User login
COVID-19: New guidance to stem mental health crisis in frontline HCPs
A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.
Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.
“Support needs to be deployed in multiple dimensions – including individual, organizational, and societal levels – and include training in resilience, stress reduction, emotional awareness, and self-care strategies,” lead author Rachel Schwartz, PhD, health services researcher, Stanford (Calif.) University, said in an interview.
The review was published Aug. 21 in the Annals of Internal Medicine.
An opportune moment
Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”
Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.
Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.
“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.
The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.
Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.
Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
‘Uniquely isolated’
Dr. Margolis noted that
“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.
Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.
Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.
Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.
“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
‘Battle buddies’
Dr. Margolis recommended the “battle buddy” model for mutual peer support.
Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.
“We connect residents with each other, and they form pairs to support each other and watch for warning signs such as withdrawal from colleagues, being frequently tearful, not showing up at work or showing up late, missing assignments, making mistakes at work, increased use of alcohol, or verbalizing serious concerns,” Dr. Anand said.
If the buddy shows any of these warning signs, he or she can be directed to appropriate resources to get help.
Since the pandemic has interfered with the ability to connect with colleagues and family members, attention should be paid to addressing the social support needs of clinicians.
Dr. Anand suggested that clinicians maintain contact with counselors, friends, and family, even if they cannot be together in person and must connect “virtually.”
Resilience and strength training are “key” components of reducing clinician distress, but trainings as well as processing groups and support workshops should be offered during protected time, Dr. Margolis advised, since it can be burdensome for clinicians to wake up early or stay late to attend these sessions.
Leaders and administrators should “model self-care and well-being,” she noted. For example, sending emails to clinicians late at night or on weekends creates an expectation of a rapid reply, which leads to additional pressure for the clinician.
“This is of the most powerful unspoken curricula we can develop,” Dr. Margolis emphasized.
Self-care critical
Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”
Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.
The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”
They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.
The authors and Dr. Shaker disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.
Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.
“Support needs to be deployed in multiple dimensions – including individual, organizational, and societal levels – and include training in resilience, stress reduction, emotional awareness, and self-care strategies,” lead author Rachel Schwartz, PhD, health services researcher, Stanford (Calif.) University, said in an interview.
The review was published Aug. 21 in the Annals of Internal Medicine.
An opportune moment
Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”
Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.
Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.
“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.
The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.
Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.
Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
‘Uniquely isolated’
Dr. Margolis noted that
“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.
Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.
Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.
Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.
“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
‘Battle buddies’
Dr. Margolis recommended the “battle buddy” model for mutual peer support.
Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.
“We connect residents with each other, and they form pairs to support each other and watch for warning signs such as withdrawal from colleagues, being frequently tearful, not showing up at work or showing up late, missing assignments, making mistakes at work, increased use of alcohol, or verbalizing serious concerns,” Dr. Anand said.
If the buddy shows any of these warning signs, he or she can be directed to appropriate resources to get help.
Since the pandemic has interfered with the ability to connect with colleagues and family members, attention should be paid to addressing the social support needs of clinicians.
Dr. Anand suggested that clinicians maintain contact with counselors, friends, and family, even if they cannot be together in person and must connect “virtually.”
Resilience and strength training are “key” components of reducing clinician distress, but trainings as well as processing groups and support workshops should be offered during protected time, Dr. Margolis advised, since it can be burdensome for clinicians to wake up early or stay late to attend these sessions.
Leaders and administrators should “model self-care and well-being,” she noted. For example, sending emails to clinicians late at night or on weekends creates an expectation of a rapid reply, which leads to additional pressure for the clinician.
“This is of the most powerful unspoken curricula we can develop,” Dr. Margolis emphasized.
Self-care critical
Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”
Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.
The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”
They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.
The authors and Dr. Shaker disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.
Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.
“Support needs to be deployed in multiple dimensions – including individual, organizational, and societal levels – and include training in resilience, stress reduction, emotional awareness, and self-care strategies,” lead author Rachel Schwartz, PhD, health services researcher, Stanford (Calif.) University, said in an interview.
The review was published Aug. 21 in the Annals of Internal Medicine.
An opportune moment
Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”
Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.
Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.
“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.
The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.
Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.
Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
‘Uniquely isolated’
Dr. Margolis noted that
“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.
Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.
Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.
Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.
“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
‘Battle buddies’
Dr. Margolis recommended the “battle buddy” model for mutual peer support.
Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.
“We connect residents with each other, and they form pairs to support each other and watch for warning signs such as withdrawal from colleagues, being frequently tearful, not showing up at work or showing up late, missing assignments, making mistakes at work, increased use of alcohol, or verbalizing serious concerns,” Dr. Anand said.
