Physician Mental Health During COVID-19: A Call to Action by Claire Zilber
(download from September 16, 2020 CPS COVID-19 Resource email) is the empowering newsletter article referenced in the CPS 2020 Winter Newsletter article Physician Burnout and Mental Health: “To Put Your Mask on First” By Kartiki Churi, MD

February 2020

Uneven Ground: Vaccination Inequity

By Claire Zilber, MD, DFAPA
CPS President
February 2021

Having saved all my vacation weeks in medical school for the very end, I was able to travel to Tibet and Nepal. I set out to climb Kala Patthar, an 18,514 foot pile of limestone and shale, from the top of which one has a clear view of Mt. Everest. Because our Sherpas threatened to mutiny so they could attend the Mani Rimdu festival scheduled for the same day as our summit, we shaved two acclimatization days off our ascent. Coming from sea level, I felt drained of energy and struggled for oxygen. I gave myself permission not to reach the summit, but talked myself into taking “just one more step.” The shale sometimes meant a step forward was really a slide back.

Recently, I have been recalling that long-ago climb, applying its lessons to this point in the pandemic. We find ourselves at a precarious place on the pandemic’s path. We have one foot on solid limestone, our hope bolstered by effective vaccines that many healthcare providers and seniors have already received. Our other foot is slipping on the shale of a mutating virus whose new variants are more contagious (UK, Brazil, South Africa and California variants) and more virulent (UK variant), provoking fear of another surge before we have completely emerged from the last one. As we struggle to navigate this terrain, some of us are better equipped than others by virtue of our health status, our ethnicity, our wealth, and/or our privilege. Just as a well-equipped and experienced mountaineer would stop to assist one who may be struggling, it is incumbent upon us to help our more vulnerable neighbors, and especially our most at-risk patients.

According to COVIDActNow, an excellent website with state and county statistics about infection rates, vaccination rates, ICU capacity and more, 9.2% of Coloradans have received their first dose of vaccine, and 3.4% have had both doses. One glaring problem is that these vaccines are disproportionately in the arms of well-off, white people. COVIDActNow doesn’t break down their data by race or ethnicity, but there is evidence of significant disparities in vaccination rates. This Colorado Sun story reports that less than 2% of Coloradans who have received the vaccine are Black, yet Black people represent 4% of the population. An even greater disparity exists in the state’s Hispanic/Latino population: they comprise 22% of Coloradans but only 4.3% of those who have been vaccinated. If anything, these groups should be vaccinated at a higher rate than the rest of the population because they are at more risk of infection, hospitalization and death from COVID. For example, this CDC Morbidity and Mortality Weekly Report reveals that in the first ten months of the pandemic in Denver, the majority of cases, hospitalizations and deaths were among Hispanics, although they represent only a quarter of the city’s population.

This Colorado Public Radio report details why it is not accurate to suggest that most healthcare providers and seniors are white as an explanation for the vaccination rate disparity. This Kaiser Health News report further unravels the myth that the reason fewer Black people have received the vaccine is because most health care workers are white. In part, the lower vaccination rates of Black Americans may be due to vaccine hesitancy, as documented in this Pew Research Report, which shows that only 42% of Blacks express willingness to receive the vaccine, compared to 61% and 63% for Latinos and Whites, respectively. But that data doesn’t explain the low vaccination rates in the Latino population. It is our duty to find ways to overcome this vaccine avoidance by Blacks, not by bullying but by building trust and engagement. It is also our responsibility to understand and remedy the low vaccination rates in Latinos. 

The current web-based systems for obtaining vaccination appointments are part of the problem. The elderly and underprivileged may lack the web-connected devices and internet skills with which to make appointments online. To mitigate this problem, CDPHE has held two mass vaccination programs in the San Luis Valley and one on the west side of Denver to reach Latino/Hispanic residents. Many more efforts like this will be needed. Pop-up vaccination events at predominantly Black churches and barbershops, at Native American health and cultural centers, and other trusted sites in Black, Indigenous and People of Color (BIPOC) communities are necessary to ensure justice in the vaccination effort. Otherwise, we will continue to see reports, like this one, that those who live in wealthy, white neighborhoods are receiving the vaccine ahead of others. Equally appalling are the stories about wealthy citizens of other countries flying to Miami, Houston and San Diego for COVID vaccines. I have heard that some have flown to Denver, driven to a church outside of Vail, and received their vaccines there. Those vaccines were intended for low-income workers. I am disgusted.

We don’t like to think that racism has infiltrated into healthcare, but it has been as deeply entrenched in medical settings as anywhere else. From the grossly unethical Tuskegee syphilis study, to the appropriation of Henrietta Lacks’ cervical cells for research without her consent, to the uneven distribution of medical resources and procedures in the US, to overt racism in clinical encounters, racism in healthcare is a profound problem that should concern and involve all of us. This recent NEJM Viewpoint, “One of Us”,  about how racism affects Black healthcare providers, is especially poignant. I am inspired by stories like this one, about individual healthcare providers finding ways to fill the gaps in underserved neighborhoods. We need to amplify these efforts, to make them universal rather than dependent on a specific individual possessed of abundant initiative. The Colorado Vaccine Equity Task Force aims to provide accurate information, knowledgeable speakers, and vaccination events to BIPOC communities. Their goal is to see 80% of Colorado BIPOC adults immunized by autumn, 2021.

As psychiatrists, we may be best situated to bring the vaccine to another population that experiences health disparities and reduced access to medical services: those with chronic mental illness (CMI). A recent study of COVID-19 mortality found that schizophrenia spectrum disorders conferred the second greatest risk, behind age, of COVID-19 mortality. Patients with schizophrenia spectrum disorders were 2.67 times more likely to die from COVID-19 within 45 days of testing positive than individuals with no mental illness. A pre-pandemic study of an intervention to address vaccination disparities for the CMI population demonstrated that creating a vaccination clinic in a community mental health center (CMHC) increased the vaccination rate from 18.75% to 83%. This remarkable success rate points to the potential for creating pop-up vaccination clinics at CMHCs to reach our most vulnerable patients. I hope that CPS and the APA will help advocate with CDPHE and the CDC, respectively, for this kind of innovation to reduce healthcare inequities among our patients, especially our CMI patients who are from BIPOC communities.

In addition to advocating for and organizing vaccination events that are more geographically and culturally accessible to the full spectrum of humanity in Colorado, psychiatrists may also want to examine the ways in which we unwittingly continue to exercise our privilege at others’ expense. This NYT op-ed by a former ER doctor turned journalist discusses those who have “jumped the line.” She says, “Pity the rule followers: Many older Americans who are not tech-savvy or lack internet access have been unable to get [appointment] slots.” Neither of my parents has had a first dose yet despite the fact that they can navigate the internet. I admit that if they lived in Colorado, I might work my connections to find them a place in line (to which they are fully entitled anyway because of their age). But another part of me thinks that’s unjust. My parents have the privilege of wealth, excellent nutrition, and overall good health. I should really be helping seniors who have fewer resources, those who struggle to buy fresh produce, pay the utility bills, and afford their medications.

Another important element of our response to the exercise of privilege in jumping the vaccination line is to educate the public and our patients about the ethics of vaccine distribution. They key point is the principle of justice in health care, which posits that resources should be allocated with systematic fairness. This viewpoint article from the NEJM offers a clear, nuanced ethical analysis of why politicians getting their vaccinations in advance of the elderly and those on the front line is an injustice.

In his paper, What Will White Psychiatrists Sacrifice?, Dr. Keith Gallagher admits, “I have shrugged my shoulders at injustice as if I were powerless to influence it.” He asserts that we must make sacrifices to right the wrongs from which we have benefited, which involves recognizing and ceding our privilege. This may mean different things for each of us. For me, this includes not getting my vaccine ahead of the general public, while advocating consistently to help my senior and/or medically vulnerable patients get theirs. I continue to explore the other ways I can give up parts of my privilege to help raise up those who struggle more than I have ever needed to do. It will mean more than making financial contributions, although those are important. It will mean being willing not to reach the summit of this trail until the entire hiking party reaches it with me.

We have been on this very steep trail for almost a year. We are exhausted. It looks like the trail may be leveling out up ahead. Don’t drink all your water and finish your trail mix yet! This is likely a false summit, and we may have miles and months ahead of us. I did make it to the top of Kala Patthar, but it wasn’t easy. I took “just one more step,” one step at a time, all the way up that heap of rocks. The view was spectacular. 

Much gratitude to Beth Cookson, MD, for sharing “One of Us” by Raymond Givens, MD, PhD.


