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Surge in firearm sales tied to COVID-19 fears, uncertainty presents risks
Use gentle assumptions and focus on home access to elicit positive answers.
In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.
In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.1 More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.
The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.4 That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.7 Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.8 It seems reasonable to expect such trends not to be diminished by recent events.
Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.
- Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
- Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
- Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
- Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”
References
1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.
2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.
3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.
4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.
5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.
6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.
7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.
8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).
Use gentle assumptions and focus on home access to elicit positive answers.
Use gentle assumptions and focus on home access to elicit positive answers.
In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.
In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.1 More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.
The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.4 That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.7 Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.8 It seems reasonable to expect such trends not to be diminished by recent events.
Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.
- Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
- Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
- Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
- Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”
References
1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.
2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.
3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.
4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.
5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.
6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.
7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.
8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).
In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.
In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.1 More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.
The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.4 That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.7 Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.8 It seems reasonable to expect such trends not to be diminished by recent events.
Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.
- Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
- Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
- Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
- Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”
References
1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.
2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.
3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.
4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.
5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.
6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.
7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.
8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).
Failure is not an option
Gene Kranz was the NASA Flight Director during the Gemini and Apollo space flights, including Apollo 11 (moon landing) and Apollo 13. He has written: “When bad things happened, we just calmly laid out all the options and failure was not one of them. We never panicked and we never gave up on finding a solution.”
2019-nCoV (coronavirus, COVID-19) will define this generation of health care providers. First identified in Wuhan, China, in December 2019 and first appearing in the United States on January 19, 2020 (NEJM 2020;382:929). COVID-19 is a coronavirus similar to SARS and MERS. The U.S. Surgeon General and multiple endoscopy societies have recommended (strongly) that elective surgical and endoscopy procedures be deferred. Availability of testing has been slow, but many centers now have developed testing capabilities (including drive-through testing) with 6-hour result turnaround. We do not know the full pathophysiology, R0 (number of secondary cases attributed to an index infection), ease of community transmission, risk to providers, definition of people at high risk (for both acquisition and complications), and much key information n to base recommendations.
Health system and practice leaders do not yet have sufficient information to know which patients to defer, which patients should still be seen, visitor policies, how to segregate waiting rooms, or how to protect providers. Despite a lack of definitive knowledge, we must make critical decisions and know that recommendations can change hourly. As the Chief Clinical Officer at Michigan Medicine, I am spending 16 hours a day immersed in these decisions and find that one of my critical jobs is to keep people from panicking.
Schools, bars, restaurants, churches and other public gathering places are closing. Three countries (to date) have instituted complete quarantine. Digestive Disease Week® has been cancelled. We are entering a time in which normal life is altered and many changes will open up our thinking about long-term alternative processes.
COVID-19 will define this generation. The public will understand the real need for science, policies based on real facts, robust public health systems, and leaders who inspire confidence based on expert guidance. And, I believe we will see gastroenterologists, health systems, hospitals, and practices all showing us what our “finest hours” look like.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Gene Kranz was the NASA Flight Director during the Gemini and Apollo space flights, including Apollo 11 (moon landing) and Apollo 13. He has written: “When bad things happened, we just calmly laid out all the options and failure was not one of them. We never panicked and we never gave up on finding a solution.”
2019-nCoV (coronavirus, COVID-19) will define this generation of health care providers. First identified in Wuhan, China, in December 2019 and first appearing in the United States on January 19, 2020 (NEJM 2020;382:929). COVID-19 is a coronavirus similar to SARS and MERS. The U.S. Surgeon General and multiple endoscopy societies have recommended (strongly) that elective surgical and endoscopy procedures be deferred. Availability of testing has been slow, but many centers now have developed testing capabilities (including drive-through testing) with 6-hour result turnaround. We do not know the full pathophysiology, R0 (number of secondary cases attributed to an index infection), ease of community transmission, risk to providers, definition of people at high risk (for both acquisition and complications), and much key information n to base recommendations.
Health system and practice leaders do not yet have sufficient information to know which patients to defer, which patients should still be seen, visitor policies, how to segregate waiting rooms, or how to protect providers. Despite a lack of definitive knowledge, we must make critical decisions and know that recommendations can change hourly. As the Chief Clinical Officer at Michigan Medicine, I am spending 16 hours a day immersed in these decisions and find that one of my critical jobs is to keep people from panicking.
Schools, bars, restaurants, churches and other public gathering places are closing. Three countries (to date) have instituted complete quarantine. Digestive Disease Week® has been cancelled. We are entering a time in which normal life is altered and many changes will open up our thinking about long-term alternative processes.
COVID-19 will define this generation. The public will understand the real need for science, policies based on real facts, robust public health systems, and leaders who inspire confidence based on expert guidance. And, I believe we will see gastroenterologists, health systems, hospitals, and practices all showing us what our “finest hours” look like.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Gene Kranz was the NASA Flight Director during the Gemini and Apollo space flights, including Apollo 11 (moon landing) and Apollo 13. He has written: “When bad things happened, we just calmly laid out all the options and failure was not one of them. We never panicked and we never gave up on finding a solution.”
2019-nCoV (coronavirus, COVID-19) will define this generation of health care providers. First identified in Wuhan, China, in December 2019 and first appearing in the United States on January 19, 2020 (NEJM 2020;382:929). COVID-19 is a coronavirus similar to SARS and MERS. The U.S. Surgeon General and multiple endoscopy societies have recommended (strongly) that elective surgical and endoscopy procedures be deferred. Availability of testing has been slow, but many centers now have developed testing capabilities (including drive-through testing) with 6-hour result turnaround. We do not know the full pathophysiology, R0 (number of secondary cases attributed to an index infection), ease of community transmission, risk to providers, definition of people at high risk (for both acquisition and complications), and much key information n to base recommendations.
Health system and practice leaders do not yet have sufficient information to know which patients to defer, which patients should still be seen, visitor policies, how to segregate waiting rooms, or how to protect providers. Despite a lack of definitive knowledge, we must make critical decisions and know that recommendations can change hourly. As the Chief Clinical Officer at Michigan Medicine, I am spending 16 hours a day immersed in these decisions and find that one of my critical jobs is to keep people from panicking.
Schools, bars, restaurants, churches and other public gathering places are closing. Three countries (to date) have instituted complete quarantine. Digestive Disease Week® has been cancelled. We are entering a time in which normal life is altered and many changes will open up our thinking about long-term alternative processes.
COVID-19 will define this generation. The public will understand the real need for science, policies based on real facts, robust public health systems, and leaders who inspire confidence based on expert guidance. And, I believe we will see gastroenterologists, health systems, hospitals, and practices all showing us what our “finest hours” look like.
John I. Allen, MD, MBA, AGAF
Editor in Chief
The Return of the Plague: A Primer on Pandemic Ethics
I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.
For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.1
In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).2 Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.3 In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.4
This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.5 As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.6 Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.7 Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.
The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.8
The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.
The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”9 In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.
The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”10 Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.
The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.11
The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.11
There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.
1. Garrett L. The Coming Plague: Newly Emerging Diseases in a World Out of Balance. New York: Penguin Books, 1995.
2. World Health Organization. FAQS: H5N1 influenza. https://www.who.int/influenza/human_animal_interface/avian_influenza/h5n1_research/faqs/en/. Accessed March 20, 2020.
3. Centers for Disease Control and Prevention. 2009 H1N1 pandemic. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html. Updated June 11, 2019. Accessed March 20, 2020.
4. Centers for Disease Control and Prevention. 2014-2016 Ebola outbreak in West Africa. https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html. Updated March 8, 2019. March 20, 2020.
5. Pier GB. On the greatly exaggerated reports of the death of infectious diseases. Clin Infect Dis. 2008;47(8):1113-1114.
6. Digital staff. Coronavirus Australia: researchers say they are close to a cure. https://7news.com.au/sunrise/on-the-show/coronavirus-australia-researchers-say-theyre-close-to-a-cure-c-746508. Published March 15, 2020. Accessed March 20, 2020.
7. Hoetz P. Testimony of Peter Hoetz, M.D, Ph.D. Before the House Committee on Space, Science and Technology of the United States House of Representatives, March 5, 2020. https://science.house.gov/imo/media/doc/Hotez%20Testimony.pdf. Accessed March 15, 2020.
8. Ferriman A. BMJ readers choose the “sanitary revolution” as greatest medical advance since 1840. BMJ. 2007;334(7585):111.
9. Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press; 2002.
10. Trump DJ. Proclamation on declaring a national emergency concerning the novel coronavirus (COVID-19) disease outbreak. https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/. Published March 13, 2020. Accessed March 20, 2020.
11. US Department of Veterans Affairs, Veterans Health Administration, National Center for Ethics in Health Care. Meeting the challenge of pandemic influenza: ethical guidance for leaders and health care professionals in the Veterans Health Administration. https://www.ethics.va.gov/activities/pandemic_influenza_preparedness.asp. Published July 2010. Accessed March 20, 2020.
I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.
For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.1
In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).2 Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.3 In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.4
This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.5 As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.6 Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.7 Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.
The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.8
The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.
The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”9 In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.
The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”10 Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.
The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.11
The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.11
There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.
I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.
For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.1
In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).2 Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.3 In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.4
This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.5 As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.6 Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.7 Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.
The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.8
The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.
The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”9 In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.
The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”10 Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.
The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.11
The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.11
There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.
1. Garrett L. The Coming Plague: Newly Emerging Diseases in a World Out of Balance. New York: Penguin Books, 1995.
2. World Health Organization. FAQS: H5N1 influenza. https://www.who.int/influenza/human_animal_interface/avian_influenza/h5n1_research/faqs/en/. Accessed March 20, 2020.
3. Centers for Disease Control and Prevention. 2009 H1N1 pandemic. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html. Updated June 11, 2019. Accessed March 20, 2020.
4. Centers for Disease Control and Prevention. 2014-2016 Ebola outbreak in West Africa. https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html. Updated March 8, 2019. March 20, 2020.
5. Pier GB. On the greatly exaggerated reports of the death of infectious diseases. Clin Infect Dis. 2008;47(8):1113-1114.
6. Digital staff. Coronavirus Australia: researchers say they are close to a cure. https://7news.com.au/sunrise/on-the-show/coronavirus-australia-researchers-say-theyre-close-to-a-cure-c-746508. Published March 15, 2020. Accessed March 20, 2020.
7. Hoetz P. Testimony of Peter Hoetz, M.D, Ph.D. Before the House Committee on Space, Science and Technology of the United States House of Representatives, March 5, 2020. https://science.house.gov/imo/media/doc/Hotez%20Testimony.pdf. Accessed March 15, 2020.
8. Ferriman A. BMJ readers choose the “sanitary revolution” as greatest medical advance since 1840. BMJ. 2007;334(7585):111.
9. Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press; 2002.
10. Trump DJ. Proclamation on declaring a national emergency concerning the novel coronavirus (COVID-19) disease outbreak. https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/. Published March 13, 2020. Accessed March 20, 2020.
11. US Department of Veterans Affairs, Veterans Health Administration, National Center for Ethics in Health Care. Meeting the challenge of pandemic influenza: ethical guidance for leaders and health care professionals in the Veterans Health Administration. https://www.ethics.va.gov/activities/pandemic_influenza_preparedness.asp. Published July 2010. Accessed March 20, 2020.
1. Garrett L. The Coming Plague: Newly Emerging Diseases in a World Out of Balance. New York: Penguin Books, 1995.
2. World Health Organization. FAQS: H5N1 influenza. https://www.who.int/influenza/human_animal_interface/avian_influenza/h5n1_research/faqs/en/. Accessed March 20, 2020.
3. Centers for Disease Control and Prevention. 2009 H1N1 pandemic. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html. Updated June 11, 2019. Accessed March 20, 2020.
4. Centers for Disease Control and Prevention. 2014-2016 Ebola outbreak in West Africa. https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html. Updated March 8, 2019. March 20, 2020.
5. Pier GB. On the greatly exaggerated reports of the death of infectious diseases. Clin Infect Dis. 2008;47(8):1113-1114.
6. Digital staff. Coronavirus Australia: researchers say they are close to a cure. https://7news.com.au/sunrise/on-the-show/coronavirus-australia-researchers-say-theyre-close-to-a-cure-c-746508. Published March 15, 2020. Accessed March 20, 2020.
7. Hoetz P. Testimony of Peter Hoetz, M.D, Ph.D. Before the House Committee on Space, Science and Technology of the United States House of Representatives, March 5, 2020. https://science.house.gov/imo/media/doc/Hotez%20Testimony.pdf. Accessed March 15, 2020.
8. Ferriman A. BMJ readers choose the “sanitary revolution” as greatest medical advance since 1840. BMJ. 2007;334(7585):111.
9. Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press; 2002.
10. Trump DJ. Proclamation on declaring a national emergency concerning the novel coronavirus (COVID-19) disease outbreak. https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/. Published March 13, 2020. Accessed March 20, 2020.
11. US Department of Veterans Affairs, Veterans Health Administration, National Center for Ethics in Health Care. Meeting the challenge of pandemic influenza: ethical guidance for leaders and health care professionals in the Veterans Health Administration. https://www.ethics.va.gov/activities/pandemic_influenza_preparedness.asp. Published July 2010. Accessed March 20, 2020.
‘We will get through this’: Advice for lessening your pandemic anxiety
The COVID-19 pandemic is an experience that is unprecedented in our lifetime. It is having a pervasive effect due to how mysterious, potentially dangerous, and sustained it is. We don’t know how bad it’s going to get or how long it’s going to last. We have natural disasters like hurricanes and earthquakes, but they are limited in time and scope. But this global pandemic is something we can’t put our arms around just yet, breeding uncertainty, worry, and fear. This is where mental health professionals need to come in.
The populations being affected by this pandemic can be placed into different groups on the basis of their mental health consequences and needs. First you have, for lack of a better term, “the worried well.” These are people with no preexisting mental disorder who are naturally worried by this and are trying to take appropriate actions to protect themselves and prepare. For such individuals, the equivalent of mental health first-aid should be useful (we’ll come back to that in a moment). Given the proper guidance and sources of information, most such people should be able to manage the anxiety, worry, and dysphoria associated with this critical pandemic.
Then there are those who have preexisting mental conditions related to mood, anxiety, stress, or obsessive tendencies. They are probably going to have an increase in their symptoms, and as such, a corresponding need for adjusting treatment. This may require an increase in their existing medications or the addition of an ad hoc medication, or perhaps more frequent contact with their doctor or therapist.
Because travel and direct visitation is discouraged at the moment, virtual methods of communication should be used to speak with these patients. Such methods have long existed but haven’t been adopted in large numbers; this may be the impetus to finally make it happen. Using the telephone, FaceTime, Skype, WebEx, Zoom, and other means of videoconferencing should be feasible. As billing procedures are being adapted for this moment, there’s no reason why individuals shouldn’t be able to contact their mental health provider.
Substance abuse is also a condition vulnerable to the stress effects of this pandemic. This will prompt or tempt those to use substances that they’ve abused or turned to in the past as a way of self-medicating and assuaging their anxiety and worry.
It’s possible that the pandemic could find its way into delusions or exacerbate symptoms, but somewhat paradoxically, people with serious mental illnesses often respond more calmly to crises than do individuals without them. As a result, the number of these patients requiring emergency room admission for possible exacerbation of symptoms is probably not going to be that much greater than normal.
How to Cope With an Unprecedented Situation
For the worried well and for the clinicians who have understandable fears about exposure, there are several things you can try to manage your anxiety. There are concentric circles of concern that you have to maintain. Think of it like the instructions on an airplane when, if there’s a drop in cabin pressure, you’re asked to apply your own oxygen mask first before placing one on your child. In the same way, you must first think about protecting yourself by limiting your exposure and monitoring your own physical state for any symptoms. But then you must be concerned about your family, your friends, and also society. This is a situation where the impulse and the ethos of worrying about your fellow persons—being your brother’s keeper—is imperative.
The epidemic has been successfully managed in some countries, like Singapore and China, which, once they got on top of it, were able to limit contagion in a very dramatic way. But these are authoritarian governments. The United States doesn’t work that way, which is what makes appealing to the principle of caring for others so crucial. You can protect yourself, but if other people aren’t also protected, it may not matter. You have to worry not just about yourself but about everyone else.
