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Thank you to our Platinum Partner for their support

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.

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Thank you to our Platinum Partner for their support

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) Guidance Document: Electroconvulsive Therapy as an Essential Procedure Guidance Document: Use of Long-acting Injectables as a Clinically Necessary Treatment Guidance Document: Considerations for Healthcare Workers and Staff Exposed to COVID-19 Death and Dying Guidance Document: Considerations for Family and Other Personal Losses Due to COVID-19-Related Death Guidance Document: Psychiatrists Returning to Clinical Service Guidance Document: Redeployment of Psychiatrists to Medicine During a Pandemic Crisis Guidance Document: COVID-19 and Impact on Incarcerated Persons Living with Mental Illness Guidance Document: Moral Injury During the COVID-19 Pandemic Support for Permanent Expansion of Telehealth Regulations After COVID-19

 

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.

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August 19, 2020

Pregnancy and the Postpartum in a Pandemic

August 5, 2020

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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.

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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 answer 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: Stress & Trauma Toolkit for Treating Historically Marginalized Populations in a Changing Political and Social Environment - a toolkit with screening and treatment recommendations to help providers understand the unique circumstances facing historically marginalized populations and the impact that the current sociopolitical climate in the United States has on their mental health. Includes resources on the following patient populations: African Americans, Asian Americans, Hispanics, Indigenous People, Jewish Americans, LGBTQ, Muslims, Undocumented Immigrants, and Women. Register for free APA Course on Racism, Black Mental Health (1 CME credit, 60 minute on demand course) - This free e-learning module prepares psychiatrists to practice with an anti-racism framework in the care of all patients, and especially Black Americans. APA - Responding to Racism from Patients, Families, and Guests Towards Residents and Practicing Psychiatrists (1 CME credit, 60 minute on demand course) (7-7-20). APA Presidential Task Force to Address Structural Racism Throughout Psychiatry webpage which includes APA position statements, webinar info, PsychNews articles and more. Also see Member Town Hall: APA Addresses Structural Racism, Part One (6-5-20), PsychNews - Black Psychiatrists Call on White Colleagues To Dismantle Racism in Profession (6-23-20) and Recommended Readings.

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.

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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

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 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.

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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)

 

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June 24, 2020

Loneliness

Dear Colleagues,

Now into our fourth month of the pandemic lifestyle, the novelty has worn thin. The trips I had planned for 2020 are all cancelled, the long-weekend family reunion to celebrate a speed-limit birthday (although the only place in the country you may go this fast legally is on Texas State Highway 130) has been replaced by a 90 minute Zoom call, and annual traditions with friends are scrapped. The most difficult part for me is not knowing when I will see certain people again. I realize I am lucky: I live with a partner I love and the best dog in the universe. The pandemic is creating unprecedented disruption in social connectedness for all of us, but especially for those who live alone. I am particularly concerned about seniors and adolescents.

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

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

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

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

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

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

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

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

 

Colorado Psychiatric Society COVID-19 Resource List

 June 24, 2020

Resources for Providers

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

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

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

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

Is it okay to laugh during a pandemic?

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

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

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

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

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

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

 

Resources for Patients

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

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

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

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

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

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

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

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

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

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

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

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

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

Virtual Narcotics Anonymous Meetings

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

 

Key Resources

CDC Website on COVID-19

Colorado Department of Public Health & Environment COVID-19       (including Resources for local public health agencies and health care providers)

Governor’s Facebook Page

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

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

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June 17, 2020

Twin Pandemics

Dear Colleagues,

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

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

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

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

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

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

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

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

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 June 17, 2020

Updates

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

 

Resources for Providers

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

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

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

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

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

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

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

HCPF - Help Us Spread the Word: Become A Health First Colorado Provider Today! Currently, the Department is offering incentives to increase provider enrollment and help provide an important public service. In an effort to increase provider enrollment, the Department is: Allowing temporary enrollment for providers during the federally designated COVID-19 emergency.  Waiving the application fee and fingerprinting process for applicable providers.  Waiving site surveys for applicable providers.

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

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

 

Resources for Patients

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

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

NYT - Your 2020 Virtual Pride Guide

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

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

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

NAMI COVID-19 Resource and Information Guide

NYT - 5 Rules to Live By During a Pandemic

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

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

 

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June 10, 2020

Suicide Risk and Prevention During the Pandemic 

Dear Colleagues,

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

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

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

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

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

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

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

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

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 June 10, 2020

Updates

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

 

Resources for Providers

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

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

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

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

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

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

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

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

 

Resources for Patients

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

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

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

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

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

 

Key Resources

CDC Website on COVID-19

Colorado Department of Public Health & Environment COVID-19       (including Resources for local public health agencies and health care providers)

Governor’s Facebook Page

 

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

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June 3, 2020

Psychiatric Disorders and the Pandemic

Dear Colleagues,

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

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

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

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

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

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

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

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

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

Stay healthy,

Claire Zilber, MD, DFAPA
CPS President

Colorado Psychiatric Society COVID-19 Resource List

 June 3, 2020

Updates

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

 

Resources for Providers

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

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

CDPHE - How to conduct a facility health screening.

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

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

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

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

 

Resources for Patients

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

Denver Post - Colorado-themed coloring pages

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

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

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

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

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

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