Colorado Psychiatric Society COVID-19 Resource List

 February 2021

Updates

HHS - Public Health Emergency Expected to be Extended Through 2021 (download) - The U.S. Department of Health and Human Services (HHS) has communicated through a letter to Governors it will likely extend the Public Health Emergency (PHE) in 90 day increments through 2021

CPR - Colorado Opens COVID-19 Vaccine Hotline - The state is launching a hotline to help Coloradans get answers to questions about COVID-19 and vaccinations - 1-877-CO-VAX-CO or 1-877-268-2926

APA - Learn More and Register - Registration is now open for APA's online 2021 Annual Meeting Finding Equity Through Advances in Mind and Brain in Unsettled Times, which will be held Saturday to Monday, May 1 to 3. National Institute of Allergy and Infectious Diseases Director Anthony Fauci, M.D., will deliver the William C. Menninger Memorial Convocation Lecture on Sunday, May 2.  $275 early registration (before March 1st), $375 standard registration.

 

 
Resources for Providers


WNYC Studios The Takeaway - Hitting the Pandemic Wall: What COVID-19 Continues to Mean for Our Mental Health (20 minute audio) - Interview with a psychologist and a psychiatrist on pandemic exhaustion/fatigue and shame in the context of sad feelings and chronicity of the pandemic. Hope of engaging in life and naming the "feeling" helps (1-26-21).
Also see John Hopkins -
COVID-19's lasting toll on mental health - The initial coronavirus surge has passed, but the mental health fallout persists (11-10-20); KHN - Colorado eases license rules to let foreign-trained health workers help during coronavirus - Early on Colorado eased some licensing requirements in anticipation of a worker shortage. Through mid-December, 36 foreign-trained doctors sought temporary licenses, although only one met all the criteria (1-25-21); and Psychiatric Services - Health Care Workers’ Mental Health and Quality of Life During COVID-19: Results From a Mid-Pandemic, National Survey - The authors sought to quantify the rates of psychological distress among health care workers (HCWs) during the COVID-19 pandemic and to identify job-related and personal risk and protective factors (12-3-20)

JAMA - Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic - These findings suggest that ED care seeking shifted s during thea pandemic, underscoring the need to integrate mental health, substance use, and violence screening and prevention services into response activities during public health crises (2-3-21). Also see Nature - COVID’s Mental-Health Toll: How Scientists Are Tracking a Surge in Depression - Researchers are using huge data sets to link changes in mental health to coronavirus-response measures (2-3-21)

KOAA Southern Colorado - Growing number of pregnant women, new mothers seeking mental health resources during COVID-19 pandemic - Quotes CCAPS members Celeste St. John-Larkin and Anastasia Klott (1-21-21)

JAMA - Virtual Care, Telemedicine Visits, and Real Connection in the Era of COVID-19 Unforeseen Opportunity in the Face of Adversity (2-2-21); and Journal of General Internal Medicine - The Transition to Telehealth d)uring the First Months of the COVID-19 Pandemic: Evidence from a National Sample of Patients - Mental Health and Substance Use Disorders the Most Common Telehealth Appointment  (1-6-21)

JAMA - Vaccine Distribution—Equity Left Behind? (1-29-21)

NYT - The Science of Reasoning With Unreasonable People - Don’t try to change someone else’s mind. Instead, help them find their own motivation to change (1-31-20)

Denver Health Volunteer Opportunity - Volunteers page - DHHA is soliciting individuals with clinical backgrounds that can fill positions specific to reconstituting medication and administering vaccines to support the need to increase capacity at the following vaccination clinics; Pavilion C, Peña, Lowry, West.

APA - Members Can Now Order PPE Through Project N95 Anytime - Vetted PPE through Project N95 is now available for APA members on an ongoing basis  

 

 
Resources for Patients

Wired - It’s Not Just You: Everyone’s Mental Health Is Suffering - If you’re thinking, “Oh, I just need to suck it up,” stop. What you’re feeling is real. Here’s how to cope (1-18-21)

CNN - The rise of the fake commute, and why it's good for your mental health (1-18-21)

CPR - Coloradans Will Not Need ID To Receive COVID Vaccine In Colorado, COVID-19 vaccine providers cannot require people to have proof of identification in order to be inoculated - ​​​Colorado providers can still ask people to give their name, age and address, but those requests cannot dictate whether or not the person will be vaccinated (1-19-21). Also see Center for Health Progress - COVID-19 Vaccine FAQ for Immigrants in Colorado in English or Spanish.

Denverite - Denver got nearly $22 million in federal money for emergency rental assistance. Here’s how you can start applying for some of it - The money will be administered by the city’s Department of Housing Stability with help from local nonprofit organizations - call 311 and select option 6 (1-26-21)

The Colorado Sun - “Hug tent” allows for safe family embraces at Colorado home for the elderly - The tent set up outside Juniper Village at Louisville allowed family members to connect through a 4-millimeter-thick clear plastic barrier (2-5-21)

HCFP - Non-Emergent Medical Transportation (NEMT) - NEMT is a Health First Colorado benefit for Colorado Medicaid members who don't have transportation to medical appointments. It can be used to help patients get vaccinated when they are eligible. NEMT is provided through one transportation broker, IntelliRide. Members and assistors can contact IntelliRide at 1-855-489-4999 or 303-398-2155 (State Relay: 711) or visit their website for more information

CHI - The Pandemic Behind Bars - COVID-19, Vaccination, and the People in Colorado’s Prisons and Jails - More than 16,000 people have contracted COVID-19 as part of outbreaks at Colorado prisons, jails, and other detention facilities, according to an analysis of state and federal data by the Colorado Health Institute (CHI) (1-28-21)

CPR - On The Fence About COVID Vaccines? These Teens Want To Talk To You - Colorado high schoolers are combining empathy and scientific truth to produce videos aimed at persuading hesitant people to get vaccinated (2-3-21)

The Colorado Sun - Fentanyl overdoses are surging in Colorado as the powerful opioid is disguised as other drugs (2-4-21). Also see Fox31 - Warning: Fentanyl found in street drugs in Boulder County (2-8-21) and Denver7 - Boulder County Health warns about another batch of fentanyl-tainted drugs being sold on the street - Tainted drugs leading to increase in overdoses (2-6-21)

Slate - All the Presidents’ Pets - A cat named Miss Pussy. A virulently racist parrot. A pair of possums, which were later eaten for dinner. All the best—and worst!—presidential pets in American history, ranked (1-31-21)

NYT - Why You Should Brave the ‘Bad’ Weather - My British upbringing taught me that socializing outdoors shouldn’t stop when rain falls and temperatures drop (11-7-20)

NYT - Surge of Student Suicides Pushes Las Vegas Schools to Reopen Firmly linking teen suicides to school closings is difficult, but rising mental health emergencies and suicide rates point to the toll the pandemic lockdown is taking (1-24-21)

CDC - New Toolkit for Pregnant People and New Parents - The CDC’s latest COVID-19 resource offers information on pregnancy, breastfeeding, and caring for infants during COVID-19 (2-8-21)

NYT - The Primal Scream, a series that examines the pandemic’s effect on working mothers in America. America’s Mothers Are in Crisis - Is anyone listening to them? Its not just the working from home, the record unemployment or the remote schooling. This is a mental health crisis too. Also see This isn’t burnout, it’s betrayal - a psychiatrist suggests ways moms can fight back when the system is stacked against them  - Includes suggestions on what to do including recognizing that these problems are systemic (2-4-21)

Psychiatric Times - Suicides in Vulnerable Populations During the COVID-19 Pandemic (6 minute video) - Early data out of Maryland suggests that suicides during the initial COVID-19 wave actually dropped, compared to previous years. At the same time, Nestadt’s research also found that suicide rates among Black Marylanders rose sharply (1-19-21)

USA Today - Black trans people are struggling to find therapists after a tough year, but these non-profits are taking action - includes links to organizations that support the Black transgender community such as Fearless Femme 100, a project to provide free mental health care to QTBIPOC in response to the COVID-19 pandemic (1-27-21)

9News - 'A process of listening and hearing': Task force aims to address minorities' vaccine concerns - A statewide survey in September showed nearly 50% of Black and Latino Coloradans would not get the COVID-19 vaccine (1-20-21)

El Pais - A room, a bar and a classroom: how the coronavirus is spread through the air - The risk of contagion is highest in indoor spaces but can be reduced by applying all available measures to combat infection via aerosols. Here is an overview of the likelihood of infection in three everyday scenarios, based on the safety measures used and the length of exposure (updated link and article)

Recovery Review - Loneliness in the pandemic: risky times (1-24-21)

 


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.


February 3, 2021

Colorado Psychiatric Society COVID-19 Vaccine Update

 February 3, 2021


When can I get vaccinated?

Colorado is currently vaccinating eligible Coloradans for Phase 1A and Phase 1B.1. Governor Polis announced that Colorado is now able to expand vaccine eligibility and begin the next stage of Phase 1B (known as Phase 1B.2). Coloradans in Phase 1B.2 will be eligible beginning February 8. See the updated vaccine phase table and the vaccine distribution phase update FAQ (both updated 1-29-21) for more information.