If the buddy shows any of these warning signs, he or she can be directed to appropriate resources to get help.
Since the pandemic has interfered with the ability to connect with colleagues and family members, attention should be paid to addressing the social support needs of clinicians.
Dr. Anand suggested that clinicians maintain contact with counselors, friends, and family, even if they cannot be together in person and must connect “virtually.”
Resilience and strength training are “key” components of reducing clinician distress, but trainings as well as processing groups and support workshops should be offered during protected time, Dr. Margolis advised, since it can be burdensome for clinicians to wake up early or stay late to attend these sessions.
Leaders and administrators should “model self-care and well-being,” she noted. For example, sending emails to clinicians late at night or on weekends creates an expectation of a rapid reply, which leads to additional pressure for the clinician.
“This is of the most powerful unspoken curricula we can develop,” Dr. Margolis emphasized.
Self-care critical
Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”
Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.
The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”
They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.
The authors and Dr. Shaker disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Colorism can lead to intrafamily conflict
The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.
Meeting the family
The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.
“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”
Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.
“Bruce gets picked on in school.”
Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”
“But they are mistreating him,” Mrs. Jaspers says.
The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.
Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.
“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”
Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.
“Bruce, what do you have to say?”
Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.
At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.
Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”
“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”
Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “
The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:
“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.
Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”
They all look back and forth at each other. There is another long silence.
“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “
“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.
“You can’t protect him forever,” says her husband, gently reaching over to her.
Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.
Dr. Sally asks the important question to the whole family.
“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”
This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.
“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."
Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.
Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”
Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.
“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.
“Mrs. Jaspers, it is now your turn to respond.”
“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”
“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”
Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?
This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.
Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
Offering perspective on colorism
In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.
“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”
Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”
and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.
Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.
The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.
Meeting the family
The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.
“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”
Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.
“Bruce gets picked on in school.”
Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”
“But they are mistreating him,” Mrs. Jaspers says.
The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.
Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.
“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”
Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.
“Bruce, what do you have to say?”
Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.
At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.
Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”
“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”
Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “
The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:
“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.
Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”
They all look back and forth at each other. There is another long silence.
“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “
“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.
“You can’t protect him forever,” says her husband, gently reaching over to her.
Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.
Dr. Sally asks the important question to the whole family.
“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”
This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.
“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."
Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.
Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”
Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.
“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.
“Mrs. Jaspers, it is now your turn to respond.”
“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”
“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”
Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?
This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.
Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
Offering perspective on colorism
In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.
“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”
Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”
and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.
Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.
The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.
Meeting the family
The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.
“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”
Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.
“Bruce gets picked on in school.”
Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”
“But they are mistreating him,” Mrs. Jaspers says.
The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.
Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.
“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”
Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.
“Bruce, what do you have to say?”
Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.
At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.
Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”
“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”
Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “
The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:
“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.
Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”
They all look back and forth at each other. There is another long silence.
“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “
“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.
“You can’t protect him forever,” says her husband, gently reaching over to her.
Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.
Dr. Sally asks the important question to the whole family.
“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”
This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.
“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."
Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.
Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”
Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.
“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.
“Mrs. Jaspers, it is now your turn to respond.”
“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”
“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”
Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?
This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.
Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
Offering perspective on colorism
In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.
“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”
Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”
and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.
Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.
COVID-19: ‘Record’ spike in Internet anxiety, panic queries
Internet searches regarding acute anxiety reached an all-time high between March and May 2020, new research shows.
Investigators used data collected by Google to monitor the daily percentage of all Internet searches originating in the United States that included the terms “anxiety” or “panic” in combination with “attack” between January 2004 and May 2020.
They found an 11% increase in all acute anxiety queries between March 2020, when President Donald Trump first declared the COVID-19 pandemic a national emergency, and May 2020. This translates into approximately 375,000 more searches than expected.
Most of the increase in inquiries occurred when specific developments in COVID-19 were reported.
“We found record levels of people potentially having panic attacks, as reflected by their online queries since early in the pandemic,” lead author John W. Ayers, PhD, associate adjunct professor of medicine, school of health sciences, University of California, San Diego, said in an interview.
“There are two main take-home messages from our research – one is that we need to think about how to address acute anxiety during COVID-19, and the other is that who is also vice chief of innovation, division of infectious diseases and global public health at the University of California, San Diego.
The study was published online August 24 in JAMA Internal Medicine.
Real-time data
“There has been a lot of speculation about collateral consequences of COVID-19, especially in mental health,” Dr. Ayers said.
