for reducing personal risk of exposure, or a sound policy? This article from UCLA strongly argues the latter, not just for psychiatrists but for all medical personnel who don’t absolutely need to touch the patient. In addition to adapting their consultations to include telehealth when appropriate, C/L psychiatrists may encounter new kinds of consult requests, such as evaluating whether a patient has capacity to request to leave the hospital AMA during the pandemic, or assessing the patient who wants to change their status to DNR in order to conserve resources for others. Johns Hopkins has published an excellent resource, Capacity Assessments During the COVID-19 Pandemic, to help clinicians navigate these unique situations.

In addition to new ethical dilemmas for outpatient and C/L psychiatrists, we may also focus on the ethics of public policy decisions during the pandemic. We are experts on cognition and communication, and can help shift the conversation about personal responsibility for public health (ie: wearing masks and conforming to physical distancing guidelines) when we notice and correct bias in messaging. This paper, Cognitive Bias and Public Health Policy During the Pandemic, identifies four types of bias evident in the public narrative that compromise public safety. Another article focuses on the virtues of compassion, solidarity and justice as important guides to public policy in the pandemic. When we incorporate these themes into our discussions with reluctant patients, workplace administrators, and policy makers, we advance the conversation along ethical lines.

Perhaps the most distressing ethical problem highlighted by the pandemic is the absence of justice (equal access to treatment for all) in US healthcare. While the President is able to receive an experimental monoclonal antibody in Phase II trials, 44 million Americans are without health insurance. Much has been written about disparities in health outcomes during the pandemic; this summary from SAMHSA is a good place to start if you want to delve more deeply into the intersections between race, behavioral health and COVID-19.

In closing, this letter identifies several ethical dilemmas uncovered by or created by our responses to the pandemic. There are many more. I will devote a future letter to inpatient psychiatry during the pandemic, including ethical issues encountered in that setting. If you have other pandemic-specific ethical questions, please contact me through [email protected] and I will endeavor to address them in later letters.

Stay healthy,

Claire

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

October 14, 2020

September 30, 2020

ON HOPE

Claire Zilber, MD, DFAPA
September 30, 2020

“Hope is being able to see that there is light despite all of the darkness.”  Desmond Tutu

As the Jewish New Year starts and the secular year crosses the threshold into its last quarter, the world feels desolate. We’re ten months into a global pandemic with no end in sight, which has sickened more than 33 million and killed over one million people globally, with over 7 million cases in the US and 205,676 deaths (from Johns Hopkins). Conspiracy theories complicate responses to the pandemic, as personal participation in precautions and attitudes towards accepting a vaccine vary depending on one’s beliefs.  Police killings disproportionately affect people of color, provoking months of protests, which in turn have sometimes led to violent clashes with counter-protesters. Economic distress because of pandemic shutdowns has led to food and housing insecurity for millions of Americans. Wildfires have scorched over five million acres across the West, a fairly abstract number that this article attempts to contextualize. Ruth Bader Ginsberg’s death has unleashed political shenanigans which are deepening our national strife, and the upcoming election has everyone on edge regardless of their political affiliation. This is a lot to hold as we go about our work, trying to help people regain and sustain mental health. I have labored in the last two weeks to reframe my despair so I can be useful to others. I look both to the past and the future to bolster my hope, and eventually end up in the present.

On the Sunday evening following Ruth Bader Ginsberg’s death, a conversation with my father-in-law planted the seed of perspective. He reminded me that things looked grim throughout much of World War II until Hitler’s army encountered the Russian winter. An unforeseen ally in the war, it turned the tide. I have been trying to imagine the thoughts and feelings of the inhabitants of France, Poland, Greece, England, and other European countries that were either occupied or imperiled by fascist forces. However menacing we feel our situation may be, the circumstances in WWII were even more dire. Yet, in the end the Allies prevailed, Europe was rebuilt, and the European Union eventually emerged, joining former enemies as partners.

Karl Menninger’s 1959 lecture to the APA Assembly addresses hope in the context of healing. He, too, goes back to WWII, to the Buchenwald concentration camp, to find an example of hope against all odds being marshalled by the physicians who were also prisoners to sustain themselves and help their fellow inmates. This eloquent lecture places hope squarely at the center of psychiatric education and practice.

Just as the world didn’t know what would happen next in the waning months of 1942, we don’t know what will happen as 2020 winds down and hands over this turmoil to 2021. Cringing, we may ask, “Can it get any worse?” I do my best to avoid that thought path, which can lead to apocalyptic fears. Instead, I focus on the signs pointing toward hope. Let’s begin with Anthony Fauci, who offered two reasons for hope earlier this month. He noted that there is a significant response in infection rates when communities choose to adhere to public health recommendations, indicating that we can control the pandemic through our collective action.  He also noted that three vaccines are in phase three trials. It’s worth clicking on this link just to see Dr. Fauci’s smile, which reliably triggers a small relaxation response in my nervous system.

Additional reasons for optimism include a spate of recent papers demonstrating the efficacy of corticosteroids in critically ill patients with COVID-19. There is now enough evidence of utility for this readily available, inexpensive medication for it to be a first line treatment for severely ill patients. This JAMA editorial offers a nice mini-review of the literature. Even better news is that two saliva tests for SARS-CoV2 received FDA approval last month. They need to be scaled up, but eventually we could end up where Dr. Paul Sax, my favorite Infectious Disease blogger, suggested we go way back in July, with at-home rapid testing. Even without a vaccine, we could be back in the office face-to-face with our patients if everyone was doing daily home testing. Finally, the Chief of the World Health Organization expresses optimism that the pandemic will end in less than two years, which will make it shorter in duration than the 1918 influenza pandemic. He says our advanced technology will allow us to respond more quickly and effectively than a century ago.

Another reason we may progress quickly is the fact that so many of the world’s scientists are all working on the same problem at the same time. This spurs innovation. For example, a research team at UC San Diego is adapting nanosponge technology, originally developed to treat bacterial pneumonia, to protect pulmonary tissue from the coronavirus. This delightfully optimistic editorial from the Canadian Family Physician projects that, having worked collaboratively to address the pandemic, the world’s scientists will learn how to come together to address other global crises such as climate change and poverty.

In addition to scientific advances in response to the current swirl of crises, we may see changes at the individual level. This military psychologist writes about post-traumatic growth, a phenomenon seen in combat-exposed soldiers. He describes a potential for many of us to go beyond resilience to personal improvement, and says that skills to foster a positive outlook, spirituality, active coping, self-efficacy, meaning-making, and acceptance of limits and circumstances can all be taught. Psychiatrists are in a prime position to teach these skills to our patients. There is a wealth of articles about adaptation and staying positive, such as this one. Indeed, you will find many others on the CPS webpage of resources for the public.

The current state of affairs is beyond stressful. Our lives are disrupted and we feel uneasy. Yet these are the very conditions that can bring about innovations and cause transformations in individuals, communities, and societies. Who would have imagined that we would transition so quickly to telehealth? This is a change in healthcare practice that will not disappear after the pandemic ends. Who would have predicted that TaNehisi Coates’ Between the World and Me would be on the NYT Bestseller list for over 100 weeks? This reflects a society-wide interest in understanding and resolving racism that will not revert. Seven months ago, I would never have believed that some of my more reluctant patients would be doubling down on their self-care practices, but they have demonstrated to themselves that meditation, exercise, gratitude lists, or whatever works for them is actually worth the effort. They cannot unlearn these skills. We have been changed, as a society, as a profession, and as individuals.

Colorado Psychiatric Society COVID-19 Resource List

 September 30, 2020

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

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

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