In addition to the health care workers, long-term facility staff, and Coloradans ages 70+ who are already eligible, beginning February 8, Colorado will begin vaccinating the following people:

  • Coloradans 65-69 years old
  • Childcare workers in licensed programs
  • Pre-k-12 educators and school staff, including teachers (full-time, student teachers, and substitutes), bus drivers, school food servicworkers, counselors, administrative staff, safety workers, and employees providing other support services offered inside the school

 


Where can I get vaccinated

The Colorado Medical Society launched a new partnership with Children's Hospital Colorado and the Colorado Department of Public Health and Environment with the focus to get "shots in the arms" of any remaining Phase 1A or 1B physicians or other front line health care worker that have yet to be vaccinated. Sign up here. 

If you or someone you love is 65 or older, click here for information on where you can get vaccinated in Colorado and how to sign up.

If you are eligible and having trouble accessing a vaccine, please contact CPS and we will do our best to assist you.

 

January 20, 2021

Vaccines are on Everyone's Mind

By Claire Zilber, MD, DFAPA
CPS President

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

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

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

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

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

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

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

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

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

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

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

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

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

Stay healthy,

Claire

Colorado Psychiatric Society COVID-19 Resource List

 January 20, 2021


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.


Thank you to our Platinum Partner for their support

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?

Fortunately, a way out of our collective nightmare has opened up this month with the approval and early distribution of two extremely effective vaccines, and others are on the way. Each state has developed its own vaccine priority protocol, and Colorado’s can be found here. Because most psychiatrists are working via telehealth, we are not considered frontline workers eligible for the earliest doses of the vaccine; however, those who must evaluate patients in person, including psychiatrists in inpatient units and prisons, and addiction psychiatrists who administer injections, are in the 1B category and may be vaccinated this winter. Here is the state’s information for health care professionals, which will include details about how to access vaccination if you aren’t able to obtain it through your employer. Both CPS and the APA are advocating to ensure our members have access to the vaccines. CPS is in contact with CDPHE and other organizations and is actively monitoring information on the logistics of vaccinations for psychiatrists not directly employed by a hospital or affiliated with a facility. As soon as there is specific guidance on how providers in category 1B who need to have direct patient contact can get a vaccine, we will notify members. Additional information is available at https://covid19.colorado.gov/vaccine.  This Colorado Sun article suggests that the line between 1A and 1B categories is somewhat fluid.

Because I can see my patients via telehealth, I feel it is more ethical to prioritize those who need the vaccine more than I do. Rather than focusing on when we get our own vaccinations, which will happen when they happen, let us turn instead to our capacity as public health professionals. Psychiatrists play a vital role in educating our patients and dispelling their anxieties. Patients with chronic mental illness have a lower influenza vaccine uptake rate than the general population, and by virtue of their economic status and chronic health conditions are at higher risk for severe COVID-19 illness. Psychiatrists are central to helping these vulnerable patients access the vaccine. We are also well positioned to help our patients and the public deal with vaccine hesitancy through motivational interviewing, as discussed in this article from CU Anschutz’s Department of Psychiatry. Another article offers five strategies to help overcome vaccine hesitancy, including making vaccination free and easily accessible, making admission to valued settings (schools, workplaces, cultural institutions, our offices) contingent upon vaccination, and using endorsements from trusted leaders to increase uptake. It is crucial to include leaders from diverse community settings, such as local religious and civic leaders, if we are to reach the communities most at risk for COVID and least trusting of health authorities.

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

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

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

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

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

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

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

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 December 23, 2020


Updates

Reminder: If you should find yourself or know of a physician or physician’s assistant colleague that needs support for the stresses of the COVID-19 crisis, and caring for those afflicted, please reach out to the COVID-19 Care Line for Physicians at 720-810-9131.

APA - Resource Document - How Psychiatrists Can Talk to Patients and Families About Race and Racism - resource developed by the APA Council on Children, Adolescents, and Their Families in consultation with the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry (11-20)

 

 
Resources for Providers


Colorado News Collaborative - What Can’t Be Washed Off: Psychiatrist Absorbs Her Patients’ Pain - Dr. Patricia Westmoreland, psychiatrist at The Medical Center of Aurora, says she, too, is rattled by the string of crises that recently have landed her patients in the hospital. Features CPS Past President Patricia Westmoreland (who previously authored the CPS COVID-19 Resource email articles) (12-11-20). This story is part of a statewide reporting project called On Edge, which aims to foster conversation about mental health in a state where stigma runs high.


CU Anschutz 360: COVID Reflections - Fallout from Mental Health Crisis Spawned by COVID-19 Disruption Will Likely Continue for Years (28 min podcast) - CCAPS member Steven Berkowitz, MD, discusses whether any of us will ever be the same – and that wholesale change could be a good thing in the long run (12-8-20)


MDEdge - Using the ‘MASK’ strategy to help patients cope with pandemic-related anxiety with Dr. Eliza W. Menninger - 29 minute podcast on how to help patients deal with anxiety related to the COVID-19 pandemic. MASK: Make boundaries, Avoid the virus, Stay connected, Keep the faith (12-9-20)


Starbucks - Starbucks is giving free coffee to health care workers through December 31st. Any customer who identifies as a front-line responder to the COVID-19 outbreak will receive a tall brewed coffee (hot or iced) at no charge. They specify that mental health workers are included!


CU Anschutz - Best Medicine During a Pandemic? How About Some Laughter? School of Medicine alumnus and comedian Brad Nieder delivers much-needed dose of humor at CU Anschutz alumni event. Watch the video (12-8-20)


CPR - Overcoming stigma during a pandemic: For Farmers And Ranchers, Coronavirus Made An Already Complicated Mental Health Picture Even Harder - Suicide rates are higher for people in agriculture than the general community -- as much as double, according to a 2016 CDC report. Public health advocates and the Department of Agriculture are looking for new methods to intervene (12-14-20)


JAMA - The Healthy Brain and Child Development Study—Shedding Light on Opioid Exposure, COVID-19, and Health Disparities - Authors: Nora D. Volkow, MD; Joshua A. Gordon, MD, PhD; Michelle P. Freund, PhD (12-9-20)


NEJM - A Pandemic within a Pandemic - Intimate Partner Violence during COVID-19 (12-10-20)


NIHCM - Addressing Loneliness & Social Isolation During the PandemicAn infographic from the National Institute for Health Care Management that highlights the risk factors associated with loneliness and explores its impact on health. Key strategies are also identified to help combat loneliness and social isolation.


NYT - China Long Avoided Discussing Mental Health. The Pandemic Changed That - The government has deployed extensive resources to address the spike in depression and anxiety. But social stigmas and long-term challenges remain (12-21-20)


JAMA - Racial Differences in Statewide Suicide Mortality Trends in Maryland During the Coronavirus Disease 2019 (COVID-19) Pandemic (12-16-20)

 

 
Resources for Patients


Colorado News Collaborative - What Can’t Be Washed Off: Psychiatrist Absorbs Her Patients’ Pain - Dr. Patricia Westmoreland, psychiatrist at The Medical Center of Aurora, says she, too, is rattled by the string of crises that recently have landed her patients in the hospital. Features CPS Past President Patricia Westmoreland (who previously authored the CPS COVID-19 Resource email articles) (12-11-20). This story is part of a statewide reporting project called On Edge, which aims to foster conversation about mental health in a state where stigma runs high.


CDC - Holidays and Stress - Being away from family and friends during the holidays can be hard. When you talk with your friends and family about plans, it’s okay if you decide to stay home and remain apart from others. Doing what’s best for you includes eating healthy foods and getting enough sleep. Take care of your body and stay active to lessen fatigue, anxiety, and sadness (12-14-20)


TED Ideas - Feeling lonely this holiday season? You can still make it special — some practical advice (12-17-20). Also see HuffPost - 11 Little Things To Do When You're Feeling Lonely During The Holidays - The coronavirus pandemic is causing isolation from family and friends this year. Here's how to cope if your mental health is suffering (12-14-20)


Washington Post - For many with eating disorders, pandemic set off ‘cascade of problems.’ Here’s how to get help (12-14-20)


9News - People are using Colorado Crisis Services 55% more in 2020 compared to 2017 - A 9Wants to Know analysis found more calls are abandoned and Coloradans are waiting longer to connect with a crisis service specialist since 2017 (12-8-20)


Governor Polis - Gov. Polis and medical and behavioral health officials update on COVID-19 and mental health practices - Watch minutes 22-29 to see presentation by Aimee Voth Siebert, Disaster Behavioral Health lead for CDPHE (12-18-20). Also see CDPHE - Mental health during the holidays.


NBC News - How to talk to your friends and family about Covid, vaccines and wearing masks - Experts who study the psychology of pandemics and human behavior say there are ways to prevent squabbles from fracturing relationships beyond repair (12-11-20)


Orchestrating Change - feature-length documentary that tells the inspiring story of the only orchestra in the world created by and for people with mental illness. Watch the trailer or watch preview scenes, learn more and read reviews on the website.