When it comes to stress management, I recommend not catastrophizing or watching the news media 24/7. Distract yourself with other work or recreational activities. Reach out and communicate—virtually, of course—with friends, family, and healthcare providers as needed. Staying in touch acts not just as a diversion but also as an outlet for assuaging your feelings, your sense of being in this alone, feeling isolated.
There are also cognitive reframing mechanisms you can employ. Consider that although this is bad, some countries have already gone through it. And we’ll get through it too. You’ll understandably ask yourself what it would mean if you were to be exposed. In most cases you can say, “I’m going to have the flu and symptoms that are not going to be pleasant, but I’ve had the flu or serious sickness before.”
Remember that there are already antiretroviral treatments being tested in clinical trials and showing efficacy. It’s good to know that before this pandemic ends, some of these treatments will probably be clinically applied, mostly to those who are severely affected and in intensive care.
Diagnose yourself. Monitor your state. Determine whether the stress is really having an impact on you. Is it affecting your sleep, appetite, concentration, mood? And if you do have a preexisting psychiatric condition, don’t feel afraid to reach out to your mental health provider. Understand that you’re going to be anxious, which may aggravate your symptoms and require an adjustment in your treatment. That’s okay. It’s to be expected and your provider should be available to help you.
Controlling this outbreak via the same epidemiologic infectious disease prevention guidance that works in authoritarian societies is not going to be applicable here because of the liberties that we experience in American society. What will determine our success is the belief that we’re in this together, that we’re going to help each other. We should be proud of that, as it shows how Americans and people around the world stand up in situations like this.
Let’s also note that even though everybody is affected and undergoing previously unimaginable levels of anticipated stress and dislocation, it’s the healthcare providers who are really on the frontlines. They’re under tremendous pressure to continue to perform heroically, at great risk to themselves. They deserve a real debt of gratitude.
We will get through this, but as we do, it will not end until we’ve undergone an extreme test of our character. I certainly hope and trust that we will be up to it.
Dr. Jeffrey A. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association.
Disclosure: Jeffrey A. Lieberman, MD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Clintara; Intracellular Therapies. Received research grant from Alkermes; Biomarin; EnVivo/Forum; Genentech; Novartis/Novation; Sunovion. Patent: Repligen.
This article first appeared on Medscape.com.
The COVID-19 pandemic is an experience that is unprecedented in our lifetime. It is having a pervasive effect due to how mysterious, potentially dangerous, and sustained it is. We don’t know how bad it’s going to get or how long it’s going to last. We have natural disasters like hurricanes and earthquakes, but they are limited in time and scope. But this global pandemic is something we can’t put our arms around just yet, breeding uncertainty, worry, and fear. This is where mental health professionals need to come in.
The populations being affected by this pandemic can be placed into different groups on the basis of their mental health consequences and needs. First you have, for lack of a better term, “the worried well.” These are people with no preexisting mental disorder who are naturally worried by this and are trying to take appropriate actions to protect themselves and prepare. For such individuals, the equivalent of mental health first-aid should be useful (we’ll come back to that in a moment). Given the proper guidance and sources of information, most such people should be able to manage the anxiety, worry, and dysphoria associated with this critical pandemic.
Then there are those who have preexisting mental conditions related to mood, anxiety, stress, or obsessive tendencies. They are probably going to have an increase in their symptoms, and as such, a corresponding need for adjusting treatment. This may require an increase in their existing medications or the addition of an ad hoc medication, or perhaps more frequent contact with their doctor or therapist.
Because travel and direct visitation is discouraged at the moment, virtual methods of communication should be used to speak with these patients. Such methods have long existed but haven’t been adopted in large numbers; this may be the impetus to finally make it happen. Using the telephone, FaceTime, Skype, WebEx, Zoom, and other means of videoconferencing should be feasible. As billing procedures are being adapted for this moment, there’s no reason why individuals shouldn’t be able to contact their mental health provider.
Substance abuse is also a condition vulnerable to the stress effects of this pandemic. This will prompt or tempt those to use substances that they’ve abused or turned to in the past as a way of self-medicating and assuaging their anxiety and worry.
It’s possible that the pandemic could find its way into delusions or exacerbate symptoms, but somewhat paradoxically, people with serious mental illnesses often respond more calmly to crises than do individuals without them. As a result, the number of these patients requiring emergency room admission for possible exacerbation of symptoms is probably not going to be that much greater than normal.
How to Cope With an Unprecedented Situation
For the worried well and for the clinicians who have understandable fears about exposure, there are several things you can try to manage your anxiety. There are concentric circles of concern that you have to maintain. Think of it like the instructions on an airplane when, if there’s a drop in cabin pressure, you’re asked to apply your own oxygen mask first before placing one on your child. In the same way, you must first think about protecting yourself by limiting your exposure and monitoring your own physical state for any symptoms. But then you must be concerned about your family, your friends, and also society. This is a situation where the impulse and the ethos of worrying about your fellow persons—being your brother’s keeper—is imperative.
The epidemic has been successfully managed in some countries, like Singapore and China, which, once they got on top of it, were able to limit contagion in a very dramatic way. But these are authoritarian governments. The United States doesn’t work that way, which is what makes appealing to the principle of caring for others so crucial. You can protect yourself, but if other people aren’t also protected, it may not matter. You have to worry not just about yourself but about everyone else.
When it comes to stress management, I recommend not catastrophizing or watching the news media 24/7. Distract yourself with other work or recreational activities. Reach out and communicate—virtually, of course—with friends, family, and healthcare providers as needed. Staying in touch acts not just as a diversion but also as an outlet for assuaging your feelings, your sense of being in this alone, feeling isolated.
There are also cognitive reframing mechanisms you can employ. Consider that although this is bad, some countries have already gone through it. And we’ll get through it too. You’ll understandably ask yourself what it would mean if you were to be exposed. In most cases you can say, “I’m going to have the flu and symptoms that are not going to be pleasant, but I’ve had the flu or serious sickness before.”
Remember that there are already antiretroviral treatments being tested in clinical trials and showing efficacy. It’s good to know that before this pandemic ends, some of these treatments will probably be clinically applied, mostly to those who are severely affected and in intensive care.
Diagnose yourself. Monitor your state. Determine whether the stress is really having an impact on you. Is it affecting your sleep, appetite, concentration, mood? And if you do have a preexisting psychiatric condition, don’t feel afraid to reach out to your mental health provider. Understand that you’re going to be anxious, which may aggravate your symptoms and require an adjustment in your treatment. That’s okay. It’s to be expected and your provider should be available to help you.
Controlling this outbreak via the same epidemiologic infectious disease prevention guidance that works in authoritarian societies is not going to be applicable here because of the liberties that we experience in American society. What will determine our success is the belief that we’re in this together, that we’re going to help each other. We should be proud of that, as it shows how Americans and people around the world stand up in situations like this.
Let’s also note that even though everybody is affected and undergoing previously unimaginable levels of anticipated stress and dislocation, it’s the healthcare providers who are really on the frontlines. They’re under tremendous pressure to continue to perform heroically, at great risk to themselves. They deserve a real debt of gratitude.
We will get through this, but as we do, it will not end until we’ve undergone an extreme test of our character. I certainly hope and trust that we will be up to it.
Dr. Jeffrey A. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association.
Disclosure: Jeffrey A. Lieberman, MD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Clintara; Intracellular Therapies. Received research grant from Alkermes; Biomarin; EnVivo/Forum; Genentech; Novartis/Novation; Sunovion. Patent: Repligen.
This article first appeared on Medscape.com.
The COVID-19 pandemic is an experience that is unprecedented in our lifetime. It is having a pervasive effect due to how mysterious, potentially dangerous, and sustained it is. We don’t know how bad it’s going to get or how long it’s going to last. We have natural disasters like hurricanes and earthquakes, but they are limited in time and scope. But this global pandemic is something we can’t put our arms around just yet, breeding uncertainty, worry, and fear. This is where mental health professionals need to come in.
The populations being affected by this pandemic can be placed into different groups on the basis of their mental health consequences and needs. First you have, for lack of a better term, “the worried well.” These are people with no preexisting mental disorder who are naturally worried by this and are trying to take appropriate actions to protect themselves and prepare. For such individuals, the equivalent of mental health first-aid should be useful (we’ll come back to that in a moment). Given the proper guidance and sources of information, most such people should be able to manage the anxiety, worry, and dysphoria associated with this critical pandemic.
Then there are those who have preexisting mental conditions related to mood, anxiety, stress, or obsessive tendencies. They are probably going to have an increase in their symptoms, and as such, a corresponding need for adjusting treatment. This may require an increase in their existing medications or the addition of an ad hoc medication, or perhaps more frequent contact with their doctor or therapist.
Because travel and direct visitation is discouraged at the moment, virtual methods of communication should be used to speak with these patients. Such methods have long existed but haven’t been adopted in large numbers; this may be the impetus to finally make it happen. Using the telephone, FaceTime, Skype, WebEx, Zoom, and other means of videoconferencing should be feasible. As billing procedures are being adapted for this moment, there’s no reason why individuals shouldn’t be able to contact their mental health provider.
Substance abuse is also a condition vulnerable to the stress effects of this pandemic. This will prompt or tempt those to use substances that they’ve abused or turned to in the past as a way of self-medicating and assuaging their anxiety and worry.
It’s possible that the pandemic could find its way into delusions or exacerbate symptoms, but somewhat paradoxically, people with serious mental illnesses often respond more calmly to crises than do individuals without them. As a result, the number of these patients requiring emergency room admission for possible exacerbation of symptoms is probably not going to be that much greater than normal.
How to Cope With an Unprecedented Situation
For the worried well and for the clinicians who have understandable fears about exposure, there are several things you can try to manage your anxiety. There are concentric circles of concern that you have to maintain. Think of it like the instructions on an airplane when, if there’s a drop in cabin pressure, you’re asked to apply your own oxygen mask first before placing one on your child. In the same way, you must first think about protecting yourself by limiting your exposure and monitoring your own physical state for any symptoms. But then you must be concerned about your family, your friends, and also society. This is a situation where the impulse and the ethos of worrying about your fellow persons—being your brother’s keeper—is imperative.
The epidemic has been successfully managed in some countries, like Singapore and China, which, once they got on top of it, were able to limit contagion in a very dramatic way. But these are authoritarian governments. The United States doesn’t work that way, which is what makes appealing to the principle of caring for others so crucial. You can protect yourself, but if other people aren’t also protected, it may not matter. You have to worry not just about yourself but about everyone else.
When it comes to stress management, I recommend not catastrophizing or watching the news media 24/7. Distract yourself with other work or recreational activities. Reach out and communicate—virtually, of course—with friends, family, and healthcare providers as needed. Staying in touch acts not just as a diversion but also as an outlet for assuaging your feelings, your sense of being in this alone, feeling isolated.
There are also cognitive reframing mechanisms you can employ. Consider that although this is bad, some countries have already gone through it. And we’ll get through it too. You’ll understandably ask yourself what it would mean if you were to be exposed. In most cases you can say, “I’m going to have the flu and symptoms that are not going to be pleasant, but I’ve had the flu or serious sickness before.”
Remember that there are already antiretroviral treatments being tested in clinical trials and showing efficacy. It’s good to know that before this pandemic ends, some of these treatments will probably be clinically applied, mostly to those who are severely affected and in intensive care.
Diagnose yourself. Monitor your state. Determine whether the stress is really having an impact on you. Is it affecting your sleep, appetite, concentration, mood? And if you do have a preexisting psychiatric condition, don’t feel afraid to reach out to your mental health provider. Understand that you’re going to be anxious, which may aggravate your symptoms and require an adjustment in your treatment. That’s okay. It’s to be expected and your provider should be available to help you.
Controlling this outbreak via the same epidemiologic infectious disease prevention guidance that works in authoritarian societies is not going to be applicable here because of the liberties that we experience in American society. What will determine our success is the belief that we’re in this together, that we’re going to help each other. We should be proud of that, as it shows how Americans and people around the world stand up in situations like this.
Let’s also note that even though everybody is affected and undergoing previously unimaginable levels of anticipated stress and dislocation, it’s the healthcare providers who are really on the frontlines. They’re under tremendous pressure to continue to perform heroically, at great risk to themselves. They deserve a real debt of gratitude.
We will get through this, but as we do, it will not end until we’ve undergone an extreme test of our character. I certainly hope and trust that we will be up to it.
Dr. Jeffrey A. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association.
Disclosure: Jeffrey A. Lieberman, MD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Clintara; Intracellular Therapies. Received research grant from Alkermes; Biomarin; EnVivo/Forum; Genentech; Novartis/Novation; Sunovion. Patent: Repligen.
This article first appeared on Medscape.com.
Sunshine on my shoulders
On March 26, 2020, it’s hard to write or think of anything beyond the COVID-19 pandemic. Those of you who are on the front lines of the battle may find it strange that I am just a bit envious. Having stepped back from clinical medicine nearly a decade ago, it is frustrating to feel that there is little I can do to help other than offering to venture into the grocery store to shop for friends and neighbors who feel more vulnerable than I do.
Here in Maine, we are blessed by geographic isolation that for the moment seems to have damped the surge from the metropolitan centers to our south. But, the virus is here and, as the state with the oldest population, we are beginning to be affected.
For nearly a century, we could count on the outhouses here in Maine would be stocked with outdated Sears Roebucks catalogs when toilet paper was in short supply. Many outhouses remain but Sears Roebucks and its catalogs have disappeared from the landscape. I take a little comfort in the learning that I’m not the only human on the planet who can envision the horror of a week or even a day without toilet paper.
So I am left to sit on the sidelines and watch how my fellow Mainers are coping with the anxiety, depression, and loneliness that come with the forced social isolation. It is pretty clear that walking outside has become the coping strategy of choice. On a usual March day the walkers comprise a skimpy mix of dog walkers and wannabe arctic explorers testing the weather-defying capabilities of their high-tech outerwear. But, to say the least, this is not a usual March and the number of walkers has surged bolstered by gym rats forced off their sweat-drenched ellipticals and treadmills.
This increase in outdoor activity is clearly perceptible even on an overcast day, but it is far less than one would expect given the magnitude of the disruption to everyone’s routines. But, when the sun comes out! The doors fly open and onto the sidewalks and quiet rural roads spill scores of people I haven’t seen for months and in some cases decades. One can almost hear John Denver singing “sunshine on my shoulders makes me happy.” Everyone is smiling and waving to each other. It feels as though the community has, at least for a few hours, been able to throw off the burden of angst that the pandemic laid on us.
There has been a good bit of research about seasonal affective disorder, and I suspect that almost everyone has heard about the value of sunshine for depression. But it is unfortunate that the psychological benefits of just being outdoors – even on an overcast day – has gone pretty much unpublicized. As part of their marketing strategy, a local company that specializes in recreational clothing and gear is encouraging its customers to become “outsiders.” It may be that the pandemic will make more people realize the psychological benefits of being active outside. As physicians we should continue to encourage our patients to be more active and remind them that they don’t need to wait for a sunny day to do so.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no relevant financial disclosures. Email him at [email protected].
On March 26, 2020, it’s hard to write or think of anything beyond the COVID-19 pandemic. Those of you who are on the front lines of the battle may find it strange that I am just a bit envious. Having stepped back from clinical medicine nearly a decade ago, it is frustrating to feel that there is little I can do to help other than offering to venture into the grocery store to shop for friends and neighbors who feel more vulnerable than I do.
Here in Maine, we are blessed by geographic isolation that for the moment seems to have damped the surge from the metropolitan centers to our south. But, the virus is here and, as the state with the oldest population, we are beginning to be affected.
For nearly a century, we could count on the outhouses here in Maine would be stocked with outdated Sears Roebucks catalogs when toilet paper was in short supply. Many outhouses remain but Sears Roebucks and its catalogs have disappeared from the landscape. I take a little comfort in the learning that I’m not the only human on the planet who can envision the horror of a week or even a day without toilet paper.