Most of the research has been conducted via self-report survey, but these types of surveys may miss individuals who do not participate in the surveys or do not seek care, Dr. Ayers added.
“We need a strategy that can measure behavioral health in real time so we can design interventions to meet these needs,” he said.
He explained that he and his colleagues “looked at one case study – panic attacks – because it is the most prevalent form of mental health problem driven by your surroundings, and it is socially contagious, meaning that when someone you know is having a severe acute anxiety or panic attack, you’re more likely to have one yourself.”
The researchers turned to publicly available nonidentifiable data collected via Google Trends – a feature of Google that shows how frequently a given search term is entered into Google’s search engine, relative to the site’s total search volume, over a specific period.
They monitored all searches containing their keywords over a 15-year period (Jan. 1, 2004–May 4, 2020). Search volumes between March 13, 2020 (when the national emergency was declared) and the last date of available data (May 9, 2020) were compared with the expected search volumes that would have been found had COVID-19 not occurred.
Headline-related spikes
Cumulatively, all acute anxiety searches were 11% higher than expected for the 58-day study period (95% confidence interval, 7%-14%). There was a dramatic increase in searches (375,000), or a total of 3.4 million searches, during that period.
Most of these searches took place between March 16, 2020, and April 14, 2020, when searches were cumulatively 17% higher than expected (95% CI, 13%-22%).
Several COVID-19–related milestones took place during that period.
- First imposition of social distancing guidelines occurred (March 16, 2020).
- The United States surpassed China with the most reported COVID-19 cases (March 26, 2020).
- Extension of social distancing guidelines occurred (March 29, 2020).
- The Centers for Disease Control and Prevention recommended use of face masks (April 3, 2020).
- The United States surpassed Italy for having the most COVID-19–related deaths (April 11, 2020).
The largest spike in acute anxiety queries occurred on March 28, 2020, on which date there were 52% more searches than expected. Queries returned to expected levels on April 15, 2020, and have fallen within expected ranges since then.
Dr. Ayers noted that, although other stressors have affected people in the United States, including electoral and economic issues, “the headlines around COVID-19 were driving the anxiety, and those days with dramatic headlines were associated with large spikes in queries.”
“Our messaging surrounding how COVID-19 is reported may need to change to prevent this,” Dr. Ayers said. “Headlines that hit people in the head by reporting how many people died and bury in the article how we can slow the spread may increase anxiety more than headlines reporting strategies that work right up front.”
He noted that media reporting of suicide has begun to change; there have been fewer sensationalized headlines, and there has been an increase in referrals to suicide hotlines. “We need to be thinking about similar strategies when reporting COVID-19,” said Dr. Ayers.
He also suggested tapping existing resources, such as state suicide hotlines, by training staff to assist persons experiencing acute anxiety and panic attacks.
As an example of this model, the authors point to an Illinois-based hotline, Call4Calm, which helps people cope with acute COVID-19 anxiety.
Google queries concerning panic and anxiety do not yield any links to helplines, although OneBox, a Google feature, provides information to people inquiring about suicide and addiction. “This approach could be used to promote resources about anxiety and panic and COVID-19,” Dr. Ayers suggested.
Call to action
Elspeth Cameron Ritchie, MD, chair of the department of psychiatry, Medstar Washington Hospital Center, said the study’s recommendations were “interesting and worth amplifying “ and that “headlines calling for calm” were “a good suggestion.” She was not involved with the study.
“A multifaceted, multimedia approach is needed – not only what’s on Google, but it would be helpful if politicians could acknowledge the anxiety and make available more mental health resources,” she added.
Dr. Ritchie, who is also vice chair of psychiatry at Georgetown University, Washington, suggested that it is a “simple option [during patient visits] to incorporate a question as to how your patient is being affected by the pandemic into your standard template, together with questions about sleep, appetite, sexual functioning, etc.”
Dr. Ayers said that the “call to action” that he and his colleagues are making is to use their methodology to “know what mental health needs are in the population” and to use existing frameworks and strategies to address them.
The study was supported by a grant from the University of California office of the president and by intramural support from the division of infectious diseases and the Center for Data Driven Health at the Qualcomm Institute, both with the University of California, San Diego. One coauthor was funded by Bill and Melinda Gates through the Global Good Fund. Dr. Ayers owns equity positions in Directing Medicine, Health Watcher, and Good Analytics, companies that advise on the use of digital data for public health surveillance. Dr. Ritchie reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Internet searches regarding acute anxiety reached an all-time high between March and May 2020, new research shows.