Playbill - Schedule of Upcoming and Current Free Live Stream Broadcasts - a list of current and upcoming free live streams of stage productions (12-21-20)


NPR - 'I Vaccinated Santa Claus,' Fauci Tells Kids (12-19-20)


Time - How to Talk to Your Kids About Celebrating the Holidays During COVID-19, According to Experts - Includes a reminder not to dismiss kids’ disappointment - “It’s very easy for us who are going through the global pandemic, dealing with financial stress and the uncertainty about our health, to judge and minimize our kids’ reactions. And that would be a mistake” (12-8-20) 


Essie Justice Group Lives on the Line: Women with Incarcerated Loved Ones and the Impact of COVID-19 Behind Bars (download) - Report explores the impact COVID-19 has had on women whose loved ones are incarcerated - Fifty-two percent of survey respondents reported that their incarcerated loved one has at least one “high-risk” underlying health condition, 33% noted that their loved one’s attorney meetings have been canceled due to the pandemic, and 62% said their loved ones were scared of losing their lives to COVID-19 while incarcerated. Also see CPR - ‘Of Course, It Feels Unsafe’: Colorado Prisons Face Staffing Crisis As Hundreds Of Guards, Inmates Sickened (12-17-20)


NYT - The Psychic Toll of a Pandemic Pregnancy - Women who had Covid while expecting experienced guilt, shame and unhealthy levels of stress  (12-14-20)


Washington Post - Military-grade camera shows risks of airborne coronavirus spread - The Washington Post uses a military-grade infrared camera to demonstrate how nearly invisible particles spread like smoke through the air every time we speak or breathe (12-11-20)


JAMA - “This Level of Death, It’s New”—Health Care Workers in Their Own Words - If you need motivation to continue wearing a mask and social distancing, read this article, which collects the words of frontline healthcare workers about what they experience at work and includes a plea to the public to help out through simple behavioral strategies (12-17-20)

 


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.


Thank you to our Platinum Partner for their support

 


 

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 

 
Resources for Providers


Governor Polis - Dr. Fauci addresses Colorado - Governor Polis provided an update on the State’s response to the COVID-19 pandemic and was joined by America's top infectious disease expert, Dr. Anthony Fauci, M.D., National Institute of Allergy and Infectious Diseases (NIAID) Director (12-1-20)


On Edge: A series on Colorado’s mental health in a time of crisis - The Colorado News Collaborative, led by Sentinel Colorado on this project, convened media outlets from across the state to focus on mental health and stress during uniquely troubled times. See Heightened anxiety, depression are testing Colorado’s already-frayed safety nets - As coronavirus makes another virulent run through Colorado, a silent epidemic of mental health challenges is feeding on the anxiety and isolation of the pandemic - Quotes CPS member Carl Clark (12-6-20)


PsychNews - Pandemic Allows Vast Natural Experiment in Socially Distant Psychotherapy - Technology has been a blessing in a time of pandemic. Experts in psychotherapy talk about the challenges and the benefits of psychotherapy at a distance (11-29-20)


KevinMD - The doctor will sneeze you now - The culture of working while sick in medicine is potentially harmful to both providers and patients (11-22-20)


KevinMD - Telehealth in underserved populations needs telecommunication expansion (11-22-20)


PsychNews -  Early Career Psychiatrists Form Global Collaboration to Take on Pandemic - A group of young psychiatrists, psychiatric trainees, and allied professionals from across the world have joined to conduct research on global mental health during the pandemic (11-16-20). Also see YouTube series - “Our Science in a Nutshell” - short videos (around 2-4 mins) summarizing the findings of papers from Think Tank (group mentioned above consisting of ECPs from 30 countries across six continents)


Psychiatry Online - Psychobehavioral Responses, Post‐Traumatic Stress and Depression in Pregnancy During the Early Phase of COVID‐19 Outbreak(11-24-20)


Webinar for Resident Fellows and Early Career Psychiatrists offered by Senior Psychiatrists - Details at Community Mental Health and Covid-19 in the USA - Register here - December 15, 2020 @ 6pm MT (8pm ET). Featured Speakers: Brian R. Sims, MD,  and Brian Hepburn, MD


Denverite - Native American residents in Denver are seeing a spike in coronavirus cases - Health officials aren’t totally sure why, but pre-existing conditions and mistrust in government agencies could be part of the reason (12-01-20)

 

 
Resources for Patients


Washington Post - How to keep your sadness from turning into depression (11-29-20)


Mayo Clinic - Discover Gratitude  - Join Mayo Clinic Health System for a free, month-long self-guided virtual program to help you improve your mental well-being through daily journaling


Pikes Peak WorkForce Center - #upskill2020 - a variety of free, online, professional training available to help the careers of those whose jobs have been affected by COVID-19. Also see YouScience - aims to help people figure out what they really want to do by using 11 fun brain games to capture real measures of aptitudes (natural abilities most important to career choice)


CDC -  Options to Reduce Quarantine for Contacts of Persons with SARS-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing - this resource applies a scientific lens to choosing a length of quarantine based on risk. The graph may be especially helpful in illuminating the difference between 7, 10 and 14 days of quarantine, and the table below it clarifies how adding a negative test may increase confidence about reducing quarantine from 14 to 10 days (12-2-20)


USA Today - Worlds align this winter solstice: Look for Jupiter, Saturn in skies this December - “You’d have to go all the way back to just before dawn on March 4, 1226, to see a closer alignment between these objects visible in the night sky.”  (12-3-20)


APA - Learn about Stigma, Prejudice and Discrimination Against People with Mental Illness -  new resource page designed for patients and families and the public at large, reviews the facts on stigma, including the various types and their harmful effects, and then shares ways to address it.
Also see Mental Health Colorado - “You’re not alone” are the three simple but powerful words that Denver Bronco Austin Fort wore on his cleats Sunday (12-6-20)

Also see NYT - I Achieved My Wildest Dreams. Then Depression Hit (5 min 30 sec video) I’d spent my life training for the Olympics, but I wasn’t prepared for what came next - Elite athletes and coaches should be trained to monitor mental health as much as physical injuries, argues Alexi Pappas, an Olympic runner who shares her own struggles with depression in a new video (12-7-20)


Greater Good Magazine - Why Is the Pandemic So Hard on Young People? Research suggests that young people are more stressed, anxious, and depressed than other age groups during COVID-19 (11-30-20)


Washington Post - How to talk to loved ones when you’re worried about their mental health (12-1-20). Also see The Scholarly Kitchen - Guest Post — A Conversation about the Reality of Neurodiversity - a 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 (12-3-20)


Denverite - Native American residents in Denver are seeing a spike in coronavirus cases - Health officials aren’t totally sure why, but pre-existing conditions and mistrust in government agencies could be part of the reason (12-01-20) 


The Colorado Sun - With coronavirus nixing gatherings, LGBTQ+ Coloradans seek new ways to foster belonging - LGBTQ+ people feel some impacts of the pandemic more sharply than the general population, but there have been silver linings to the shutdown (12-4-20) (simply close the box to access the article if you do not want to share your email)


On Edge: A series on Colorado’s mental health in a time of crisis - The Colorado News Collaborative, led by Sentinel Colorado on this project, convened media outlets from across the state to focus on mental health and stress during uniquely troubled times. See Heightened anxiety, depression are testing Colorado’s already-frayed safety nets - As coronavirus makes another virulent run through Colorado, a silent epidemic of mental health challenges is feeding on the anxiety and isolation of the pandemic - Quotes CPS member Carl Clark (12-6-20)


Washington Post - What was lost when covid forced addiction support groups online — and what was gained (11-23-20)

 


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

 


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 33rd 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.)

Interested in learning about the outcomes of the Governor’s Behavioral Health Task Force and potential legislation in the 2021 session?

REGISTER HERE
for the CPS-CMS VIRTUAL GRAND ROUNDS: COLORADO'S BEHAVIORAL HEALTH BLUEPRINT
Next Wednesday, December 2nd, 2020
6:00pm - 7:30pm

The event features CPS members C. Neill Epperson, MD and Elizabeth Lowdermilk, MD, along with CDHS Executive Director Michelle Barnes and others. This activity has been approved for AMA PRA Category 1 Credit

NOTE: You do NOT need to be a CMS member to attend this event.  if you do not have a CMS member number or do not know your CMS member number, you can write n/a or enter any number when requested in the registration form


Colorado Psychiatric Society COVID-19 Resource List

 November 25, 2020


Updates

Register for all 4 upcoming CPS events - The pandemic may hinder us from gathering in person, but CPS is here to ensure you have ample opportunity to stay connected to friends and colleagues. Event details at https://www.coloradopsychiatric.org/events.