So I am left to sit on the sidelines and watch how my fellow Mainers are coping with the anxiety, depression, and loneliness that come with the forced social isolation. It is pretty clear that walking outside has become the coping strategy of choice. On a usual March day the walkers comprise a skimpy mix of dog walkers and wannabe arctic explorers testing the weather-defying capabilities of their high-tech outerwear. But, to say the least, this is not a usual March and the number of walkers has surged bolstered by gym rats forced off their sweat-drenched ellipticals and treadmills.
This increase in outdoor activity is clearly perceptible even on an overcast day, but it is far less than one would expect given the magnitude of the disruption to everyone’s routines. But, when the sun comes out! The doors fly open and onto the sidewalks and quiet rural roads spill scores of people I haven’t seen for months and in some cases decades. One can almost hear John Denver singing “sunshine on my shoulders makes me happy.” Everyone is smiling and waving to each other. It feels as though the community has, at least for a few hours, been able to throw off the burden of angst that the pandemic laid on us.
There has been a good bit of research about seasonal affective disorder, and I suspect that almost everyone has heard about the value of sunshine for depression. But it is unfortunate that the psychological benefits of just being outdoors – even on an overcast day – has gone pretty much unpublicized. As part of their marketing strategy, a local company that specializes in recreational clothing and gear is encouraging its customers to become “outsiders.” It may be that the pandemic will make more people realize the psychological benefits of being active outside. As physicians we should continue to encourage our patients to be more active and remind them that they don’t need to wait for a sunny day to do so.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no relevant financial disclosures. Email him at [email protected].
On March 26, 2020, it’s hard to write or think of anything beyond the COVID-19 pandemic. Those of you who are on the front lines of the battle may find it strange that I am just a bit envious. Having stepped back from clinical medicine nearly a decade ago, it is frustrating to feel that there is little I can do to help other than offering to venture into the grocery store to shop for friends and neighbors who feel more vulnerable than I do.
Here in Maine, we are blessed by geographic isolation that for the moment seems to have damped the surge from the metropolitan centers to our south. But, the virus is here and, as the state with the oldest population, we are beginning to be affected.
For nearly a century, we could count on the outhouses here in Maine would be stocked with outdated Sears Roebucks catalogs when toilet paper was in short supply. Many outhouses remain but Sears Roebucks and its catalogs have disappeared from the landscape. I take a little comfort in the learning that I’m not the only human on the planet who can envision the horror of a week or even a day without toilet paper.
So I am left to sit on the sidelines and watch how my fellow Mainers are coping with the anxiety, depression, and loneliness that come with the forced social isolation. It is pretty clear that walking outside has become the coping strategy of choice. On a usual March day the walkers comprise a skimpy mix of dog walkers and wannabe arctic explorers testing the weather-defying capabilities of their high-tech outerwear. But, to say the least, this is not a usual March and the number of walkers has surged bolstered by gym rats forced off their sweat-drenched ellipticals and treadmills.
This increase in outdoor activity is clearly perceptible even on an overcast day, but it is far less than one would expect given the magnitude of the disruption to everyone’s routines. But, when the sun comes out! The doors fly open and onto the sidewalks and quiet rural roads spill scores of people I haven’t seen for months and in some cases decades. One can almost hear John Denver singing “sunshine on my shoulders makes me happy.” Everyone is smiling and waving to each other. It feels as though the community has, at least for a few hours, been able to throw off the burden of angst that the pandemic laid on us.
There has been a good bit of research about seasonal affective disorder, and I suspect that almost everyone has heard about the value of sunshine for depression. But it is unfortunate that the psychological benefits of just being outdoors – even on an overcast day – has gone pretty much unpublicized. As part of their marketing strategy, a local company that specializes in recreational clothing and gear is encouraging its customers to become “outsiders.” It may be that the pandemic will make more people realize the psychological benefits of being active outside. As physicians we should continue to encourage our patients to be more active and remind them that they don’t need to wait for a sunny day to do so.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no relevant financial disclosures. Email him at [email protected].
Are psychiatrists more prepared for COVID-19 than we think?
Helping patients navigate surreal situations is what we do
A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.
As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.
All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.
Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.
I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.
A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.
The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.
The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:
- Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
- Reach out to loved ones and friends who remind you of strength and better times.
- Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
- Take care of your body and mind with exercise.
- Try for 8 hours of sleep a night (even if it doesn’t happen).
- Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.
All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.
Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.
After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.
Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.
As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.
Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.
I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.
Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.
Helping patients navigate surreal situations is what we do
Helping patients navigate surreal situations is what we do
A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.
As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.
All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.
Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.
I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.
A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.
The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.
The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:
- Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
- Reach out to loved ones and friends who remind you of strength and better times.
- Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
- Take care of your body and mind with exercise.
- Try for 8 hours of sleep a night (even if it doesn’t happen).
- Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.
All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.
Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.
After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.
Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.
As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.
Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.
I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.
Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.
A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.
As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.
All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.
Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.
I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.
A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.
The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.
The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:
- Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
- Reach out to loved ones and friends who remind you of strength and better times.
- Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
- Take care of your body and mind with exercise.
- Try for 8 hours of sleep a night (even if it doesn’t happen).
- Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.
All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.
Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.
After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.
Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.
As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.
Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.
I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.
Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.
More on ‘We are physicians, not providers’
I enjoyed Dr. Nasrallah’s recent editorial “We are physicians, not providers, and we treat patients, not clients!” (From the Editor,
A stethoscope, pressure cuff, and ophthalmoscope sit on the side table next to my psychotherapy chair, and I use them often. For years, I have administered electroconvulsive therapy and managed vagus nerve stimulation. I inject long-acting depot antipsychotics as well as depot buprenorphine and naltrexone, and I provide esketamine treatment. I spend significant parts of my patients’ visits explaining the treatments their other physicians have prescribed, in words they can understand. I still spend hours each week providing psychotherapy.
My psychiatric training afforded me the insight that my brother’s remark caused a lifelong change in my own behavior. Our capacity to blend psychology and medicine distinguishes us from our medical brethren and psychology colleagues.
I agree wholeheartedly that the medical bureaucracy/insurance industry degrades and demeans our profession, and we should do all in our power to resist this.
Norton Shores, Michigan
I congratulate Dr. Nasrallah on his forceful and clear editorial aimed at demystifying labels that only blur our identity and the nature of the patient-physician covenant.
Washington, DC
Continue to: I absolutely...
I absolutely agree with Dr. Nasrallah’s position that we are physicians, not “providers,” and that the people we care for are patients, not “clients.” Given the enthusiasm with which insurance companies have embraced the term provider (under the notion that we are indistinguishable from other types of trained professionals providing care), perhaps we should stop referring to them as “payors” because this does not seem to be their primary function. Instead, we can refer to them as “withholders” to better indicate the difference between what clinicians do (provide care) and what insurance companies do (withhold payment and thus delay care, sometimes with disastrous consequences).
Orefield, Pennsylvania
Regarding being called “providers,” I believe we have brought this on ourselves by allowing “management experts” to decide how we treat our patients.
Shyamala Vatsa, MBBS, DPM
Bengaluru, India
Being called a “provider” has been one of the most annoying and insulting things that we have had to endure in the last few years. Until Dr. Nasrallah’s editorial, I had never heard anyone raise this issue in a medical journal. The American Psychiatric Association (APA) and the American Medical Association (AMA) must help us with this. I have been saying for years that we are all going to be replaced by nurse practitioners (NPs)!
Chicago, Illinois
Continue to: I thank...
I thank Dr. Nasrallah very much for his editorial about being called “providers,” which has always irritated me. We worked hard to get our MDs. I’ve told my residents for a long time that the term “provider” sounds more like a wholesale grocery company. A similar term also confounds me: behavioral medicine. What is that, an old-fashioned reform school? We don’t change patients’ behavior to conform; we treat their illnesses and symptoms so that they can do better for themselves.
Bronx, New York
I commend Dr. Nasrallah’s recent editorial. Society must reconsider the concept that health care is a “product.” Patient education is key!
This editorial was translated into Portuguese by a colleague, and it has started a very interesting and fruitful debate.
Rio de Janeiro, Brasil
I was extremely impressed with the wisdom Dr. Nasrallah expressed in his editorial about how we should be referred to as physicians, not as “providers.” For many years, I have referred to my primary care colleagues as “PCPs,” which stands for primary care providers. I will do this no more and instead use the preferred and more accurate term primary care physicians. And yes, I do support his suggestion that the APA’s name be changed to the American Psychiatric Physicians Association, and hope that the plan to implement these improvements succeeds throughout the United States.
Rochester, New York
Continue to: I absolutely...
I absolutely loved Dr. Nasrallah's editorial and completely agree with him. Perhaps we could begin a letter-writing campaign urging Congress to amend Public Law 93-641 by replacing “provider” with “physicians and/or other health specialists” or something to that effect. With enough persuasion, the AMA might even take the lead on this.
Deborah Young, MD
Encinitas, California
I found Dr. Nasrallah's editorial extremely interesting and on target. I agree with his concern about the trend towards “bottom line” medicine.
I understand that, justifiably, Dr. Nasrallah's basic interest is in the realm of psychiatry (both clinicians and patients); however, shouldn’t that concern be broadened by recognizing that in all medical relationships, the individual (ie, physician assistant [PA], NP, registered nurse, respiratory therapist, etc.) is a “clinician” who cares for a patient
Also, while more and more people are willing to admit to being a patient undergoing mental health care, there still are many people who prefer not to called a patient when—or if—they describe the experience of receiving mental health care.
I teach a class called “Legal & Ethical Issues In Medicine” in a PA program, and one of the major objectives is to get the students to recognize and feel that they are becoming professionals. They are becoming clinicians who will help manage the health care of a patient.
Again, I appreciate Dr. Nasrallah's points, and wish that they could have a broader exposure.
Robert C. Grosz, EdD
Ft. Lauderdale, Florida
Continue to: I love...
I love Dr. Nasrallah's editorial. It was so refreshing to read, and we really need more of this all around. The language we use is important, and as a teaching faculty member, I see medical students and residents tossing around the term "provider" flippantly; it seems the term has been drilled into them. It is completely and totally demoralizing to our profession and has everything to do with the corporate takeover of health care. I lecture my students on physician advocacy, specifically regarding midlevel encroachment into medicine, but there is so much misuse of health care terminology. Now, everyone is a doctor, clinician, provider, or prescriber. Why not just identify everyone by their actual credentials? I also completely agree about the term “client,” which is also ridiculous.
I found Dr. Nasrallah's editorial to be a breath of fresh air. I thank him for it!
Laura K. Kendall, MD
Los Angeles, California
I want to congratulate Dr. Nasrallah for addressing the "provider" issue in his editorial. It is right on the mark and has been a thorn in my side for many years (as is the “client” vs “patient” issue). He worded it very well! I thank Dr. Nasrallah for discussing this.
René S. Kahn, MD, PhD
New York, New York
Continue to: Dr. Nasrallah responds
Dr. Nasrallah responds
I thank my colleagues, whose letters confirm that being called “providers” instead of “physicians” is something that all psychiatrists resent and oppose. I hope each psychiatric physician reader of
Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri
I enjoyed Dr. Nasrallah’s recent editorial “We are physicians, not providers, and we treat patients, not clients!” (From the Editor,
A stethoscope, pressure cuff, and ophthalmoscope sit on the side table next to my psychotherapy chair, and I use them often. For years, I have administered electroconvulsive therapy and managed vagus nerve stimulation. I inject long-acting depot antipsychotics as well as depot buprenorphine and naltrexone, and I provide esketamine treatment. I spend significant parts of my patients’ visits explaining the treatments their other physicians have prescribed, in words they can understand. I still spend hours each week providing psychotherapy.
My psychiatric training afforded me the insight that my brother’s remark caused a lifelong change in my own behavior. Our capacity to blend psychology and medicine distinguishes us from our medical brethren and psychology colleagues.
I agree wholeheartedly that the medical bureaucracy/insurance industry degrades and demeans our profession, and we should do all in our power to resist this.
Norton Shores, Michigan
I congratulate Dr. Nasrallah on his forceful and clear editorial aimed at demystifying labels that only blur our identity and the nature of the patient-physician covenant.
Washington, DC
Continue to: I absolutely...
I absolutely agree with Dr. Nasrallah’s position that we are physicians, not “providers,” and that the people we care for are patients, not “clients.” Given the enthusiasm with which insurance companies have embraced the term provider (under the notion that we are indistinguishable from other types of trained professionals providing care), perhaps we should stop referring to them as “payors” because this does not seem to be their primary function. Instead, we can refer to them as “withholders” to better indicate the difference between what clinicians do (provide care) and what insurance companies do (withhold payment and thus delay care, sometimes with disastrous consequences).
Orefield, Pennsylvania
Regarding being called “providers,” I believe we have brought this on ourselves by allowing “management experts” to decide how we treat our patients.
Shyamala Vatsa, MBBS, DPM
Bengaluru, India
Being called a “provider” has been one of the most annoying and insulting things that we have had to endure in the last few years. Until Dr. Nasrallah’s editorial, I had never heard anyone raise this issue in a medical journal. The American Psychiatric Association (APA) and the American Medical Association (AMA) must help us with this. I have been saying for years that we are all going to be replaced by nurse practitioners (NPs)!
Chicago, Illinois
Continue to: I thank...
I thank Dr. Nasrallah very much for his editorial about being called “providers,” which has always irritated me. We worked hard to get our MDs. I’ve told my residents for a long time that the term “provider” sounds more like a wholesale grocery company. A similar term also confounds me: behavioral medicine. What is that, an old-fashioned reform school? We don’t change patients’ behavior to conform; we treat their illnesses and symptoms so that they can do better for themselves.
Bronx, New York
I commend Dr. Nasrallah’s recent editorial. Society must reconsider the concept that health care is a “product.” Patient education is key!
This editorial was translated into Portuguese by a colleague, and it has started a very interesting and fruitful debate.
Rio de Janeiro, Brasil
I was extremely impressed with the wisdom Dr. Nasrallah expressed in his editorial about how we should be referred to as physicians, not as “providers.” For many years, I have referred to my primary care colleagues as “PCPs,” which stands for primary care providers. I will do this no more and instead use the preferred and more accurate term primary care physicians. And yes, I do support his suggestion that the APA’s name be changed to the American Psychiatric Physicians Association, and hope that the plan to implement these improvements succeeds throughout the United States.
Rochester, New York
Continue to: I absolutely...
I absolutely loved Dr. Nasrallah's editorial and completely agree with him. Perhaps we could begin a letter-writing campaign urging Congress to amend Public Law 93-641 by replacing “provider” with “physicians and/or other health specialists” or something to that effect. With enough persuasion, the AMA might even take the lead on this.
Deborah Young, MD
Encinitas, California
I found Dr. Nasrallah's editorial extremely interesting and on target. I agree with his concern about the trend towards “bottom line” medicine.
I understand that, justifiably, Dr. Nasrallah's basic interest is in the realm of psychiatry (both clinicians and patients); however, shouldn’t that concern be broadened by recognizing that in all medical relationships, the individual (ie, physician assistant [PA], NP, registered nurse, respiratory therapist, etc.) is a “clinician” who cares for a patient
Also, while more and more people are willing to admit to being a patient undergoing mental health care, there still are many people who prefer not to called a patient when—or if—they describe the experience of receiving mental health care.
I teach a class called “Legal & Ethical Issues In Medicine” in a PA program, and one of the major objectives is to get the students to recognize and feel that they are becoming professionals. They are becoming clinicians who will help manage the health care of a patient.
Again, I appreciate Dr. Nasrallah's points, and wish that they could have a broader exposure.
Robert C. Grosz, EdD
Ft. Lauderdale, Florida
Continue to: I love...
I love Dr. Nasrallah's editorial. It was so refreshing to read, and we really need more of this all around. The language we use is important, and as a teaching faculty member, I see medical students and residents tossing around the term "provider" flippantly; it seems the term has been drilled into them. It is completely and totally demoralizing to our profession and has everything to do with the corporate takeover of health care. I lecture my students on physician advocacy, specifically regarding midlevel encroachment into medicine, but there is so much misuse of health care terminology. Now, everyone is a doctor, clinician, provider, or prescriber. Why not just identify everyone by their actual credentials? I also completely agree about the term “client,” which is also ridiculous.