NYT - How to Have a Fully Remote Family Thanksgiving - Skipping travel this year to stop the spread of Covid-19? Here’s how to digitally reimagine the holiday, from meal prep to after-dinner activities (11-18-20)

 

 
Resources for Providers


The Colorado Sun - Colorado agency erred in dumping a mental health program for doctors, judge rules - An administrative law ruling says DORA’s new contract is void. But the case that has riled the state’s physicians is far from over. Quotes CPS President Claire Zilber, “The current pandemic, which is exerting enormous strain on physicians, is happening on top of a preexisting epidemic of demoralization and burnout,” she wrote. “To remove our trusted source of peer support in the middle of this crisis invites tragedy.” (11-12-20)


Researchers find nearly one in five COVID-19 survivors is diagnosed with a mental health disorder - Researchers from The University of Oxford found the results by comparing COVID-19 patients to people who have experienced other health events this year. Quotes CPS Past President Patricia Westmoreland (11-12-20). Also see The Lancet - Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA (11-9-20) and KUNC - How COVID-19 Impacts Mental Health - COVID-19 Diagnosis Linked To Subsequent Mental Illness - quotes CPS member Kimberly Nordstrom (25 min audio, Dr. Nordstrom featured at the beginning of the show through minute 6:20) (11-19-20)


Denver Post - Colorado moving Denver, 14 other counties to Level Red in latest bid to avoid COVID-19 lockdown - New restrictions, including prohibition on personal gatherings and indoor dining at restaurants. Level Red is the second highest level, one away from a stay-at-home order. Also see CDPHE - Public Health Order and COVID-19 Dial and Gov. Polis - executive order allows Colorado emergency rooms that reach capacity to turn away patients or transfer them to another facility without written or informed consent.


PRMS - Cybersecurity Booklet (download) - Includes specific guidance regarding the COVID-19 pandemic.


AAMC - How COVID-19 Threatens the Careers of Women in Medicine - Even before the pandemic, women physicians and researchers earned less, did more at home, and were lower on the professional ladder compared to men. Here’s how the pandemic could further hurt women’s careers - Includes suggested solutions to address the ways the pandemic threatens progress for women in medicine (11-12-20). Also see KevinMD - Will women in medicine survive COVID-19? (11-12-20)


Psychiatric Services - Health Conditions Associated With Severe Illness From COVID-19 Among Individuals With Serious Mental Illness - Individuals with serious mental illness have more chronic medical conditions that increase their risk for contracting severe COVID-19 compared with individuals without serious mental illness and are more likely to be distinctly affected by the pandemic (11-19-20)


NPR’s 1A - The Pandemic Is The Worst. What Can We Do To Keep Coping? (47 minute radio show) - episode on the psychological and emotional toll of COVID-19 with the U.K.’s Minister of Loneliness and NPR’s Shankar Vedantam (11-21-20)


Georgia Tech - COVID-19 Event Risk Assessment Planning Tool (works best in Chrome) - The COVID-19 Event Risk Assessment Planning Tool is a collaborative project led by Prof. Joshua Weitz and Prof. Clio Andris at the Georgia Institute of Technology, along with researchers at the Applied Bioinformatics Laboratory and Stanford University, and powered by RStudio. Also see Nature Human Behaviour - Real-time, interactive website for US-county-level COVID-19 event risk assessment (11-9-20)


CHI - Value and Impact of Telemedicine During the COVID-19 Response - Three new publications, including a report on The Financial Impact on Providers and Payers in Colorado (download), developed in collaboration with the Colorado Office of eHealth Innovation, highlight the value of telemedicine during the COVID-19 pandemic and beyond (11-4-20)


JAMA Viewpoint - Older Adults and the Mental Health Effects of COVID-19 - counter to expectation, older adults as a group may be more resilient to the anxiety, depression, and stress-related mental health disorders characteristic of younger populations during the initial phase of the COVID-19 pandemic (11-20-20). Also see Conversations with Dr Bauchner: Older Adults and the Mental Health Effects of COVID-19 - a 22 min audio interview with Ipsit V. Vahia, MD, author of Older Adults and the Mental Health Effects of COVID-19 (and a PsychSummit panelist)


PsychNews - SUD Patients More Susceptible to COVID-19, Adverse Outcomes - Although individuals with substance use disorders made up only 10.3% of the 73 million patients involved in a recent study, they represented 15.6% of COVID-19 cases. Policy changes and effective interventions are needed now to help this population (11-3-20). Also see CDPHE - CMS letter of Approval (download) - CMS approves Colorado's Section 1115 Substance Use Disorder (SUD) demonstration, titled "Expanding the Substance Use Disorder Continuum of Care."


MedRxiv - Association of social distancing and masking with risk of COVID-19 (download) - Individuals living in communities with the greatest social distancing had a 31% lower risk of predicted COVID-19 compared with those living in communities with poor social distancing. Self-reported masking was associated with a 63% reduced risk of predicted COVID-19 even among individuals living in a community with poor social distancing (11-13-20)


CDC - Community Use of Cloth Masks to Control the Spread of SARS-CoV-2 - Asymptomatic transmission & masks - Over 50% of COVID-19 transmissions may result from presymptomatic or asymptomatic spread, the CDC says in an updated scientific briefing that endorses universal face masking. The agency notes: "The prevention benefit of masking is derived from the combination of source control and personal protection for the mask wearer. The relationship between source control and personal protection is likely complementary and possibly synergistic, so that individual benefit increases with increasing community mask use."  The CDC also cited data showing that increasing universal masking by 15% could prevent lockdowns and decrease losses by up to $1 trillion. At the same time, the agency published an MMWR article showing that in Kansas, counties that required masks in public experienced a 6% decrease in COVID-19 incidence last summer, while counties without mask mandates saw a 100% increase (11-20-20)

 

 
Resources for Patients


NYT - How to Deal With Quarantine-Induced Social Anxiety - Yes, you can enjoy socializing again. But it might take a little effort (11-12-2020)


CNBC - CDC now says wearing a mask protects the wearer, too (11-11-20). Also see CDC - Scientific Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2 (11-20-20)


KHN - Take It From an Expert: Fauci’s Hierarchy of Safety During COVID - interview with KHN Editor-in-Chief Elisabeth Rosenthal, Anthony Fauci (11-19-20). The full interview can be heard in a KHN ‘What the Health? podcast episode - What Would Dr. Fauci Do? (21 minute podcast and transcript)


NYT - How to Have a Fully Remote Family Thanksgiving - Skipping travel this year to stop the spread of Covid-19? Here’s how to digitally reimagine the holiday, from meal prep to after-dinner activities (11-18-20)


Denver Post - There’s still one way you can see “The Nutcracker” in Colorado this Christmas season - Rocky Mountain PBS will broadcast “The Nutcracker” on Thursday, Nov. 26 – 7pm; Friday, Nov. 27 – 3pm; Friday, Dec. 18 – 9pm; Saturday, Dec. 19 – 1am; Thursday Dec. 24 – 7pm; Friday Dec. 25 – 12am. It will also be available via the RMPBS app (11-22-20). Also see Hip Hop Nutcracker Denver - Livestream + On Demand - Dec 22nd at 7pm.


National Geographic - How art helps us make sense of COVID-19's incomprehensible toll - As the United States reaches 250,000 deaths, people are finding creative and symbolic ways to come to terms with the tragic milestone (12-18-20)


American Psychiatric Association Foundation - Register for Mentally-Healthy Families in Times of a Pandemic - December 2, 2020 from 6-7 pm MTY (8-9pm ET) - During this virtual town hall, our psychiatric experts will participate in a candid discussion to help parents and caregivers recognize common signs of stress, learn ways to manage stress, and explore examples of how you can plan stress relief activities for your family. This town hall also features a newly released resource on Notice. Talk. Act. at Home: Coping Skills (download) – a resource to help parents and caregivers stay mentally healthy through the public health emergency. Audience: The general public, including parents of younger children, caregivers of older adults, and others


Mass General Perinatal and Reproductive Psychiatry Program- Resource: A Woman’s Guide to Pregnancy and the Postpartum Period During the COVID-19 Pandemic


NYT - Developmental Disabilities Heighten Risk of Covid Death - People with intellectual disabilities and developmental disorders are three times more likely to die of Covid-19, compared with patients without the conditions, a new analysis found (11-12-20)


Envision:You - COVID-19 Behavioral Health Support Program - This program, in partnership with Caring for Denver Foundation, provides no-cost virtual telehealth services to support LGBTQ+ individuals with mental health, emotional and substance use issues, and interpersonal relationship concerns that have arisen due to the COVID-19 pandemic.


9News - Researchers find nearly one in five COVID-19 survivors is diagnosed with a mental health disorder - Researchers from The University of Oxford found the results by comparing COVID-19 patients to people who have experienced other health events this year. Quotes CPS Past President Patricia Westmoreland (11-12-20). Also see KUNC - How COVID-19 Impacts Mental Health - COVID-19 Diagnosis Linked To Subsequent Mental Illness - quotes CPS member Kimberly Nordstrom (25 min audio, Dr. Nordstrom featured at the beginning of the show through minute 6:20) (11-19-20)


NPR’s 1A - The Pandemic Is The Worst. What Can We Do To Keep Coping? (47 minute radio show) - episode on the psychological and emotional toll of COVID-19 with the U.K.’s Minister of Loneliness and NPR’s Shankar Vedantam (11-21-20)

 


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 -  Also see the November 2020 COVID-19 Response Update from the Office of Governor Jared Polis (download) *NEW*


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.


Thank you to our Platinum Partner for their support


November 11, 2020
Inpatient Psychiatry in the Pandemic

By Claire Zilber, MD, DFAPA
CPS President

For many of us, our first exposure to the field of psychiatry was as a student on an inpatient ward. In college, a course on Abnormal Psychology included a field trip to the Philadelphia State Hospital where each student was paired with a patient. I was assigned to a man with Tourette’s syndrome, who shouted obscenities while pacing the halls and gesticulating. I imagine how dangerous life would have been for him in public, where people would misunderstand his illness as aggression; however, at the time, he alarmed me so much I could barely conduct the interview. An inpatient unit is simultaneously a safe haven and a scary place, and the pandemic has amplified this dichotomy. This week I’ve explored the risks particular to inpatient psychiatric settings, the guidance issued to help mitigate those risks, some ethical quandaries that have emerged, and several creative solutions.

As if obstacles to inpatient admission weren’t already extensive, including insurance barriers, bed shortages, stigma, and past traumatic experiences with treatment, now patients may fear presenting to the hospital because of COVID. Indeed, this report from February about an outbreak in a psychiatric hospital in South Korea, which led to over 100 infected patients and 17 deaths, reinforces beliefs that the hospital is unsafe. Lest we think such carelessness couldn’t happen here, this September 29 article from The Gazette reports on the closing of a psychiatric hospital in Johnstown (just east of Loveland) because of inadequate pandemic precautions as well as allegations of patient abuse.

Unlike medical and surgical units, psychiatric units are organized around the therapeutic milieu, based on the concept that interactions among patients as well as with staff have therapeutic value. How can we maintain a group milieu while isolating potentially infectious patients? Some direction has been provided by our government. For example, this SAMHSA guidance, issued in May, considers ways to reduce morbidity and mortality by mitigating risks for patients and staff while preserving the functioning of the healthcare system. Updated October 13, here is the link to the APA’s practice guide for COVID-19. Scroll down to the heading on inpatient psychiatry. These resources relate to a March 18 guidance issued by CMS (Centers for Medicare & Medicaid Services) about tiers of care, which triggered APA’s statement that ECT should be considered an essential procedure, not an elective procedure that could be postponed during a lockdown.

More substantial guidelines have been offered by our colleagues. This July 2020 literature review about psychiatric care in the US during the pandemic addresses all locations of psychiatric treatment (ie: outpatient, emergency rooms, C/L, and inpatient). Scroll down to section 3.3 to read their findings about inpatient psychiatry, and then move on to section 4, which includes a consideration of the ethical implications of admitting patients to an inpatient unit, which some have compared to a nursing home in terms of exposure risk. Informed consent about this risk is necessary, but may be difficult to obtain from a psychotic patient. This excellent double case report highlights ethical and logistical considerations when caring for older adults on inpatient psychiatric units. This paper from the Journal of Medical Ethics also uses a case study to elucidate ethical dilemmas and policy recommendations for when patients refuse COVID-19 testing and won’t comply with quarantine or social distancing on psychiatric inpatient units.

A variety of adaptations have been adopted across the country. The University of Rochester created a COVID-19-positive psychiatric unit so that inpatients can benefit from the milieu and group support while also receiving expert medical care. In Colorado, the predominant model (based on information from Denver Health and Porter Hospital) is to hospitalize COVID-positive psychiatric patients on the medical service and support those patients with telepsychiatry from the C/L team.

Telepsychiatry is not being used on the inpatient service at Denver Health. Patients are tested prior to admission, and only those who test negative are admitted to the psychiatry unit. Staff and patients are screened for symptoms daily, social distancing is enforced as much as possible, mask wearing is encouraged, and the unit is frequently sanitized. Groups and other therapeutic programs are being continued. Initially quiet, the inpatient units at Denver Health have been busy since September, which likely reflects the “mental health wave” of the epidemic we’ve been anticipating. Staff have remained healthy, with only four positive tests among the inpatient and ER teams, all of whom recovered quickly. Staff burnout is a big concern, as is how to manage patients who refuse COVID testing (go back to the Journal of Medical Ethics case study to read the discussion about balancing a patient’s right to auonomy against the public health imperative to not place other patients and an entire staff at risk).Staff burnout and maintaining inadequate staffing are real problems. The compelling part of this article addresses how longstanding problems with understaffing and inadequate inpatient beds, which leads to long stays in non-therapeutic emergency departments, has been exacerbated by the pandemic. One psychiatrist has accelerated his pre-pandemic project to create truly therapeutic spaces for psychotic or suicidal patients in emergency departments, with the goal of being able to send 75-80% of patients home without inpatient admission. Similarly, this report from a London hospital asserts that the kinds of adaptations we see happening now may lead to positive changes in inpatient units that will persist beyond the pandemic. For example, they instituted point-of-care testing for clozapine levels, which expedited dose titration; enhanced videoconferencing connections with community agencies to facilitate a smooth and efficient discharge plan; and even used telehealth to meet with patients’ family members during rounds.

Inpatient psychiatric services are a crucial component of mental health treatment, and will continue to be necessary throughout the pandemic and its aftermath. While the challenges COVID-19 has brought to inpatient psychiatry are formidable, the solutions emerging from this crisis reveal the creativity and adaptability of our colleagues. We don’t have all the answers, but at least we’re identifying important questions to help respond to the needs of acutely psychotic or suicidal patients while containing the risk of infection as much as possible.

I am grateful to Drs. Steve Mayes, Beth Cookson and Christian Thurstone for their valuable contributions.


 

Colorado Psychiatric Society COVID-19 Resource List

 November 11, 2020

Updates

9News - Here are the Colorado counties that are moving to tighter COVID-19 restrictions - A list of Colorado counties that have recently tightened restrictions due to an uptick in COVID-19 cases. Includes information on Denver’s Home by 10 curfew (updated 11-9-20). Also see the Colorado County COVID-19 dial dashboard (updated daily)

CO HCPF - Register for the Telemedicine Stakeholders Engagement Meeting - Thursday, November 12, 2020 4:00 PM MST - 5:00 PM MST - The Department of Health Care Policy and Financing is continuing its consideration of telemedicine policies and their effects on access, quality of care, budget, and provider and member experiences. Their goal is to ensure that members have access to quality telemedicine services while managing their fiscal responsibilities. They have been assessing and developing policy around telemedicine. Proposed policy will be shared and feedback requested.

APA - Register for the APA Town Hall on Structural Racism, Part 3: The Trauma of Structural Racism and its Transmission Across Generations - Monday, November 16 | 6-7:30 MT (8:00 - 9:30 p.m. ET) - Disparities in mental health for people of color remain pervasive and persist across generations. There is a growing consensus that structural and interpersonal racial discrimination fundamentally impact mental health in communities of color. The persistent stress of experiencing discrimination has an impact across generations, and the degree to which the health consequences of racism and bigotry can be passed down from one generation to the next is an important avenue of exploration. This town hall will delve into this issue. Have a question you would like the panel to address? Submit your question at this link.