I found Dr. Nasrallah's editorial to be a breath of fresh air. I thank him for it!
Laura K. Kendall, MD
Los Angeles, California
I want to congratulate Dr. Nasrallah for addressing the "provider" issue in his editorial. It is right on the mark and has been a thorn in my side for many years (as is the “client” vs “patient” issue). He worded it very well! I thank Dr. Nasrallah for discussing this.
René S. Kahn, MD, PhD
New York, New York
Continue to: Dr. Nasrallah responds
Dr. Nasrallah responds
I thank my colleagues, whose letters confirm that being called “providers” instead of “physicians” is something that all psychiatrists resent and oppose. I hope each psychiatric physician reader of
Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri
I enjoyed Dr. Nasrallah’s recent editorial “We are physicians, not providers, and we treat patients, not clients!” (From the Editor,
A stethoscope, pressure cuff, and ophthalmoscope sit on the side table next to my psychotherapy chair, and I use them often. For years, I have administered electroconvulsive therapy and managed vagus nerve stimulation. I inject long-acting depot antipsychotics as well as depot buprenorphine and naltrexone, and I provide esketamine treatment. I spend significant parts of my patients’ visits explaining the treatments their other physicians have prescribed, in words they can understand. I still spend hours each week providing psychotherapy.
My psychiatric training afforded me the insight that my brother’s remark caused a lifelong change in my own behavior. Our capacity to blend psychology and medicine distinguishes us from our medical brethren and psychology colleagues.
I agree wholeheartedly that the medical bureaucracy/insurance industry degrades and demeans our profession, and we should do all in our power to resist this.
Norton Shores, Michigan
I congratulate Dr. Nasrallah on his forceful and clear editorial aimed at demystifying labels that only blur our identity and the nature of the patient-physician covenant.
Washington, DC
Continue to: I absolutely...
I absolutely agree with Dr. Nasrallah’s position that we are physicians, not “providers,” and that the people we care for are patients, not “clients.” Given the enthusiasm with which insurance companies have embraced the term provider (under the notion that we are indistinguishable from other types of trained professionals providing care), perhaps we should stop referring to them as “payors” because this does not seem to be their primary function. Instead, we can refer to them as “withholders” to better indicate the difference between what clinicians do (provide care) and what insurance companies do (withhold payment and thus delay care, sometimes with disastrous consequences).
Orefield, Pennsylvania
Regarding being called “providers,” I believe we have brought this on ourselves by allowing “management experts” to decide how we treat our patients.
Shyamala Vatsa, MBBS, DPM
Bengaluru, India
Being called a “provider” has been one of the most annoying and insulting things that we have had to endure in the last few years. Until Dr. Nasrallah’s editorial, I had never heard anyone raise this issue in a medical journal. The American Psychiatric Association (APA) and the American Medical Association (AMA) must help us with this. I have been saying for years that we are all going to be replaced by nurse practitioners (NPs)!
Chicago, Illinois
Continue to: I thank...
I thank Dr. Nasrallah very much for his editorial about being called “providers,” which has always irritated me. We worked hard to get our MDs. I’ve told my residents for a long time that the term “provider” sounds more like a wholesale grocery company. A similar term also confounds me: behavioral medicine. What is that, an old-fashioned reform school? We don’t change patients’ behavior to conform; we treat their illnesses and symptoms so that they can do better for themselves.
Bronx, New York
I commend Dr. Nasrallah’s recent editorial. Society must reconsider the concept that health care is a “product.” Patient education is key!
This editorial was translated into Portuguese by a colleague, and it has started a very interesting and fruitful debate.
Rio de Janeiro, Brasil
I was extremely impressed with the wisdom Dr. Nasrallah expressed in his editorial about how we should be referred to as physicians, not as “providers.” For many years, I have referred to my primary care colleagues as “PCPs,” which stands for primary care providers. I will do this no more and instead use the preferred and more accurate term primary care physicians. And yes, I do support his suggestion that the APA’s name be changed to the American Psychiatric Physicians Association, and hope that the plan to implement these improvements succeeds throughout the United States.
Rochester, New York
Continue to: I absolutely...
I absolutely loved Dr. Nasrallah's editorial and completely agree with him. Perhaps we could begin a letter-writing campaign urging Congress to amend Public Law 93-641 by replacing “provider” with “physicians and/or other health specialists” or something to that effect. With enough persuasion, the AMA might even take the lead on this.
Deborah Young, MD
Encinitas, California
I found Dr. Nasrallah's editorial extremely interesting and on target. I agree with his concern about the trend towards “bottom line” medicine.
I understand that, justifiably, Dr. Nasrallah's basic interest is in the realm of psychiatry (both clinicians and patients); however, shouldn’t that concern be broadened by recognizing that in all medical relationships, the individual (ie, physician assistant [PA], NP, registered nurse, respiratory therapist, etc.) is a “clinician” who cares for a patient
Also, while more and more people are willing to admit to being a patient undergoing mental health care, there still are many people who prefer not to called a patient when—or if—they describe the experience of receiving mental health care.
I teach a class called “Legal & Ethical Issues In Medicine” in a PA program, and one of the major objectives is to get the students to recognize and feel that they are becoming professionals. They are becoming clinicians who will help manage the health care of a patient.
Again, I appreciate Dr. Nasrallah's points, and wish that they could have a broader exposure.
Robert C. Grosz, EdD
Ft. Lauderdale, Florida
Continue to: I love...
I love Dr. Nasrallah's editorial. It was so refreshing to read, and we really need more of this all around. The language we use is important, and as a teaching faculty member, I see medical students and residents tossing around the term "provider" flippantly; it seems the term has been drilled into them. It is completely and totally demoralizing to our profession and has everything to do with the corporate takeover of health care. I lecture my students on physician advocacy, specifically regarding midlevel encroachment into medicine, but there is so much misuse of health care terminology. Now, everyone is a doctor, clinician, provider, or prescriber. Why not just identify everyone by their actual credentials? I also completely agree about the term “client,” which is also ridiculous.
I found Dr. Nasrallah's editorial to be a breath of fresh air. I thank him for it!
Laura K. Kendall, MD
Los Angeles, California
I want to congratulate Dr. Nasrallah for addressing the "provider" issue in his editorial. It is right on the mark and has been a thorn in my side for many years (as is the “client” vs “patient” issue). He worded it very well! I thank Dr. Nasrallah for discussing this.
René S. Kahn, MD, PhD
New York, New York
Continue to: Dr. Nasrallah responds
Dr. Nasrallah responds
I thank my colleagues, whose letters confirm that being called “providers” instead of “physicians” is something that all psychiatrists resent and oppose. I hope each psychiatric physician reader of
Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri
Pre-authorization is illegal, unethical, and adversely disrupts patient care
Pre-authorization is a despicable scam. It’s a national racket by avaricious insurance companies, and it must be stopped. Since it first reared its ugly head 2 decades ago, it has inflicted great harm to countless patients, demoralized their physicians, and needlessly imposed higher costs in clinical practice while simultaneously depriving patients of the treatment their physicians prescribed for them.
Pre-authorization has become the nemesis of medical care. It recklessly and arbitrarily vetoes the clinical decision-making of competent physicians doing their best to address their patients’ medical needs. Yet, despite its outrageous disruption of the clinical practice of hundreds of thousands of practitioners, it continues unabated, without a forceful pushback. It has become the “new normal,” but in fact, it is the “new abnormal.” This harassment of clinicians must be outlawed.
Think about it: Pre-authorization is essentially practicing medicine without a license, which is a felony. When a remote and invisible insurance company staff member either prevents a patient from receiving a medication prescribed by that patient’s personal physician following a full diagnostic evaluation or pressures the physician to prescribe a different medication, he/she is basically deciding what the treatment should be for a patient who that insurance company employee has never seen, let alone examined. How did for-profit insurance companies empower themselves to tyrannize clinical practice so that the treatment administered isn’t customized to the patient’s need but instead to fatten the profits of the insurance company? That is patently unethical, in addition to being a felonious practice of medicine by an absentee person unqualified to decide what a patient needs without a direct examination.
Consider the multiple malignant consequences of such brazen and egregious restriction or distortion of medical care:
1. The physician’s clinical judgment is abrogated, even when it is clearly in the patient’s best interest.
2. Patients are deprived of receiving the medication that their personal physician deemed optimal.
3. The physician in private practice has to spend an inordinate amount of time going to web sites, such as CoverMyMeds.com, to fill out extensive forms containing numerous questions about the patient’s illness and diagnosis, and then selecting from a list of medications that the insurance company ironically labels as “smart choices.” These medications often are not necessarily what the physician considers a smart choice, but are the cheapest (regardless of whether their efficacy, safety, or tolerability are the best fit for the patient). After the physician completes the forms, there is a waiting period, followed by additional questions that consume more valuable time and take the physician away from seeing more patients. Some busy colleagues told me they often take the pre-authorization “homework” with them to do at home, consuming part of what should be their family time. For physicians who see patients in an institutional “clinic,” medical assistants or nurses must be hired at significant expense to work full-time on pre-authorizations, adding to the overhead of the clinic while increasing the profits of the third-party insurer.
4. Patients who have been stable on a medication for months, even years, are forced to switch to another medication if they change jobs and become covered by a different insurance company that does not have the patient’s current medication on their infamous list of “approved drugs,” an evil euphemism for “cheapest drugs.” Switching medications is known to be a possibly hazardous process with lower efficacy and/or tolerability, but that appears to be irrelevant to the insurance company. The welfare of the patient is not on the insurance company’s radar screen, perhaps because it is crowded out by dollar signs. We should all urge policymakers to pass legislation that goes beyond requiring insurance companies to cover “pre-existing conditions” and expands it to cover “pre-existing medications.”
Continue to: Often, frustrated physicians...
5. Often, frustrated physicians who do not want to see their patients receive a medication they do not believe is appropriate may spend valuable time writing letters of appeal, making phone calls, or printing and faxing scientific articles to the insurance company to convince them to authorize a medication that is not on the “approved list.” Based on my own clinical experience, that justification sometimes works and sometimes doesn’t.
6. Physicians are inevitably and understandably demoralized because their expertise and sound clinical judgment are arbitrarily dismissed and overruled by an invisible insurance employee whose knowledge about and compassion for the patient is miniscule at best.
7. New medication development has collided with the biased despotism of pre-authorization, which generally rejects any new medication (always costlier than generics) irrespective of whether the new medication was demonstrated in controlled clinical trials to have a measurably better profile than older generics. This has ominous implications for numerous medical disorders that do not have any approved medications (for psychiatry, a published study1 found that 82% of DSM disorders do not have a FDA-approved medication).
The lack of utilizing newly introduced medications has discouraged the pharmaceutical industry from investing to develop innovative new mechanisms of action for a variety of complex neuropsychiatric medical conditions. Some companies have already abandoned psychiatric drug development, which is dire for clinical care because pharmaceutical companies are the only entities that develop new treatments for our patients (some health care professionals wish the government had a pharmaceutical agency that develops medications for various illness, but no such agency has ever existed).
8. Hospitalization for a seriously ill patient is either denied, delayed, or eventually approved for an absurdly short period (a few days), which is woefully inadequate, culminating in discharging patients with unresolved symptoms. This can lead to disastrous consequences, including suicide, homicide, or incarceration.
Continue to: I have been personally infuriated...
I have been personally infuriated many times because of the adverse impact pre-authorization had on my patients. One example that still haunts me is a 23-year-old college graduate with severe treatment-resistant depression who failed multiple antidepressant trials, including IV ketamine. She harbored daily thoughts of suicide (throwing herself in front of a train, which she saw daily as she drove to work). She admitted to frequently contemplating which dress she should wear in her coffin. Based on several published double-blind studies showing that modafinil improved bipolar depression,2 I prescribed modafinil, 200 mg/d, as adjunctive treatment to venlafaxine, 300 mg/d, and she improved significantly for 10 months. Suddenly, the insurance company refused to renew her refill of modafinil, and it took 4 weeks of incessant communication (phone calls, faxes, letters, sending published articles) before it was finally approved. In the meantime, the patient deteriorated and began to have active suicidal urges. When she was restarted on modafinil, she never achieved the same level of improvement she had prior to discontinuing modafinil. The insurance company damaged this patient’s recovery with its refusal to authorize a medication that was “not approved” for depression despite the clear benefit it had provided this treatment-resistant patient for almost 1 year. Their motive was clearly to avoid covering the high cost of modafinil, regardless of this patient’s high risk of suicide.
Every physician can recite a litany of complaints about the evil of pre-authorizations. We must therefore unite and vigorously lobby legislators to pass laws that protect patients and uphold physicians’ authority to determine the right treatment for their patients. We must terminate the plague of pre-authorization that takes our patients hostage to the greed of insurance companies, who have no regard to the agony of patients who are prevented from receiving the medication that their personal physician prescribes. Physicians’ well-being would be greatly enhanced if they were not enslaved to the avarice of insurance companies.
The travesty of pre-authorization and its pervasive and deleterious effects on medical care, society, and citizens must be stopped. It’s a plague that sacrifices the practice of medicine on the altar of financial greed. Just because it has gone on for many years does not mean it should be accepted as the “new normal.” It must be condemned as the “new abnormal,” a cancerous lesion on health care delivery that must be excised and discarded.
1. Devulapalli KK, Nasrallah HA. An analysis of the high psychotropic off-label use in psychiatric disorders: the majority of psychiatric diagnoses have no approved drug. Asian J Psychiatr. 2009;2(1):29-36.
2. Nunez NA, Singh B, Romo-Nava F, et al. Efficacy and tolerability of adjunctive modafinil/armodafinil in bipolar depression: a meta-analysis of randomized controlled trials. Bipolar Dipsord. 2019;10.1111/bdi.12859. doi: 10.1111/bdi.12859
Pre-authorization is a despicable scam. It’s a national racket by avaricious insurance companies, and it must be stopped. Since it first reared its ugly head 2 decades ago, it has inflicted great harm to countless patients, demoralized their physicians, and needlessly imposed higher costs in clinical practice while simultaneously depriving patients of the treatment their physicians prescribed for them.
Pre-authorization has become the nemesis of medical care. It recklessly and arbitrarily vetoes the clinical decision-making of competent physicians doing their best to address their patients’ medical needs. Yet, despite its outrageous disruption of the clinical practice of hundreds of thousands of practitioners, it continues unabated, without a forceful pushback. It has become the “new normal,” but in fact, it is the “new abnormal.” This harassment of clinicians must be outlawed.
Think about it: Pre-authorization is essentially practicing medicine without a license, which is a felony. When a remote and invisible insurance company staff member either prevents a patient from receiving a medication prescribed by that patient’s personal physician following a full diagnostic evaluation or pressures the physician to prescribe a different medication, he/she is basically deciding what the treatment should be for a patient who that insurance company employee has never seen, let alone examined. How did for-profit insurance companies empower themselves to tyrannize clinical practice so that the treatment administered isn’t customized to the patient’s need but instead to fatten the profits of the insurance company? That is patently unethical, in addition to being a felonious practice of medicine by an absentee person unqualified to decide what a patient needs without a direct examination.
Consider the multiple malignant consequences of such brazen and egregious restriction or distortion of medical care:
1. The physician’s clinical judgment is abrogated, even when it is clearly in the patient’s best interest.
2. Patients are deprived of receiving the medication that their personal physician deemed optimal.
3. The physician in private practice has to spend an inordinate amount of time going to web sites, such as CoverMyMeds.com, to fill out extensive forms containing numerous questions about the patient’s illness and diagnosis, and then selecting from a list of medications that the insurance company ironically labels as “smart choices.” These medications often are not necessarily what the physician considers a smart choice, but are the cheapest (regardless of whether their efficacy, safety, or tolerability are the best fit for the patient). After the physician completes the forms, there is a waiting period, followed by additional questions that consume more valuable time and take the physician away from seeing more patients. Some busy colleagues told me they often take the pre-authorization “homework” with them to do at home, consuming part of what should be their family time. For physicians who see patients in an institutional “clinic,” medical assistants or nurses must be hired at significant expense to work full-time on pre-authorizations, adding to the overhead of the clinic while increasing the profits of the third-party insurer.
4. Patients who have been stable on a medication for months, even years, are forced to switch to another medication if they change jobs and become covered by a different insurance company that does not have the patient’s current medication on their infamous list of “approved drugs,” an evil euphemism for “cheapest drugs.” Switching medications is known to be a possibly hazardous process with lower efficacy and/or tolerability, but that appears to be irrelevant to the insurance company. The welfare of the patient is not on the insurance company’s radar screen, perhaps because it is crowded out by dollar signs. We should all urge policymakers to pass legislation that goes beyond requiring insurance companies to cover “pre-existing conditions” and expands it to cover “pre-existing medications.”
Continue to: Often, frustrated physicians...
5. Often, frustrated physicians who do not want to see their patients receive a medication they do not believe is appropriate may spend valuable time writing letters of appeal, making phone calls, or printing and faxing scientific articles to the insurance company to convince them to authorize a medication that is not on the “approved list.” Based on my own clinical experience, that justification sometimes works and sometimes doesn’t.
6. Physicians are inevitably and understandably demoralized because their expertise and sound clinical judgment are arbitrarily dismissed and overruled by an invisible insurance employee whose knowledge about and compassion for the patient is miniscule at best.
7. New medication development has collided with the biased despotism of pre-authorization, which generally rejects any new medication (always costlier than generics) irrespective of whether the new medication was demonstrated in controlled clinical trials to have a measurably better profile than older generics. This has ominous implications for numerous medical disorders that do not have any approved medications (for psychiatry, a published study1 found that 82% of DSM disorders do not have a FDA-approved medication).
The lack of utilizing newly introduced medications has discouraged the pharmaceutical industry from investing to develop innovative new mechanisms of action for a variety of complex neuropsychiatric medical conditions. Some companies have already abandoned psychiatric drug development, which is dire for clinical care because pharmaceutical companies are the only entities that develop new treatments for our patients (some health care professionals wish the government had a pharmaceutical agency that develops medications for various illness, but no such agency has ever existed).
8. Hospitalization for a seriously ill patient is either denied, delayed, or eventually approved for an absurdly short period (a few days), which is woefully inadequate, culminating in discharging patients with unresolved symptoms. This can lead to disastrous consequences, including suicide, homicide, or incarceration.
Continue to: I have been personally infuriated...
I have been personally infuriated many times because of the adverse impact pre-authorization had on my patients. One example that still haunts me is a 23-year-old college graduate with severe treatment-resistant depression who failed multiple antidepressant trials, including IV ketamine. She harbored daily thoughts of suicide (throwing herself in front of a train, which she saw daily as she drove to work). She admitted to frequently contemplating which dress she should wear in her coffin. Based on several published double-blind studies showing that modafinil improved bipolar depression,2 I prescribed modafinil, 200 mg/d, as adjunctive treatment to venlafaxine, 300 mg/d, and she improved significantly for 10 months. Suddenly, the insurance company refused to renew her refill of modafinil, and it took 4 weeks of incessant communication (phone calls, faxes, letters, sending published articles) before it was finally approved. In the meantime, the patient deteriorated and began to have active suicidal urges. When she was restarted on modafinil, she never achieved the same level of improvement she had prior to discontinuing modafinil. The insurance company damaged this patient’s recovery with its refusal to authorize a medication that was “not approved” for depression despite the clear benefit it had provided this treatment-resistant patient for almost 1 year. Their motive was clearly to avoid covering the high cost of modafinil, regardless of this patient’s high risk of suicide.
Every physician can recite a litany of complaints about the evil of pre-authorizations. We must therefore unite and vigorously lobby legislators to pass laws that protect patients and uphold physicians’ authority to determine the right treatment for their patients. We must terminate the plague of pre-authorization that takes our patients hostage to the greed of insurance companies, who have no regard to the agony of patients who are prevented from receiving the medication that their personal physician prescribes. Physicians’ well-being would be greatly enhanced if they were not enslaved to the avarice of insurance companies.
The travesty of pre-authorization and its pervasive and deleterious effects on medical care, society, and citizens must be stopped. It’s a plague that sacrifices the practice of medicine on the altar of financial greed. Just because it has gone on for many years does not mean it should be accepted as the “new normal.” It must be condemned as the “new abnormal,” a cancerous lesion on health care delivery that must be excised and discarded.
Pre-authorization is a despicable scam. It’s a national racket by avaricious insurance companies, and it must be stopped. Since it first reared its ugly head 2 decades ago, it has inflicted great harm to countless patients, demoralized their physicians, and needlessly imposed higher costs in clinical practice while simultaneously depriving patients of the treatment their physicians prescribed for them.
Pre-authorization has become the nemesis of medical care. It recklessly and arbitrarily vetoes the clinical decision-making of competent physicians doing their best to address their patients’ medical needs. Yet, despite its outrageous disruption of the clinical practice of hundreds of thousands of practitioners, it continues unabated, without a forceful pushback. It has become the “new normal,” but in fact, it is the “new abnormal.” This harassment of clinicians must be outlawed.
Think about it: Pre-authorization is essentially practicing medicine without a license, which is a felony. When a remote and invisible insurance company staff member either prevents a patient from receiving a medication prescribed by that patient’s personal physician following a full diagnostic evaluation or pressures the physician to prescribe a different medication, he/she is basically deciding what the treatment should be for a patient who that insurance company employee has never seen, let alone examined. How did for-profit insurance companies empower themselves to tyrannize clinical practice so that the treatment administered isn’t customized to the patient’s need but instead to fatten the profits of the insurance company? That is patently unethical, in addition to being a felonious practice of medicine by an absentee person unqualified to decide what a patient needs without a direct examination.
Consider the multiple malignant consequences of such brazen and egregious restriction or distortion of medical care:
1. The physician’s clinical judgment is abrogated, even when it is clearly in the patient’s best interest.
2. Patients are deprived of receiving the medication that their personal physician deemed optimal.
3. The physician in private practice has to spend an inordinate amount of time going to web sites, such as CoverMyMeds.com, to fill out extensive forms containing numerous questions about the patient’s illness and diagnosis, and then selecting from a list of medications that the insurance company ironically labels as “smart choices.” These medications often are not necessarily what the physician considers a smart choice, but are the cheapest (regardless of whether their efficacy, safety, or tolerability are the best fit for the patient). After the physician completes the forms, there is a waiting period, followed by additional questions that consume more valuable time and take the physician away from seeing more patients. Some busy colleagues told me they often take the pre-authorization “homework” with them to do at home, consuming part of what should be their family time. For physicians who see patients in an institutional “clinic,” medical assistants or nurses must be hired at significant expense to work full-time on pre-authorizations, adding to the overhead of the clinic while increasing the profits of the third-party insurer.
4. Patients who have been stable on a medication for months, even years, are forced to switch to another medication if they change jobs and become covered by a different insurance company that does not have the patient’s current medication on their infamous list of “approved drugs,” an evil euphemism for “cheapest drugs.” Switching medications is known to be a possibly hazardous process with lower efficacy and/or tolerability, but that appears to be irrelevant to the insurance company. The welfare of the patient is not on the insurance company’s radar screen, perhaps because it is crowded out by dollar signs. We should all urge policymakers to pass legislation that goes beyond requiring insurance companies to cover “pre-existing conditions” and expands it to cover “pre-existing medications.”
Continue to: Often, frustrated physicians...
5. Often, frustrated physicians who do not want to see their patients receive a medication they do not believe is appropriate may spend valuable time writing letters of appeal, making phone calls, or printing and faxing scientific articles to the insurance company to convince them to authorize a medication that is not on the “approved list.” Based on my own clinical experience, that justification sometimes works and sometimes doesn’t.
6. Physicians are inevitably and understandably demoralized because their expertise and sound clinical judgment are arbitrarily dismissed and overruled by an invisible insurance employee whose knowledge about and compassion for the patient is miniscule at best.
7. New medication development has collided with the biased despotism of pre-authorization, which generally rejects any new medication (always costlier than generics) irrespective of whether the new medication was demonstrated in controlled clinical trials to have a measurably better profile than older generics. This has ominous implications for numerous medical disorders that do not have any approved medications (for psychiatry, a published study1 found that 82% of DSM disorders do not have a FDA-approved medication).
The lack of utilizing newly introduced medications has discouraged the pharmaceutical industry from investing to develop innovative new mechanisms of action for a variety of complex neuropsychiatric medical conditions. Some companies have already abandoned psychiatric drug development, which is dire for clinical care because pharmaceutical companies are the only entities that develop new treatments for our patients (some health care professionals wish the government had a pharmaceutical agency that develops medications for various illness, but no such agency has ever existed).
8. Hospitalization for a seriously ill patient is either denied, delayed, or eventually approved for an absurdly short period (a few days), which is woefully inadequate, culminating in discharging patients with unresolved symptoms. This can lead to disastrous consequences, including suicide, homicide, or incarceration.
Continue to: I have been personally infuriated...
I have been personally infuriated many times because of the adverse impact pre-authorization had on my patients. One example that still haunts me is a 23-year-old college graduate with severe treatment-resistant depression who failed multiple antidepressant trials, including IV ketamine. She harbored daily thoughts of suicide (throwing herself in front of a train, which she saw daily as she drove to work). She admitted to frequently contemplating which dress she should wear in her coffin. Based on several published double-blind studies showing that modafinil improved bipolar depression,2 I prescribed modafinil, 200 mg/d, as adjunctive treatment to venlafaxine, 300 mg/d, and she improved significantly for 10 months. Suddenly, the insurance company refused to renew her refill of modafinil, and it took 4 weeks of incessant communication (phone calls, faxes, letters, sending published articles) before it was finally approved. In the meantime, the patient deteriorated and began to have active suicidal urges. When she was restarted on modafinil, she never achieved the same level of improvement she had prior to discontinuing modafinil. The insurance company damaged this patient’s recovery with its refusal to authorize a medication that was “not approved” for depression despite the clear benefit it had provided this treatment-resistant patient for almost 1 year. Their motive was clearly to avoid covering the high cost of modafinil, regardless of this patient’s high risk of suicide.
Every physician can recite a litany of complaints about the evil of pre-authorizations. We must therefore unite and vigorously lobby legislators to pass laws that protect patients and uphold physicians’ authority to determine the right treatment for their patients. We must terminate the plague of pre-authorization that takes our patients hostage to the greed of insurance companies, who have no regard to the agony of patients who are prevented from receiving the medication that their personal physician prescribes. Physicians’ well-being would be greatly enhanced if they were not enslaved to the avarice of insurance companies.
The travesty of pre-authorization and its pervasive and deleterious effects on medical care, society, and citizens must be stopped. It’s a plague that sacrifices the practice of medicine on the altar of financial greed. Just because it has gone on for many years does not mean it should be accepted as the “new normal.” It must be condemned as the “new abnormal,” a cancerous lesion on health care delivery that must be excised and discarded.
1. Devulapalli KK, Nasrallah HA. An analysis of the high psychotropic off-label use in psychiatric disorders: the majority of psychiatric diagnoses have no approved drug. Asian J Psychiatr. 2009;2(1):29-36.
2. Nunez NA, Singh B, Romo-Nava F, et al. Efficacy and tolerability of adjunctive modafinil/armodafinil in bipolar depression: a meta-analysis of randomized controlled trials. Bipolar Dipsord. 2019;10.1111/bdi.12859. doi: 10.1111/bdi.12859
1. Devulapalli KK, Nasrallah HA. An analysis of the high psychotropic off-label use in psychiatric disorders: the majority of psychiatric diagnoses have no approved drug. Asian J Psychiatr. 2009;2(1):29-36.
2. Nunez NA, Singh B, Romo-Nava F, et al. Efficacy and tolerability of adjunctive modafinil/armodafinil in bipolar depression: a meta-analysis of randomized controlled trials. Bipolar Dipsord. 2019;10.1111/bdi.12859. doi: 10.1111/bdi.12859
The psychiatric clinic of the future
Despite the tremendous advances in psychiatry in recent years, the current clinical practice of psychiatry continues to rely on data from intermittent assessments along with subjective and unquantifiable accounts from patients and caregivers. Furthermore, there continues to be significant diagnostic variations among practitioners. Fortunately, technology to address these issues appears to be on the horizon.
How might the psychiatric clinic of the future look? What changes could we envision? These 4 critical factors may soon bring about dynamic changes in the way we practice psychiatry:
- precision psychiatry
- digital psychiatry
- technology-enhanced psychotherapy
- electronic health record (EHR) reforms.
In this article, we review how advances in each of these areas might lead to improved care for our patients.
Precision psychiatry
Precision psychiatry takes into account each patient’s variability in genes, environment, and lifestyle to determine individualized treatment and prevention strategies. It relies on pharmacogenomic testing as the primary tool. Pharmacogenomics is the study of variability in drug response due to heredity.
Emerging data on the clinical utility and cost-effectiveness of pharmacogenomic testing are encouraging, but its routine use is not well supported by current evidence.2 One limit to using pharmacogenomic testing is that many genes simultaneously exert an effect on the structure and function of neurons and associated pathophysiology. According to the International Society of Psychiatric Genetics, no single genetic variant is sufficient to cause psychiatric disorders such as depression, bipolar disorder, substance dependence, or schizophrenia. This limits the possibility of using genetic tests to establish a diagnosis.3
In the future, better algorithms could promote more accurate pharmacogenomics profiles for individual patients, which could influence treatment.
Precision psychiatry could lead to:
- identification of novel targets for new medications
- pharmacogenetic profiling of the patient to predict disease susceptibility and medication response
- personalized therapy: the right drug at the right dose for the right patient.
- improved efficacy and fewer adverse medication reactions.
Continue to: Digital psychiatry
Digital psychiatry
Integrating computer-based technology into psychiatric practice has given birth to a new frontier that could be called digital psychiatry. This might encompass the following:
- telepsychiatry
- social media with a mental health focus
- web-based applications/devices
- artificial intelligence (AI).
Telepsychiatry. Videoconferencing is the most widely used form of telepsychiatry. It provides patients with easier access to mental health treatment.4 Telepsychiatry has the potential to match patients and clinicians with similar cultural backgrounds, thus minimizing cultural gaps and misunderstandings. Most importantly, it is comparable to face-to-face interviews in terms of the reliability of assessment and treatment outcomes.5
Telepsychiatry might be particularly helpful for patients with restricted mobility, such as those who live in remote areas, nursing homes, or correctional facilities. In correctional settings, transferring prisoners is expensive and carries the risk of escape. In a small study (N = 86) conducted in Hong Kong, Chen et al6 found that using videoconferencing to conduct clinical interviews of inmates was cost-efficient and scored high in terms of patient acceptability.
Social media. Social media could be a powerful platform for early detection of mental illness. Staying connected with patients on social media could allow psychiatrists to be more aware of their patient’s mood fluctuations, which might lead to more timely assessments. Physicians could be automatically notified about changes in their patients’ social media activity that indicate changes in mental state, which could solicit immediate intervention and treatment. On the other hand, such use of social media could blur professional boundaries. Psychiatrists also could use social media to promote awareness of mental health and educate the public on ways to improve or maintain their mental well-being.7
Web-based applications/devices. Real-time monitoring through applications or internet-based smart devices creates a new avenue for patients to receive personalized assessments, treatment, and intervention.8 Smartwatches with internet connectivity may offer a glimpse of the wearer’s sleep architecture and duration, thus providing real-time data on patients who have insomnia. We can now passively collect objective data from devices, such as smartphones and laptops, to phenotype an individual’s mood and mental state, a process called digital phenotyping. The Table9 lists examples of the types of mental health–related metrics that can be captured by smartphones, smartwatches, and similar technology. Information from these devices can be accumulated to create a database that can be used to predict symptoms.10 For example, the way people use a smartphone’s keyboard, including latency time between space and character types, can be used to generate variables for data. This type of information is being studied for use in screening depression and passively assessing mood in real time.11
Continue to: Artificial intelligence
Artificial intelligence—the development of computer systems able to perform tasks that normally require human intelligence—is being increasingly used in psychiatry. Some studies have suggested AI can be used to identify patients’ risk of suicide12-15 or psychosis.16,17 Kalanderian and Nasrallah18 reviewed several of these studies in
Other researchers have found clinical uses for machine learning, a subset of AI that uses methods to automatically detect patterns and make predictions based on those patterns. In one study, a machine learning analysis of functional MRI scans was able to identify 4 distinct subtypes of depression.19 In another study, a machine learning model was able to predict with 60% accuracy which patients with depression would respond to antidepressants.20
In the future, AI might be used to change mental health classification systems. Because many mental health disorders share similar symptom clusters, machine learning can help to identify associations between symptoms, behavior, brain function, and real-world function across different diagnoses, potentially affecting how we will classify mental disorders.21
Technology-enhanced psychotherapy
In the future, it might be common for psychotherapy to be provided by a computer, or “virtual therapist.” Several studies have evaluated the use of technology-enhanced psychotherapy.