APA - Register Here for an Update on 2021 Changes to Billing and Documentation for Outpatient E/M Services - Tuesday, November 17, 6pm MT (8 pm ET) - Join this webinar to learn about the changes to billing and documentation for Outpatient E/M services that will take effect on January 1, 2021. The webinar will include how to select the appropriate CPT code based on medical decision making or time, a review of the necessary documentation, and a Q&A portion with APA’s CPT coding and documentation experts. Also see Bump in Medicare Values for E/M Codes Could Increase Psychiatrist Payment (8-31-20) and AMA - E/M office-visit changes on track for 2021: What doctors must know (8-5-20)

 

 
Resources for Providers


NEJM - The Human Touch — Addressing Health Care’s Workforce Problem amid the Pandemic (9-16-20). Also see AMA - 6 areas health systems must focus on long after pandemic ends (11-4-20)


JAMA - Science Denial and COVID Conspiracy Theories Potential Neurological Mechanisms and Possible Responses (11-2-20)


AAP - Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic (10-26-20)


PsychNews - Telehealth Options for Treating Patients with SUD Expand - Videoconferencing, store-and-forward telehealth, remote patient monitoring, and mobile health all fall under the umbrella of “telehealth,” but which ones are most useful for treating substance use disorders? (10-28-20). Colorado passed telehealth legislation last session and CPS worked with the APA, bill sponsors and stakeholders on amendment language to ensure the term “store-and-forward transfers” was included in the definition of telehealth in SB 212 – Reimbursement for Health Care Services Provided through Telehealth


El País via the Colorado Sun - A room, a bar and a classroom: how the coronavirus is spread through the air - Highly useful illustration of how to mitigate risk and the importance of ventilation and masks (and University of Colorado Boulder atmospheric chemist Jose-Luis Jimenez developed the analytic tool) (10-29-20)


KHN - For Each Critically Ill COVID Patient, a Family Is Suffering, Too - A decade ago, critical care clinicians coined the term post-intensive care syndrome, or PICS. It describes the muscle weakness, cognitive changes, anxiety and other physical and mental symptoms that some ICU patients cope with after leaving the hospital. Now they worry that some family members of critically ill COVID patients may develop a related syndrome: PICS-Family (10-28-20)


NYT - How America Helped Defeat the Coronavirus*   Just not in the US (15 min video) (10-28-20)

 

 
Resources for Patients


HuffPost - 9 Things Sleep Doctors Would Never Do At Night Before Going To Bed - Experts reveal which bedtime habits to avoid if you want to feel rested in the morning (11-4-20)


Eating Recovery Center - Four Square Breathing Meditation (8:30 min video) - detailed instructions of one method of four square breathing


NYT - ‘Clearly, Coloradans have lapsed’: New virus cases are setting records in Colorado (11-2-20). Also see 9News - Here are the Colorado counties that are moving to tighter COVID-19 restrictions - A list of Colorado counties that have recently tightened restrictions due to an uptick in COVID-19 cases. Includes information on Denver’s Home by 10 curfew (updated 11-9-20). Also see the Colorado County COVID-19 dial dashboard (updated daily)


MedPage Today - Don't Bring COVID Home for the Holidays — Essential steps for college students to see family safely (11-2-20)


HuffPost - How To Teach Kids To Cope With Uncertainty - COVID-19. The election. 2020 has brought one unknown after the next. So how can we raise kids who are experts at living with uncertainty? (11-06-20)


El País via the Colorado Sun - A room, a bar and a classroom: how the coronavirus is spread through the air - Highly useful illustration of how to mitigate risk and the importance of ventilation and masks (and University of Colorado Boulder atmospheric chemist Jose-Luis Jimenez developed the analytic tool) (10-29-20)


AAP - Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic (10-26-20)


GoNoodle on YouTube - Melting Flow - Practice melting away that icky frozen feeling you get when you're scared, frustrated, or angry (3.5 min video)


CNBC - Doctors Worry Coronavirus Pandemic May Hit LGBTQ People Harder than Most (10-29-20)


NYT - COVID in the US - Latest Map and Case Count (updated daily)


National Jewish - Coronavirus: Information & Resources


USNews - People With Down Syndrome Face Higher Risk of Severe COVID-19 (10-27-20)

 


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. Also see the November 2020 COVID-19 Response Update from the Office of Governor Jared Polis (download) *NEW*


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.


 

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

Claire Zilber, MD, DFAPA
October 28, 2020

 

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

Updates

COVID-19 Exposure Notifications have started in Colorado! You can now activate this service to protect your community while maintaining your privacy. CO Exposure Notifications can quickly and anonymously notify you if you’ve likely been exposed, allowing you to reduce risk for your loved ones, seek timely medical attention, and stay home. Find out more at addyourphone.com.

Mayor Michael Hancock announced two additional public health orders in Denver.
● Face coverings are now required in more spaces, including outside. Starting immediately, if you are outside and around other people, you must be wearing a face covering/mask.
● The number of non-related people allowed to gather has been reduced from 10 to 5. This includes public and private gatherings such as non-organized athletic events (i.e. basketball games at the park) and workplace settings. This does not include members of your household.
Neither of these Public Health orders apply to Denver Public Schools. DPS is working closely with the city to construct plans to protect Denver students, staff, and faculty.

Also see yesterday’s update - State Moves Denver Back to Level 3 Restrictions - CDPHE has moved the City and County of Denver, among other counties, to the more restrictive Safer at Home Dial Level 3 (10-27-20)

CPR - New Health Order Limits Personal Gatherings To 10 People From No More Than 2 Households In Most Counties (10-23-20). Also see amendment to the health order (download) (10-23-20)

 

 
Resources for Providers


JAMA - COVID-19: Beyond Tomorrow - Suicide Prevention in the COVID-19 Era: Transforming Threat Into Opportunity - Includes COVID-19–Specific Suicide Prevention Strategies (10-16-20)


PsychNews - Overwhelming Second Wave of Psychiatric Disorders Expected Due to Pandemic (10-14-20)


Mental Health America - 2020 State of Mental Health in America (download) - See “COVID-19 and Mental Health: 2020 Data” starting on page 33 - From April to September 2020, among people who screened with moderate to severe symptoms of anxiety or depression, 70 percent reported that one of the top three things contributing to their mental health concerns was loneliness or isolation.


JAMA - Harnessing Collaborative Care to Meet Mental Health Demands in the Era of COVID-19 (10-21-20)


PsychNews - Positive Psychology: Not a ‘Just Be Happy’ Approach to Physician Wellness in 2020 The COVID-19 pandemic has altered the way that many people cope with general stress, but there are still steps you can take to protect against burnout and stay connected to yourself, your loved ones, and community (10-8-20)


JAMA - Factors Associated With Mental Health Disorders Among University Students in France Confined During the COVID-19 Pandemic - Among risk factors identified, female or nonbinary gender, problems with income or housing, history of psychiatric follow-up, symptoms compatible with COVID-19, social isolation, and low quality of information received were associated with altered mental health (10-23-20). Also see CU Boulder commitment totals $1.8 million to expand student mental health and wellness (10-22-20)


Smithsonian Magazine - How Patients With Eating Disorders Have Been Affected by the Pandemic - A recent study suggests that worries related to Covid-19 may exacerbate conditions including anorexia and binge eating (10-13-20). Article links to recommendations - Eating Disorders and COVID-19: What Individuals and Families/Caregivers Need to Know


ActionPPE - "The Official Guide: When An Employee Tests Positive"

 

 
Resources for Patients


NPR - Sleepless Nights, Hair Loss and Cracked Teeth: Pandemic Stress Takes Its Toll (10-14-20)


HuffPost - 8 Tricks Sleep Experts Use When 2020 Anxiety Keeps Them Awake - The COVID-19 pandemic, election, racial injustice and more have made this year hell. Here's how the pros get rest during it all (10-20-20)


MSN - Feel like you’re losing control of life? Psychiatrist shares her advice (5 min video) (10-14-20)


NYT - What Scandinavians Can Teach Us About Embracing Winter - In the pandemic, rather than feeling depressed that the arrival of cold weather will mean you’ll be isolated indoors, try adopting a positive winter mind-set (10-15-20)


The Denver Foundation and the Colorado Health Institute - RSVP for the New Better: Ethical Leadership to Guide Our Pandemic Recovery Thursday, November 12, 11:30 a.m. to 12:30 p.m. (MST) - The panel discussion will focus on mental health and the impact of social isolation and anxiety brought about by physical distancing and how we will strive to create a new and better society following the COVID-19 pandemic.


5280 Magazine - "What It's Like to Experience Homelessness During a Global Pandemic" Life, loss, fear, and hope in one Denver homeless encampment as the novel coronavirus upended services for some of the city's most vulnerable citizens (10-2020). Also see Colorado Village Collaborative.


Washington Post - CDC expands definition of who is a ‘close contact’ of an individual with covid-19 - The new guidance is likely to have the biggest impact on schools, workplaces and other group settings since more people are likely to be considered at risk (10-21-20)


NPR - Got A COVID Problem? These 7 Women Changemakers Have A Solution (10-16-20)


NYT - 5 Ways Families Can Prepare as Coronavirus Cases Surge - As winter approaches, we still need to be vigilant about taking precautions (10-19-20)


National Geographic - CORONAVIRUS UPDATE: How to fight the COVID-19 'infodemic A guide to overcoming COVID-19 misinformation - False information about the pandemic is rampant, but seasoned defenders of climate science can offer tips for how to fight it (10-22-20)


TIA&TW - Modern Telepsychiatry and Depression (27 min video) - with CPS Member Jay Shore, MD (10-16-20)

 


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.


Thank you to our Platinum Partner for their support


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

Updates


CARES Act Provider Relief Funds - $20 Billion for Phase 3 General Distribution of Provider Relief Funds Beginning October 5, 2020. – HHS recently announced new funds for an expanded group of behavioral health providers including any psychiatrist whether or not they take insurance.  These funds are intended to assist providers who are confronting the rising need for treatment of mental health and substance use issues exacerbated by the COVID 19 pandemic.  HHS is urging all eligible providers to apply early.