Lucas et al22 investigated patients’ interactions with a virtual therapist. Participants were interviewed by an avatar named Ellie, who they saw on a TV screen. Half of the participants were told Ellie was not human, and half were told Ellie was being controlled remotely by a human. Three psychologists who were blinded to group allocations analyzed transcripts of the interviews and video recordings of participants’ facial expressions to quantify the participants’ fear, sadness, and other emotional responses during the interviews, as well as their openness to the questions. Participants who believed Ellie was fully automated reported significantly lower fear of self-disclosure and impression management (attempts to control how others perceive them) than participants who were told that Ellie was operated by a human. Additionally, participants who believed they were interacting with a computer were more open during the interview.22
Continue to: Researchers at the University of Southern California...
Researchers at the University of Southern California developed software that assessed 74 acoustic features, including pitch, volume, quality, shimmer, jitter, and prosody, to predict outcomes among patients receiving couples therapy. This software was able to predict marital discord at least as well as human therapists.23
Many mental health apps purport to implement specific components of psychotherapy. Many of these apps focus on cognitive-behavioral therapy worksheets, mindfulness exercises, and/or mood tracking. The features provided by such apps emulate the tasks and intended outcomes of traditional psychotherapy, but in an entirely decentralized venue.24
Some have expressed concern that an increased use of virtual therapists powered by AI might lead to a dehumanization of psychiatry (Box25,26).
Box
Whether there are aspects of the psychiatric patient encounter that cannot be managed by a “virtual clinician” created by artificial intelligence (AI) remains to be determined. Some of the benefits of using AI in this manner may be difficult to anticipate, or may be specific to an individual’s relationship with his/her clinician.25
On the other hand, AI systems blur previously assumed boundaries between reality and fiction, and this could have complex effects on patients. Similar to therapeutic relationships with a human clinician, there is the risk of transference of emotions, thoughts, and feelings to a virtual therapist powered by AI. Unlike with a psychiatrist or therapist, however, there is no person on the other side of this transference. Whether virtual clinicians will be able to manage such transference remains to be seen.
In Deep Medicine,26 cardiologist Eric Topol, MD, emphasizes a crucial component of a patient encounter that AI will be unlikely able to provide: empathy. Virtual therapists powered by AI will inherit the tasks best done by machines, leaving humans more time to do what they do best—providing empathy and being “present” for patients.
Electronic health record reforms
Although many clinicians find EHRs to be onerous and time-consuming, EHR technology is constantly improving, and EHRs have revolutionized documentation and order implementation. Several potential advances could improve clinical practice. For example, EHRs could incorporate a clinical decision support system that uses AI-based algorithms to assist psychiatrists with diagnosis, monitoring, and treatment.27 In the future, EHRs might have the ability to monitor and learn from errors and adverse events, and automatically design an algorithm to avoid them.28 They should be designed to better manage analysis of pharmacogenetic test results, which is challenging due to the amount and complexity of the data.29 Future EHRs should eliminate the non-intuitive and multi-click interfaces and cumbersome data searches of today’s EHRs.30
Technology brings new ethical considerations
Mental health interventions based on AI typically work with algorithms, and algorithms bring ethical issues. Mental health devices or systems that use AI could contain biases that have the potential to harm in unintended ways, such as a data-driven sexist or racist bias.31 This may require investing additional time to explain to patients (and their families) what an algorithm is and how it works in relation to the therapy provided.
Continue to: Another concern is patient...
Another concern is patient autonomy.32 For example, it would be ethically problematic if a patient were to assume that there was a human physician “at the other end” of a virtual therapist or other technology who is communicating or reviewing his/her messages. Similarly, an older adult or a patient with intellectual disabilities may not be able to understand advanced technology or what it does when it is installed in their home to monitor the patient’s activities. This would increase the risk of privacy violations, manipulation, or even coercion if the requirements for informed consent are not satisfied.
A flowchart for the future
Although current research and innovations typically target specific areas of psychiatry, these advances can be integrated by devising algorithms and protocols that will change the current practice of psychiatry. The Figure provides a glimpse of how the psychiatry clinic of the future might work. A maxim of management is that “the best way to predict the future is to create it.” However, the mere conception of a vision is not enough—working towards it is essential.
Bottom Line
With advances in technology, psychiatric practice will soon be radically different from what it is today. The expanded use of telepsychiatry, social media, artificial intelligence, and web-based applications/devices holds great promise for psychiatric assessment, diagnosis, and treatment, although certain ethical and privacy concerns need to be adequately addressed.
Related Resources
- National Institute of Mental Health. Technology and the future of mental health treatment. www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/index.shtml. Revised September 2019.
- Hays R, Farrell HM, Touros J. Mobile apps and mental health: using technology to quantify real-time clinical risk. Current Psychiatry. 2019;18(6):37-41.
- Torous J, Luo J, Chan SR. Mental health apps: what to tell patients. Current Psychiatry. 2018;17(3):21-25.
1. Pirmohamed M. Pharmacogenetics and pharmacogenomics. Br J Clin Pharmacol. 2001;52(4):345-347.
2. Benitez J, Cool CL, Scotti DJ. Use of combinatorial pharmacogenomic guidance in treating psychiatric disorders. Per Med. 2018;15(6):481-494.
3. Cannon TD. Candidate gene studies in the GWAS era: the MET proto-oncogene, neurocognition, and schizophrenia. Am J Psychiatry. 2010;167(4):4,369-372.
4. Greenwood J, Chamberlain C, Parker G. Evaluation of a rural telepsychiatry service. Australas Psychiatry. 2004;12(3):268-272.
5. Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016;6(2):269-282.
6. Cheng KM, Siu BW, Yeung CC, et al. Telepsychiatry for stable Chinese psychiatric out-patients in custody in Hong Kong: a case-control pilot study. Hong Kong Med J. 2018;24(4):378-383.
7. Frankish K, Ryan C, Harris A. Psychiatry and online social media: potential, pitfalls and ethical guidelines for psychiatrists and trainees. Australasian Psychiatry. 2012;20(3):181-187.
8. de la Torre Díez I, Alonso SG, Hamrioui S, et al. IoT-based services and applications for mental health in the literature. J Med Syst. 2019;43(1):4-9.
9. Topol E. Deep Medicine. New York, NY: Basic Books; 2019:168.
10. Adams RA, Huys QJM, Roiser JP. Computational Psychiatry: towards a mathematically informed understanding of mental illness. J Neurol Neurosurg Psychiatry. 2016;87(1):53-63.
11. Insel TR. Bending the curve for mental health: technology for a public health approach. Am J Public Health. 2019;109(suppl 3):S168-S170.
12. Just MA, Pan L, Cherkassky VL, et al. Machine learning of neural representations of suicide and emotion concepts identifies suicidal youth. Nat Hum Behav. 2017;1:911-919.
13. Pestian J, Nasrallah H, Matykiewicz P, et al. Suicide note classification using natural language processing: a content analysis. Biomed Inform Insights. 2010;2010(3):19-28.
14. Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science. 2017;5(3):457-469.
15. Pestian JP, Sorter M, Connolly B, et al; STM Research Group. A machine learning approach to identifying the thought markers of suicidal subjects: a prospective multicenter trial. Suicide Life Threat Behav. 2017;47(1):112-121.
16. Corcoran CM, Carrillo F, Fernández-Slezak D, et al. Prediction of psychosis across protocols and risk cohorts using automated language analysis. World Psychiatry. 2018;17(1):67-75.
17. Bedi G, Carrillo F, Cecchi GA, et al. Automated analysis of free speech predicts psychosis onset in high-risk youths. NPJ Schizophr. 2015;1:15030. doi: 10.1038/npjschz.2015.30.
18. Kalanderian H, Nasrallah HA. Artificial intelligence in psychiatry. Current Psychiatry. 2019;18(8):33-38.
19. Drysdale AT, Grosenick L, Downar J, et al. Resting-state connectivity biomarkers define neurophysiological subtypes of depression. Nat Med. 2017;23(1):28-38.
20. Chekroud AM, Zotti RJ, Shehzad Z, et al. Cross-trial prediction of treatment outcome in depression: a machine learning approach. Lancet Psychiatry. 2016;3(3):243-250.
21. Grisanzio KA, Goldstein-Piekarski AN, Wang MY, et al. Transdiagnostic symptom clusters and associations with brain, behavior, and daily function in mood, anxiety, and trauma disorders. JAMA Psychiatry. 2018;75(2):201-209.
22. Lucas G, Gratch J, King A, et al. It’s only a computer: virtual humans increase willingness to disclose. Computers in Human Behavior. 2014;37:94-100.
23. Nasir M, Baucom BR, Georgiou P, et al. Predicting couple therapy outcomes based on speech acoustic features. PLoS One. 2017;12(9):e0185123. doi: 10.1371/journal.pone.0185123.
24. Huguet A, Rao S, McGrath PJ, et al. A systematic review of cognitive behavioral therapy and behavioral activation apps for depression. PLoS One. 2016;11(5):e0154248. doi: 10.1371/journal.pone.0154248.
25. Scholten MR, Kelders SM, Van Gemert-Pijnen JE. Self-guided web-based interventions: scoping review on user needs and the potential of embodied conversational agents to address them. J Med Internet Res. 2017;19(11):e383.
26. Topol E. Deep Medicine. New York, NY: Basic Books; 2019:283-310.
27. Abramson EL, McGinnis S, Edwards A, et al. Electronic health record adoption and health information exchange among hospitals in New York State. J Eval Clin Pract. 2012;18(6):1156-1162.
28. Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc. 2014;21(6):1053-1059.
29. Kho AN, Rasmussen LV, Connolly JJ, et al. Practical challenges in integrating genomic data into the electronic health record. Genet Med. 2013;15(10):772-778.
30. Ornstein SM, Oates RB, Fox GN. The computer-based medical record: current status. J Fam Pract. 1992;35(5):556-565.
31. Corea F. Machine ethics and artificial moral agents. In: Applied artificial intelligence: where AI can be used in business. Basel, Switzerland: Springer; 2019:33-41.
32. Beauchamp T, Childress J. Principles of biomedical ethics. 7th ed. New York, NY: Oxford University Press; 2012:44.
Despite the tremendous advances in psychiatry in recent years, the current clinical practice of psychiatry continues to rely on data from intermittent assessments along with subjective and unquantifiable accounts from patients and caregivers. Furthermore, there continues to be significant diagnostic variations among practitioners. Fortunately, technology to address these issues appears to be on the horizon.
How might the psychiatric clinic of the future look? What changes could we envision? These 4 critical factors may soon bring about dynamic changes in the way we practice psychiatry:
- precision psychiatry
- digital psychiatry
- technology-enhanced psychotherapy
- electronic health record (EHR) reforms.
In this article, we review how advances in each of these areas might lead to improved care for our patients.
Precision psychiatry
Precision psychiatry takes into account each patient’s variability in genes, environment, and lifestyle to determine individualized treatment and prevention strategies. It relies on pharmacogenomic testing as the primary tool. Pharmacogenomics is the study of variability in drug response due to heredity.
Emerging data on the clinical utility and cost-effectiveness of pharmacogenomic testing are encouraging, but its routine use is not well supported by current evidence.2 One limit to using pharmacogenomic testing is that many genes simultaneously exert an effect on the structure and function of neurons and associated pathophysiology. According to the International Society of Psychiatric Genetics, no single genetic variant is sufficient to cause psychiatric disorders such as depression, bipolar disorder, substance dependence, or schizophrenia. This limits the possibility of using genetic tests to establish a diagnosis.3
In the future, better algorithms could promote more accurate pharmacogenomics profiles for individual patients, which could influence treatment.
Precision psychiatry could lead to:
- identification of novel targets for new medications
- pharmacogenetic profiling of the patient to predict disease susceptibility and medication response
- personalized therapy: the right drug at the right dose for the right patient.
- improved efficacy and fewer adverse medication reactions.
Continue to: Digital psychiatry
Digital psychiatry
Integrating computer-based technology into psychiatric practice has given birth to a new frontier that could be called digital psychiatry. This might encompass the following:
- telepsychiatry
- social media with a mental health focus
- web-based applications/devices
- artificial intelligence (AI).
Telepsychiatry. Videoconferencing is the most widely used form of telepsychiatry. It provides patients with easier access to mental health treatment.4 Telepsychiatry has the potential to match patients and clinicians with similar cultural backgrounds, thus minimizing cultural gaps and misunderstandings. Most importantly, it is comparable to face-to-face interviews in terms of the reliability of assessment and treatment outcomes.5
Telepsychiatry might be particularly helpful for patients with restricted mobility, such as those who live in remote areas, nursing homes, or correctional facilities. In correctional settings, transferring prisoners is expensive and carries the risk of escape. In a small study (N = 86) conducted in Hong Kong, Chen et al6 found that using videoconferencing to conduct clinical interviews of inmates was cost-efficient and scored high in terms of patient acceptability.
Social media. Social media could be a powerful platform for early detection of mental illness. Staying connected with patients on social media could allow psychiatrists to be more aware of their patient’s mood fluctuations, which might lead to more timely assessments. Physicians could be automatically notified about changes in their patients’ social media activity that indicate changes in mental state, which could solicit immediate intervention and treatment. On the other hand, such use of social media could blur professional boundaries. Psychiatrists also could use social media to promote awareness of mental health and educate the public on ways to improve or maintain their mental well-being.7
Web-based applications/devices. Real-time monitoring through applications or internet-based smart devices creates a new avenue for patients to receive personalized assessments, treatment, and intervention.8 Smartwatches with internet connectivity may offer a glimpse of the wearer’s sleep architecture and duration, thus providing real-time data on patients who have insomnia. We can now passively collect objective data from devices, such as smartphones and laptops, to phenotype an individual’s mood and mental state, a process called digital phenotyping. The Table9 lists examples of the types of mental health–related metrics that can be captured by smartphones, smartwatches, and similar technology. Information from these devices can be accumulated to create a database that can be used to predict symptoms.10 For example, the way people use a smartphone’s keyboard, including latency time between space and character types, can be used to generate variables for data. This type of information is being studied for use in screening depression and passively assessing mood in real time.11
Continue to: Artificial intelligence
Artificial intelligence—the development of computer systems able to perform tasks that normally require human intelligence—is being increasingly used in psychiatry. Some studies have suggested AI can be used to identify patients’ risk of suicide12-15 or psychosis.16,17 Kalanderian and Nasrallah18 reviewed several of these studies in
Other researchers have found clinical uses for machine learning, a subset of AI that uses methods to automatically detect patterns and make predictions based on those patterns. In one study, a machine learning analysis of functional MRI scans was able to identify 4 distinct subtypes of depression.19 In another study, a machine learning model was able to predict with 60% accuracy which patients with depression would respond to antidepressants.20
In the future, AI might be used to change mental health classification systems. Because many mental health disorders share similar symptom clusters, machine learning can help to identify associations between symptoms, behavior, brain function, and real-world function across different diagnoses, potentially affecting how we will classify mental disorders.21
Technology-enhanced psychotherapy
In the future, it might be common for psychotherapy to be provided by a computer, or “virtual therapist.” Several studies have evaluated the use of technology-enhanced psychotherapy.