Application can be made here: Provider Relief Fund Application and Attestation Portal.

Deadline: November 6, 2020

 

 
Resources for Providers


The Hour - Colorado sees drug overdose rise with virus-related stress Quotes CPS Member Carl Clark, MD (9-28-20)


Psychiatric Services - Clinical Risk Factors for COVID-19 Among People With Substance Use Disorders People with opioid use disorder and methamphetamine use disorder deserve particular attention, given the detrimental effects of long-term drug use on pulmonary function, other major organ systems, and the immune system (10-6-20)


Colorado Consortium for Prescription Drug Abuse Prevention - Register for the Virtual Addiction Medicine Symposium - Wednesday, October 21: 8:30 a.m. to 4 p.m. - Join healthcare providers from across Colorado as we explore the convergence of substance use disorder and current affairs affecting our nation. Local and national experts will discuss racial inequality as it relates to healthcare, the impacts COVID-19 has had on substance use disorder, including self-care for front line workers, the current methamphetamine and fentanyl epidemics, and reproductive health considerations for women with substance use disorder.


CDC Health Alert Network (HAN) Health Advisory - Recent HIV Clusters and Outbreaks Across the United States Among People Who Inject Drugs and Considerations During the COVID-19 Pandemic (10-5-20)


KFF - Mental Illnesses May Soon Be the Most Common Pre-Existing Conditions Because the prevalence of depression and anxiety disorders appears to have increased substantially since the start of the Coronavirus pandemic, if the ACA is repealed, mental illnesses could be the most common pre-existing conditions (10-8-20)


APA On-Demand Webinar - Exploring Treatment Options for Schizophrenia in an Era of Social Disruption. Features CPS Member Carl Clark, MD.


Denver Post - View the video of a Facebook Live conversation about the elevated rate of youth suicides in Colorado and how teens can better care for their mental health during the coronavirus pandemic. Features CCAPS member Dr. Casey Wolf.


JAMA - Association of a Prior Psychiatric Diagnosis With Mortality Among Hospitalized Patients With Coronavirus Disease 2019 (COVID-19) Infection Patients with a prior psychiatric diagnosis while hospitalized for COVID-19 had a higher mortality rate compared those without a psychiatric condition (9-30-20)


JAMA - Mental Health Disorders Related to COVID-19–Related Deaths (10-12-20)


Psychiatric Services - How to Mitigate the Mental Health Care Consequences of the COVID-19 Financial Crisis As the COVID-19 crisis wanes, federal, state, and local officials should devote increased resources to suicide prevention in the wake of unprecedented unemployment, rising suicide rates before the pandemic, and sharp increases in gun purchases that began in January 2020 (9-29-20)


CPR News - Burnout among Colorado health care workers is growing amid the coronavirus (10-9-20). Also see Psychiatric Services - The Mental Health of Frontline Health Care Providers During Pandemics: A Rapid Review of the Literature (10-6-20) and American Journal of Psychotherapy - Applying Psychotherapeutic Principles to Bolster Resilience Among Health Care Workers During the COVID-19 Pandemic (9-28-20)


World Health Organization (WHO) - COVID-19 Disrupting Mental Health Services in Most Countries, WHO Survey (10-5-20)

 

 
Resources for Patients


Yale Medicine - Taking Your 'Mental Health' Temperature During COVID-19 Strong emotions during the pandemic are normal, but some may find that their reactions grow worse over time. Yale doctors offer strategies for coping. Also see free app highlighted in article - COVID Coach includes mindfulness exercises, mood trackers, and other tools.


CNBC - Covid-19 isn’t going away — 6 ways to stay calmer and happier long-term


MHA - Mental Health and COVID-19 Information and Resources


The Colorado Sun - Opinion - Scientific innovation and trust in experts is our light at the end of the tunnel by Rep. Yadira Caraveo, a Colorado pediatrician (10-4-20)


Denver Workforce Services - RSVP for notifications about upcoming sessions of the “Now Hiring” webinar. If you’re looking for a job, tune in every Wednesday morning from 10am-10:30am to get tips and tricks on interviewing (via phone and online), resume assistance & social media help. Also includes information on new jobs, overview of Workforce Services, virtual job fairs, hiring events and more.


JAMA - Risk of COVID-19 During Air Travel (10-1-20)


KUNC - CDPHE Advises Getting Creative With Tricks And Treats This Halloween What’s the best way for your family to celebrate Halloween this year? The Colorado Department of Public Health and Environment is urging Coloradans to follow health and safety protocols now so as to avoid a COVID-19 spike at the end of the month (10-8-20)


APAF - Virtual Town Hall: What do Disruptive Behaviors Indicate? October 21st, 2020 from 6-7pm MT (8:00-9:00 pm ET). A discussion about what disruptive behaviors in youth mean, how to approach those behaviors as parents, school staff, and adults in communities, and how it relates to the School-to-Prison Pipeline. Also see What do Disruptive Behaviors Indicate? (download) a recently released resource that will guide the conversation.


JAMA - Current and COVID-19 Challenges With Childhood and Adolescent Sleep (9-28-20)


CNN - Lifetime Experiences Help Older Adults Build Resilience to Pandemic Trauma (10-6-20). Also see The Journals of Gerontology - Age Differences in Risk and Resilience Factors in COVID-19-Related Stress (8-3-20, online ahead of print)


NEJM - Lessons We’ve Learned — Covid-19 and the Undocumented Latinx Community (10-7-20)


Denverite - Why are Latinx residents in Denver still facing disproportionately higher COVID-19 infection and hospitalization rates? Latinx residents still make up more than half of all confirmed coronavirus cases and hospitalizations in the city — despite only comprising 30 percent of the population (10-9-20)


KFF - Lower Flu Vaccination Rates Among Black, Hispanic, and Low-Income Seniors Suggest Challenges for COVID-19 Vaccination Efforts (10-6-20)

 


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

 

 


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

 
Resources for Providers


COVID-19 and Grief (download) by CPS Member Nancy Arko, MD


Governor Polis Press Conference featuring CPS Member and current CCAPS President Chris Rogers, MD starting around minute 27 (9-29-20)


The Denver Channel - Another epidemic: "deaths of despair" from suicide, and teens are at risk, doctors say - Article and video interview with CPS Member and current CCAPS President Chris Rogers, MD (9-21-20)


NIH - Substance use disorders linked to COVID-19 susceptibility (9-14-20). JAMA - Analysis of Drug Test Results Before and After the US Declaration of a National Emergency Concerning the COVID-19 Outbreak offers information on specific drug use increases (9-18-20)


Psychiatric Services - A Marshall Plan for Children’s Mental Health After COVID-19 Something like a Marshall Plan for children’s mental health after COVID-19 will be essential to ensure that the next generation does not comprise the longest-living victims of the pandemic, with higher rates of anxiety, poverty, depression, suicide, and other negative consequences (9-16-20). Also see KFF - Children’s Health and Well Being During the Coronavirus Pandemic (9-24-20)


Psychiatric Services - Telepsychiatry, Hospitals, and the COVID-19 Pandemic (9-16-20)


NEJM Perspective - A Pandemic within a Pandemic — Intimate Partner Violence during Covid-19 This article serves as a reminder to screen patients for intimate partner violence (9-16-20)


PsychNews - College Students Struggle Amid Pandemic’s Uncertainty (9-23-20). Also see “Youth and COVID-19: Impacts on Jobs, Education, Rights, and Mental Well-Being” (download) and College Mental Health, Telepsychiatry: Best Practices, Policy Considerations & COVID-19 (download), a new resource developed by APA’s Committee on Telepsychiatry and APA's College Mental Health Caucus.


PsychNews - Tips on Reopening Psychiatric Practices During Pandemic Article includes information on the Interstate Medical Licensure Compact (IMLC) (9-10-20)


JAMA Viewpoint - Psychiatry and COVID-19 Article conclusion highlights the importance of collaboration between psychiatry and primary care and the need for additional resources (9-22/29-20)


KevinMD - In the age of misinformation, here’s how physicians can help [15 minute PODCAST] (9-22-20)


JAMA Viewpoint - COVID-19 and Human Trafficking—the Amplified Impact on Vulnerable Populations (9-21-20)

 

 
Resources for Patients


HuffPost - How To Create A Morning Routine That Reduces Anxiety And Stress The self-care rituals you practice in the morning can improve your mental health for the rest of the day (9-16-20)


NYT - What My Sled Dogs Taught Me About Planning for the Unknown (9-23-20)


Denver Post - Dating during COVID-19: What you need to know if you're single in Denver (9-17-20)


The Washington Post - Covid-19 etiquette: A comprehensive guide (9-10-20)


KHN - How Families Are Keeping Halloween From Turning Into a COVID Nightmare Quotes Dr. Heather Isaacson, a Colorado pediatrician who served in a focus group for a CCAPS project (9-23-20)

 


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 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