Lucas et al22 investigated patients’ interactions with a virtual therapist. Participants were interviewed by an avatar named Ellie, who they saw on a TV screen. Half of the participants were told Ellie was not human, and half were told Ellie was being controlled remotely by a human. Three psychologists who were blinded to group allocations analyzed transcripts of the interviews and video recordings of participants’ facial expressions to quantify the participants’ fear, sadness, and other emotional responses during the interviews, as well as their openness to the questions. Participants who believed Ellie was fully automated reported significantly lower fear of self-disclosure and impression management (attempts to control how others perceive them) than participants who were told that Ellie was operated by a human. Additionally, participants who believed they were interacting with a computer were more open during the interview.22
Continue to: Researchers at the University of Southern California...
Researchers at the University of Southern California developed software that assessed 74 acoustic features, including pitch, volume, quality, shimmer, jitter, and prosody, to predict outcomes among patients receiving couples therapy. This software was able to predict marital discord at least as well as human therapists.23
Many mental health apps purport to implement specific components of psychotherapy. Many of these apps focus on cognitive-behavioral therapy worksheets, mindfulness exercises, and/or mood tracking. The features provided by such apps emulate the tasks and intended outcomes of traditional psychotherapy, but in an entirely decentralized venue.24
Some have expressed concern that an increased use of virtual therapists powered by AI might lead to a dehumanization of psychiatry (Box25,26).
Box
Whether there are aspects of the psychiatric patient encounter that cannot be managed by a “virtual clinician” created by artificial intelligence (AI) remains to be determined. Some of the benefits of using AI in this manner may be difficult to anticipate, or may be specific to an individual’s relationship with his/her clinician.25
On the other hand, AI systems blur previously assumed boundaries between reality and fiction, and this could have complex effects on patients. Similar to therapeutic relationships with a human clinician, there is the risk of transference of emotions, thoughts, and feelings to a virtual therapist powered by AI. Unlike with a psychiatrist or therapist, however, there is no person on the other side of this transference. Whether virtual clinicians will be able to manage such transference remains to be seen.
In Deep Medicine,26 cardiologist Eric Topol, MD, emphasizes a crucial component of a patient encounter that AI will be unlikely able to provide: empathy. Virtual therapists powered by AI will inherit the tasks best done by machines, leaving humans more time to do what they do best—providing empathy and being “present” for patients.
Electronic health record reforms
Although many clinicians find EHRs to be onerous and time-consuming, EHR technology is constantly improving, and EHRs have revolutionized documentation and order implementation. Several potential advances could improve clinical practice. For example, EHRs could incorporate a clinical decision support system that uses AI-based algorithms to assist psychiatrists with diagnosis, monitoring, and treatment.27 In the future, EHRs might have the ability to monitor and learn from errors and adverse events, and automatically design an algorithm to avoid them.28 They should be designed to better manage analysis of pharmacogenetic test results, which is challenging due to the amount and complexity of the data.29 Future EHRs should eliminate the non-intuitive and multi-click interfaces and cumbersome data searches of today’s EHRs.30
Technology brings new ethical considerations
Mental health interventions based on AI typically work with algorithms, and algorithms bring ethical issues. Mental health devices or systems that use AI could contain biases that have the potential to harm in unintended ways, such as a data-driven sexist or racist bias.31 This may require investing additional time to explain to patients (and their families) what an algorithm is and how it works in relation to the therapy provided.
Continue to: Another concern is patient...
Another concern is patient autonomy.32 For example, it would be ethically problematic if a patient were to assume that there was a human physician “at the other end” of a virtual therapist or other technology who is communicating or reviewing his/her messages. Similarly, an older adult or a patient with intellectual disabilities may not be able to understand advanced technology or what it does when it is installed in their home to monitor the patient’s activities. This would increase the risk of privacy violations, manipulation, or even coercion if the requirements for informed consent are not satisfied.
A flowchart for the future
Although current research and innovations typically target specific areas of psychiatry, these advances can be integrated by devising algorithms and protocols that will change the current practice of psychiatry. The Figure provides a glimpse of how the psychiatry clinic of the future might work. A maxim of management is that “the best way to predict the future is to create it.” However, the mere conception of a vision is not enough—working towards it is essential.
Bottom Line
With advances in technology, psychiatric practice will soon be radically different from what it is today. The expanded use of telepsychiatry, social media, artificial intelligence, and web-based applications/devices holds great promise for psychiatric assessment, diagnosis, and treatment, although certain ethical and privacy concerns need to be adequately addressed.
Related Resources
- National Institute of Mental Health. Technology and the future of mental health treatment. www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/index.shtml. Revised September 2019.
- Hays R, Farrell HM, Touros J. Mobile apps and mental health: using technology to quantify real-time clinical risk. Current Psychiatry. 2019;18(6):37-41.
- Torous J, Luo J, Chan SR. Mental health apps: what to tell patients. Current Psychiatry. 2018;17(3):21-25.
Despite the tremendous advances in psychiatry in recent years, the current clinical practice of psychiatry continues to rely on data from intermittent assessments along with subjective and unquantifiable accounts from patients and caregivers. Furthermore, there continues to be significant diagnostic variations among practitioners. Fortunately, technology to address these issues appears to be on the horizon.
How might the psychiatric clinic of the future look? What changes could we envision? These 4 critical factors may soon bring about dynamic changes in the way we practice psychiatry:
- precision psychiatry
- digital psychiatry
- technology-enhanced psychotherapy
- electronic health record (EHR) reforms.
In this article, we review how advances in each of these areas might lead to improved care for our patients.
Precision psychiatry
Precision psychiatry takes into account each patient’s variability in genes, environment, and lifestyle to determine individualized treatment and prevention strategies. It relies on pharmacogenomic testing as the primary tool. Pharmacogenomics is the study of variability in drug response due to heredity.
Emerging data on the clinical utility and cost-effectiveness of pharmacogenomic testing are encouraging, but its routine use is not well supported by current evidence.2 One limit to using pharmacogenomic testing is that many genes simultaneously exert an effect on the structure and function of neurons and associated pathophysiology. According to the International Society of Psychiatric Genetics, no single genetic variant is sufficient to cause psychiatric disorders such as depression, bipolar disorder, substance dependence, or schizophrenia. This limits the possibility of using genetic tests to establish a diagnosis.3
In the future, better algorithms could promote more accurate pharmacogenomics profiles for individual patients, which could influence treatment.
Precision psychiatry could lead to:
- identification of novel targets for new medications
- pharmacogenetic profiling of the patient to predict disease susceptibility and medication response
- personalized therapy: the right drug at the right dose for the right patient.
- improved efficacy and fewer adverse medication reactions.
Continue to: Digital psychiatry
Digital psychiatry
Integrating computer-based technology into psychiatric practice has given birth to a new frontier that could be called digital psychiatry. This might encompass the following:
- telepsychiatry
- social media with a mental health focus
- web-based applications/devices
- artificial intelligence (AI).
Telepsychiatry. Videoconferencing is the most widely used form of telepsychiatry. It provides patients with easier access to mental health treatment.4 Telepsychiatry has the potential to match patients and clinicians with similar cultural backgrounds, thus minimizing cultural gaps and misunderstandings. Most importantly, it is comparable to face-to-face interviews in terms of the reliability of assessment and treatment outcomes.5
Telepsychiatry might be particularly helpful for patients with restricted mobility, such as those who live in remote areas, nursing homes, or correctional facilities. In correctional settings, transferring prisoners is expensive and carries the risk of escape. In a small study (N = 86) conducted in Hong Kong, Chen et al6 found that using videoconferencing to conduct clinical interviews of inmates was cost-efficient and scored high in terms of patient acceptability.
Social media. Social media could be a powerful platform for early detection of mental illness. Staying connected with patients on social media could allow psychiatrists to be more aware of their patient’s mood fluctuations, which might lead to more timely assessments. Physicians could be automatically notified about changes in their patients’ social media activity that indicate changes in mental state, which could solicit immediate intervention and treatment. On the other hand, such use of social media could blur professional boundaries. Psychiatrists also could use social media to promote awareness of mental health and educate the public on ways to improve or maintain their mental well-being.7
Web-based applications/devices. Real-time monitoring through applications or internet-based smart devices creates a new avenue for patients to receive personalized assessments, treatment, and intervention.8 Smartwatches with internet connectivity may offer a glimpse of the wearer’s sleep architecture and duration, thus providing real-time data on patients who have insomnia. We can now passively collect objective data from devices, such as smartphones and laptops, to phenotype an individual’s mood and mental state, a process called digital phenotyping. The Table9 lists examples of the types of mental health–related metrics that can be captured by smartphones, smartwatches, and similar technology. Information from these devices can be accumulated to create a database that can be used to predict symptoms.10 For example, the way people use a smartphone’s keyboard, including latency time between space and character types, can be used to generate variables for data. This type of information is being studied for use in screening depression and passively assessing mood in real time.11
Continue to: Artificial intelligence
Artificial intelligence—the development of computer systems able to perform tasks that normally require human intelligence—is being increasingly used in psychiatry. Some studies have suggested AI can be used to identify patients’ risk of suicide12-15 or psychosis.16,17 Kalanderian and Nasrallah18 reviewed several of these studies in
Other researchers have found clinical uses for machine learning, a subset of AI that uses methods to automatically detect patterns and make predictions based on those patterns. In one study, a machine learning analysis of functional MRI scans was able to identify 4 distinct subtypes of depression.19 In another study, a machine learning model was able to predict with 60% accuracy which patients with depression would respond to antidepressants.20
In the future, AI might be used to change mental health classification systems. Because many mental health disorders share similar symptom clusters, machine learning can help to identify associations between symptoms, behavior, brain function, and real-world function across different diagnoses, potentially affecting how we will classify mental disorders.21
Technology-enhanced psychotherapy
In the future, it might be common for psychotherapy to be provided by a computer, or “virtual therapist.” Several studies have evaluated the use of technology-enhanced psychotherapy.
Lucas et al22 investigated patients’ interactions with a virtual therapist. Participants were interviewed by an avatar named Ellie, who they saw on a TV screen. Half of the participants were told Ellie was not human, and half were told Ellie was being controlled remotely by a human. Three psychologists who were blinded to group allocations analyzed transcripts of the interviews and video recordings of participants’ facial expressions to quantify the participants’ fear, sadness, and other emotional responses during the interviews, as well as their openness to the questions. Participants who believed Ellie was fully automated reported significantly lower fear of self-disclosure and impression management (attempts to control how others perceive them) than participants who were told that Ellie was operated by a human. Additionally, participants who believed they were interacting with a computer were more open during the interview.22
Continue to: Researchers at the University of Southern California...
Researchers at the University of Southern California developed software that assessed 74 acoustic features, including pitch, volume, quality, shimmer, jitter, and prosody, to predict outcomes among patients receiving couples therapy. This software was able to predict marital discord at least as well as human therapists.23
Many mental health apps purport to implement specific components of psychotherapy. Many of these apps focus on cognitive-behavioral therapy worksheets, mindfulness exercises, and/or mood tracking. The features provided by such apps emulate the tasks and intended outcomes of traditional psychotherapy, but in an entirely decentralized venue.24
Some have expressed concern that an increased use of virtual therapists powered by AI might lead to a dehumanization of psychiatry (Box25,26).
Box
Whether there are aspects of the psychiatric patient encounter that cannot be managed by a “virtual clinician” created by artificial intelligence (AI) remains to be determined. Some of the benefits of using AI in this manner may be difficult to anticipate, or may be specific to an individual’s relationship with his/her clinician.25
On the other hand, AI systems blur previously assumed boundaries between reality and fiction, and this could have complex effects on patients. Similar to therapeutic relationships with a human clinician, there is the risk of transference of emotions, thoughts, and feelings to a virtual therapist powered by AI. Unlike with a psychiatrist or therapist, however, there is no person on the other side of this transference. Whether virtual clinicians will be able to manage such transference remains to be seen.
In Deep Medicine,26 cardiologist Eric Topol, MD, emphasizes a crucial component of a patient encounter that AI will be unlikely able to provide: empathy. Virtual therapists powered by AI will inherit the tasks best done by machines, leaving humans more time to do what they do best—providing empathy and being “present” for patients.
Electronic health record reforms
Although many clinicians find EHRs to be onerous and time-consuming, EHR technology is constantly improving, and EHRs have revolutionized documentation and order implementation. Several potential advances could improve clinical practice. For example, EHRs could incorporate a clinical decision support system that uses AI-based algorithms to assist psychiatrists with diagnosis, monitoring, and treatment.27 In the future, EHRs might have the ability to monitor and learn from errors and adverse events, and automatically design an algorithm to avoid them.28 They should be designed to better manage analysis of pharmacogenetic test results, which is challenging due to the amount and complexity of the data.29 Future EHRs should eliminate the non-intuitive and multi-click interfaces and cumbersome data searches of today’s EHRs.30
Technology brings new ethical considerations
Mental health interventions based on AI typically work with algorithms, and algorithms bring ethical issues. Mental health devices or systems that use AI could contain biases that have the potential to harm in unintended ways, such as a data-driven sexist or racist bias.31 This may require investing additional time to explain to patients (and their families) what an algorithm is and how it works in relation to the therapy provided.
Continue to: Another concern is patient...
Another concern is patient autonomy.32 For example, it would be ethically problematic if a patient were to assume that there was a human physician “at the other end” of a virtual therapist or other technology who is communicating or reviewing his/her messages. Similarly, an older adult or a patient with intellectual disabilities may not be able to understand advanced technology or what it does when it is installed in their home to monitor the patient’s activities. This would increase the risk of privacy violations, manipulation, or even coercion if the requirements for informed consent are not satisfied.
A flowchart for the future
Although current research and innovations typically target specific areas of psychiatry, these advances can be integrated by devising algorithms and protocols that will change the current practice of psychiatry. The Figure provides a glimpse of how the psychiatry clinic of the future might work. A maxim of management is that “the best way to predict the future is to create it.” However, the mere conception of a vision is not enough—working towards it is essential.
Bottom Line
With advances in technology, psychiatric practice will soon be radically different from what it is today. The expanded use of telepsychiatry, social media, artificial intelligence, and web-based applications/devices holds great promise for psychiatric assessment, diagnosis, and treatment, although certain ethical and privacy concerns need to be adequately addressed.
Related Resources
- National Institute of Mental Health. Technology and the future of mental health treatment. www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/index.shtml. Revised September 2019.
- Hays R, Farrell HM, Touros J. Mobile apps and mental health: using technology to quantify real-time clinical risk. Current Psychiatry. 2019;18(6):37-41.
- Torous J, Luo J, Chan SR. Mental health apps: what to tell patients. Current Psychiatry. 2018;17(3):21-25.
1. Pirmohamed M. Pharmacogenetics and pharmacogenomics. Br J Clin Pharmacol. 2001;52(4):345-347.
2. Benitez J, Cool CL, Scotti DJ. Use of combinatorial pharmacogenomic guidance in treating psychiatric disorders. Per Med. 2018;15(6):481-494.
3. Cannon TD. Candidate gene studies in the GWAS era: the MET proto-oncogene, neurocognition, and schizophrenia. Am J Psychiatry. 2010;167(4):4,369-372.
4. Greenwood J, Chamberlain C, Parker G. Evaluation of a rural telepsychiatry service. Australas Psychiatry. 2004;12(3):268-272.
5. Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016;6(2):269-282.
6. Cheng KM, Siu BW, Yeung CC, et al. Telepsychiatry for stable Chinese psychiatric out-patients in custody in Hong Kong: a case-control pilot study. Hong Kong Med J. 2018;24(4):378-383.
7. Frankish K, Ryan C, Harris A. Psychiatry and online social media: potential, pitfalls and ethical guidelines for psychiatrists and trainees. Australasian Psychiatry. 2012;20(3):181-187.
8. de la Torre Díez I, Alonso SG, Hamrioui S, et al. IoT-based services and applications for mental health in the literature. J Med Syst. 2019;43(1):4-9.
9. Topol E. Deep Medicine. New York, NY: Basic Books; 2019:168.
10. Adams RA, Huys QJM, Roiser JP. Computational Psychiatry: towards a mathematically informed understanding of mental illness. J Neurol Neurosurg Psychiatry. 2016;87(1):53-63.
11. Insel TR. Bending the curve for mental health: technology for a public health approach. Am J Public Health. 2019;109(suppl 3):S168-S170.
12. Just MA, Pan L, Cherkassky VL, et al. Machine learning of neural representations of suicide and emotion concepts identifies suicidal youth. Nat Hum Behav. 2017;1:911-919.
13. Pestian J, Nasrallah H, Matykiewicz P, et al. Suicide note classification using natural language processing: a content analysis. Biomed Inform Insights. 2010;2010(3):19-28.
14. Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science. 2017;5(3):457-469.
15. Pestian JP, Sorter M, Connolly B, et al; STM Research Group. A machine learning approach to identifying the thought markers of suicidal subjects: a prospective multicenter trial. Suicide Life Threat Behav. 2017;47(1):112-121.
16. Corcoran CM, Carrillo F, Fernández-Slezak D, et al. Prediction of psychosis across protocols and risk cohorts using automated language analysis. World Psychiatry. 2018;17(1):67-75.
17. Bedi G, Carrillo F, Cecchi GA, et al. Automated analysis of free speech predicts psychosis onset in high-risk youths. NPJ Schizophr. 2015;1:15030. doi: 10.1038/npjschz.2015.30.
18. Kalanderian H, Nasrallah HA. Artificial intelligence in psychiatry. Current Psychiatry. 2019;18(8):33-38.
19. Drysdale AT, Grosenick L, Downar J, et al. Resting-state connectivity biomarkers define neurophysiological subtypes of depression. Nat Med. 2017;23(1):28-38.
20. Chekroud AM, Zotti RJ, Shehzad Z, et al. Cross-trial prediction of treatment outcome in depression: a machine learning approach. Lancet Psychiatry. 2016;3(3):243-250.
21. Grisanzio KA, Goldstein-Piekarski AN, Wang MY, et al. Transdiagnostic symptom clusters and associations with brain, behavior, and daily function in mood, anxiety, and trauma disorders. JAMA Psychiatry. 2018;75(2):201-209.
22. Lucas G, Gratch J, King A, et al. It’s only a computer: virtual humans increase willingness to disclose. Computers in Human Behavior. 2014;37:94-100.
23. Nasir M, Baucom BR, Georgiou P, et al. Predicting couple therapy outcomes based on speech acoustic features. PLoS One. 2017;12(9):e0185123. doi: 10.1371/journal.pone.0185123.
24. Huguet A, Rao S, McGrath PJ, et al. A systematic review of cognitive behavioral therapy and behavioral activation apps for depression. PLoS One. 2016;11(5):e0154248. doi: 10.1371/journal.pone.0154248.
25. Scholten MR, Kelders SM, Van Gemert-Pijnen JE. Self-guided web-based interventions: scoping review on user needs and the potential of embodied conversational agents to address them. J Med Internet Res. 2017;19(11):e383.
26. Topol E. Deep Medicine. New York, NY: Basic Books; 2019:283-310.
27. Abramson EL, McGinnis S, Edwards A, et al. Electronic health record adoption and health information exchange among hospitals in New York State. J Eval Clin Pract. 2012;18(6):1156-1162.
28. Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc. 2014;21(6):1053-1059.
29. Kho AN, Rasmussen LV, Connolly JJ, et al. Practical challenges in integrating genomic data into the electronic health record. Genet Med. 2013;15(10):772-778.
30. Ornstein SM, Oates RB, Fox GN. The computer-based medical record: current status. J Fam Pract. 1992;35(5):556-565.
31. Corea F. Machine ethics and artificial moral agents. In: Applied artificial intelligence: where AI can be used in business. Basel, Switzerland: Springer; 2019:33-41.
32. Beauchamp T, Childress J. Principles of biomedical ethics. 7th ed. New York, NY: Oxford University Press; 2012:44.
1. Pirmohamed M. Pharmacogenetics and pharmacogenomics. Br J Clin Pharmacol. 2001;52(4):345-347.
2. Benitez J, Cool CL, Scotti DJ. Use of combinatorial pharmacogenomic guidance in treating psychiatric disorders. Per Med. 2018;15(6):481-494.
3. Cannon TD. Candidate gene studies in the GWAS era: the MET proto-oncogene, neurocognition, and schizophrenia. Am J Psychiatry. 2010;167(4):4,369-372.
4. Greenwood J, Chamberlain C, Parker G. Evaluation of a rural telepsychiatry service. Australas Psychiatry. 2004;12(3):268-272.
5. Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016;6(2):269-282.
6. Cheng KM, Siu BW, Yeung CC, et al. Telepsychiatry for stable Chinese psychiatric out-patients in custody in Hong Kong: a case-control pilot study. Hong Kong Med J. 2018;24(4):378-383.
7. Frankish K, Ryan C, Harris A. Psychiatry and online social media: potential, pitfalls and ethical guidelines for psychiatrists and trainees. Australasian Psychiatry. 2012;20(3):181-187.
8. de la Torre Díez I, Alonso SG, Hamrioui S, et al. IoT-based services and applications for mental health in the literature. J Med Syst. 2019;43(1):4-9.
9. Topol E. Deep Medicine. New York, NY: Basic Books; 2019:168.
10. Adams RA, Huys QJM, Roiser JP. Computational Psychiatry: towards a mathematically informed understanding of mental illness. J Neurol Neurosurg Psychiatry. 2016;87(1):53-63.
11. Insel TR. Bending the curve for mental health: technology for a public health approach. Am J Public Health. 2019;109(suppl 3):S168-S170.
12. Just MA, Pan L, Cherkassky VL, et al. Machine learning of neural representations of suicide and emotion concepts identifies suicidal youth. Nat Hum Behav. 2017;1:911-919.
13. Pestian J, Nasrallah H, Matykiewicz P, et al. Suicide note classification using natural language processing: a content analysis. Biomed Inform Insights. 2010;2010(3):19-28.
14. Walsh CG, Ribeiro JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science. 2017;5(3):457-469.
15. Pestian JP, Sorter M, Connolly B, et al; STM Research Group. A machine learning approach to identifying the thought markers of suicidal subjects: a prospective multicenter trial. Suicide Life Threat Behav. 2017;47(1):112-121.
16. Corcoran CM, Carrillo F, Fernández-Slezak D, et al. Prediction of psychosis across protocols and risk cohorts using automated language analysis. World Psychiatry. 2018;17(1):67-75.
17. Bedi G, Carrillo F, Cecchi GA, et al. Automated analysis of free speech predicts psychosis onset in high-risk youths. NPJ Schizophr. 2015;1:15030. doi: 10.1038/npjschz.2015.30.
18. Kalanderian H, Nasrallah HA. Artificial intelligence in psychiatry. Current Psychiatry. 2019;18(8):33-38.
19. Drysdale AT, Grosenick L, Downar J, et al. Resting-state connectivity biomarkers define neurophysiological subtypes of depression. Nat Med. 2017;23(1):28-38.
20. Chekroud AM, Zotti RJ, Shehzad Z, et al. Cross-trial prediction of treatment outcome in depression: a machine learning approach. Lancet Psychiatry. 2016;3(3):243-250.
21. Grisanzio KA, Goldstein-Piekarski AN, Wang MY, et al. Transdiagnostic symptom clusters and associations with brain, behavior, and daily function in mood, anxiety, and trauma disorders. JAMA Psychiatry. 2018;75(2):201-209.
22. Lucas G, Gratch J, King A, et al. It’s only a computer: virtual humans increase willingness to disclose. Computers in Human Behavior. 2014;37:94-100.
23. Nasir M, Baucom BR, Georgiou P, et al. Predicting couple therapy outcomes based on speech acoustic features. PLoS One. 2017;12(9):e0185123. doi: 10.1371/journal.pone.0185123.
24. Huguet A, Rao S, McGrath PJ, et al. A systematic review of cognitive behavioral therapy and behavioral activation apps for depression. PLoS One. 2016;11(5):e0154248. doi: 10.1371/journal.pone.0154248.
25. Scholten MR, Kelders SM, Van Gemert-Pijnen JE. Self-guided web-based interventions: scoping review on user needs and the potential of embodied conversational agents to address them. J Med Internet Res. 2017;19(11):e383.
26. Topol E. Deep Medicine. New York, NY: Basic Books; 2019:283-310.
27. Abramson EL, McGinnis S, Edwards A, et al. Electronic health record adoption and health information exchange among hospitals in New York State. J Eval Clin Pract. 2012;18(6):1156-1162.
28. Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc. 2014;21(6):1053-1059.
29. Kho AN, Rasmussen LV, Connolly JJ, et al. Practical challenges in integrating genomic data into the electronic health record. Genet Med. 2013;15(10):772-778.
30. Ornstein SM, Oates RB, Fox GN. The computer-based medical record: current status. J Fam Pract. 1992;35(5):556-565.
31. Corea F. Machine ethics and artificial moral agents. In: Applied artificial intelligence: where AI can be used in business. Basel, Switzerland: Springer; 2019:33-41.
32. Beauchamp T, Childress J. Principles of biomedical ethics. 7th ed. New York, NY: Oxford University Press; 2012:44.
In the Phoenix area, we are in a lull before the coronavirus storm
“There is no sound save the throb of the blowers and the vibration of the hard-driven engines. There is little motion as the gun crews man their guns and the fire-control details stand with heads bent and their hands clapped over their headphones. Somewhere out there are the enemy planes.”
That’s from one of my favorite WW2 histories, “Torpedo Junction,” by Robert J. Casey. He was a reporter stationed on board the cruiser USS Salt Lake City. The entry is from a day in February 1942 when the ship was part of a force that bombarded the Japanese encampment on Wake Island. The excerpt describes the scene later that afternoon, as they awaited a counterattack from Japanese planes.
For some reason that paragraph kept going through my mind this past Sunday afternoon, in the comparatively mundane situation of sitting in the hospital library signing off on my dictations and reviewing test results. I certainly was in no danger of being bombed or strafed, yet ...
Around me, the hospital was preparing for battle. As I rounded, most of the beds were empty and many of the floors above me were shut down and darkened. Waiting rooms were empty. If you hadn’t read the news you’d think there was a sudden lull in the health care world.
But the real truth is that it’s the calm before an anticipated storm. The elective procedures have all been canceled. Nonurgent outpatient tests are on hold. Only the sickest are being admitted, and they’re being sent out as soon as possible. Every bed possible is being kept open for the feared onslaught of coronavirus patients in the coming weeks. Protective equipment, already in short supply, is being stockpiled as it becomes available. Plans have been made to erect triage tents in the parking lots.
I sit in the library and think of this. It’s quiet except for the soft hum of the air conditioning blowers as Phoenix starts to warm up for another summer. The muted purr of the computer’s hard drive as I click away on the keys. On the floors above me the nurses and respiratory techs and doctors go about their daily business of patient care, wondering when the real battle will begin (probably 2-3 weeks from the time of this writing, if not sooner).
These are scary times. I’d be lying if I said I wasn’t frightened about what might happen to me, my family, my friends, my coworkers, my patients.
The people working in the hospital above me are in the same boat, all nervous about what’s going to happen. None of them is any more immune to coronavirus than the people they’ll be treating.
But, like the crew of the USS Salt Lake City, they’re ready to do their jobs. Because it’s part of what drove each of us into our own part of this field. Because we care and want to help. And health care doesn’t work unless the whole team does.
I respect them all for it. I always have and always will, and now more than ever.
Good luck.
Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.
“There is no sound save the throb of the blowers and the vibration of the hard-driven engines. There is little motion as the gun crews man their guns and the fire-control details stand with heads bent and their hands clapped over their headphones. Somewhere out there are the enemy planes.”
That’s from one of my favorite WW2 histories, “Torpedo Junction,” by Robert J. Casey. He was a reporter stationed on board the cruiser USS Salt Lake City. The entry is from a day in February 1942 when the ship was part of a force that bombarded the Japanese encampment on Wake Island. The excerpt describes the scene later that afternoon, as they awaited a counterattack from Japanese planes.
For some reason that paragraph kept going through my mind this past Sunday afternoon, in the comparatively mundane situation of sitting in the hospital library signing off on my dictations and reviewing test results. I certainly was in no danger of being bombed or strafed, yet ...
Around me, the hospital was preparing for battle. As I rounded, most of the beds were empty and many of the floors above me were shut down and darkened. Waiting rooms were empty. If you hadn’t read the news you’d think there was a sudden lull in the health care world.
But the real truth is that it’s the calm before an anticipated storm. The elective procedures have all been canceled. Nonurgent outpatient tests are on hold. Only the sickest are being admitted, and they’re being sent out as soon as possible. Every bed possible is being kept open for the feared onslaught of coronavirus patients in the coming weeks. Protective equipment, already in short supply, is being stockpiled as it becomes available. Plans have been made to erect triage tents in the parking lots.
I sit in the library and think of this. It’s quiet except for the soft hum of the air conditioning blowers as Phoenix starts to warm up for another summer. The muted purr of the computer’s hard drive as I click away on the keys. On the floors above me the nurses and respiratory techs and doctors go about their daily business of patient care, wondering when the real battle will begin (probably 2-3 weeks from the time of this writing, if not sooner).
These are scary times. I’d be lying if I said I wasn’t frightened about what might happen to me, my family, my friends, my coworkers, my patients.
The people working in the hospital above me are in the same boat, all nervous about what’s going to happen. None of them is any more immune to coronavirus than the people they’ll be treating.
But, like the crew of the USS Salt Lake City, they’re ready to do their jobs. Because it’s part of what drove each of us into our own part of this field. Because we care and want to help. And health care doesn’t work unless the whole team does.
I respect them all for it. I always have and always will, and now more than ever.
Good luck.
Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.
“There is no sound save the throb of the blowers and the vibration of the hard-driven engines. There is little motion as the gun crews man their guns and the fire-control details stand with heads bent and their hands clapped over their headphones. Somewhere out there are the enemy planes.”
That’s from one of my favorite WW2 histories, “Torpedo Junction,” by Robert J. Casey. He was a reporter stationed on board the cruiser USS Salt Lake City. The entry is from a day in February 1942 when the ship was part of a force that bombarded the Japanese encampment on Wake Island. The excerpt describes the scene later that afternoon, as they awaited a counterattack from Japanese planes.
For some reason that paragraph kept going through my mind this past Sunday afternoon, in the comparatively mundane situation of sitting in the hospital library signing off on my dictations and reviewing test results. I certainly was in no danger of being bombed or strafed, yet ...
Around me, the hospital was preparing for battle. As I rounded, most of the beds were empty and many of the floors above me were shut down and darkened. Waiting rooms were empty. If you hadn’t read the news you’d think there was a sudden lull in the health care world.
But the real truth is that it’s the calm before an anticipated storm. The elective procedures have all been canceled. Nonurgent outpatient tests are on hold. Only the sickest are being admitted, and they’re being sent out as soon as possible. Every bed possible is being kept open for the feared onslaught of coronavirus patients in the coming weeks. Protective equipment, already in short supply, is being stockpiled as it becomes available. Plans have been made to erect triage tents in the parking lots.
I sit in the library and think of this. It’s quiet except for the soft hum of the air conditioning blowers as Phoenix starts to warm up for another summer. The muted purr of the computer’s hard drive as I click away on the keys. On the floors above me the nurses and respiratory techs and doctors go about their daily business of patient care, wondering when the real battle will begin (probably 2-3 weeks from the time of this writing, if not sooner).
These are scary times. I’d be lying if I said I wasn’t frightened about what might happen to me, my family, my friends, my coworkers, my patients.
The people working in the hospital above me are in the same boat, all nervous about what’s going to happen. None of them is any more immune to coronavirus than the people they’ll be treating.
But, like the crew of the USS Salt Lake City, they’re ready to do their jobs. Because it’s part of what drove each of us into our own part of this field. Because we care and want to help. And health care doesn’t work unless the whole team does.
I respect them all for it. I always have and always will, and now more than ever.
Good luck.
Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.