Investigators used data collected by Google to monitor the daily percentage of all Internet searches originating in the United States that included the terms “anxiety” or “panic” in combination with “attack” between January 2004 and May 2020.
They found an 11% increase in all acute anxiety queries between March 2020, when President Donald Trump first declared the COVID-19 pandemic a national emergency, and May 2020. This translates into approximately 375,000 more searches than expected.
Most of the increase in inquiries occurred when specific developments in COVID-19 were reported.
“We found record levels of people potentially having panic attacks, as reflected by their online queries since early in the pandemic,” lead author John W. Ayers, PhD, associate adjunct professor of medicine, school of health sciences, University of California, San Diego, said in an interview.
“There are two main take-home messages from our research – one is that we need to think about how to address acute anxiety during COVID-19, and the other is that who is also vice chief of innovation, division of infectious diseases and global public health at the University of California, San Diego.
The study was published online August 24 in JAMA Internal Medicine.
Real-time data
“There has been a lot of speculation about collateral consequences of COVID-19, especially in mental health,” Dr. Ayers said.
Most of the research has been conducted via self-report survey, but these types of surveys may miss individuals who do not participate in the surveys or do not seek care, Dr. Ayers added.
“We need a strategy that can measure behavioral health in real time so we can design interventions to meet these needs,” he said.
He explained that he and his colleagues “looked at one case study – panic attacks – because it is the most prevalent form of mental health problem driven by your surroundings, and it is socially contagious, meaning that when someone you know is having a severe acute anxiety or panic attack, you’re more likely to have one yourself.”
The researchers turned to publicly available nonidentifiable data collected via Google Trends – a feature of Google that shows how frequently a given search term is entered into Google’s search engine, relative to the site’s total search volume, over a specific period.
They monitored all searches containing their keywords over a 15-year period (Jan. 1, 2004–May 4, 2020). Search volumes between March 13, 2020 (when the national emergency was declared) and the last date of available data (May 9, 2020) were compared with the expected search volumes that would have been found had COVID-19 not occurred.
Headline-related spikes
Cumulatively, all acute anxiety searches were 11% higher than expected for the 58-day study period (95% confidence interval, 7%-14%). There was a dramatic increase in searches (375,000), or a total of 3.4 million searches, during that period.
Most of these searches took place between March 16, 2020, and April 14, 2020, when searches were cumulatively 17% higher than expected (95% CI, 13%-22%).
Several COVID-19–related milestones took place during that period.
- First imposition of social distancing guidelines occurred (March 16, 2020).
- The United States surpassed China with the most reported COVID-19 cases (March 26, 2020).
- Extension of social distancing guidelines occurred (March 29, 2020).
- The Centers for Disease Control and Prevention recommended use of face masks (April 3, 2020).
- The United States surpassed Italy for having the most COVID-19–related deaths (April 11, 2020).
The largest spike in acute anxiety queries occurred on March 28, 2020, on which date there were 52% more searches than expected. Queries returned to expected levels on April 15, 2020, and have fallen within expected ranges since then.
Dr. Ayers noted that, although other stressors have affected people in the United States, including electoral and economic issues, “the headlines around COVID-19 were driving the anxiety, and those days with dramatic headlines were associated with large spikes in queries.”
“Our messaging surrounding how COVID-19 is reported may need to change to prevent this,” Dr. Ayers said. “Headlines that hit people in the head by reporting how many people died and bury in the article how we can slow the spread may increase anxiety more than headlines reporting strategies that work right up front.”
He noted that media reporting of suicide has begun to change; there have been fewer sensationalized headlines, and there has been an increase in referrals to suicide hotlines. “We need to be thinking about similar strategies when reporting COVID-19,” said Dr. Ayers.
He also suggested tapping existing resources, such as state suicide hotlines, by training staff to assist persons experiencing acute anxiety and panic attacks.
As an example of this model, the authors point to an Illinois-based hotline, Call4Calm, which helps people cope with acute COVID-19 anxiety.
Google queries concerning panic and anxiety do not yield any links to helplines, although OneBox, a Google feature, provides information to people inquiring about suicide and addiction. “This approach could be used to promote resources about anxiety and panic and COVID-19,” Dr. Ayers suggested.
Call to action
Elspeth Cameron Ritchie, MD, chair of the department of psychiatry, Medstar Washington Hospital Center, said the study’s recommendations were “interesting and worth amplifying “ and that “headlines calling for calm” were “a good suggestion.” She was not involved with the study.
“A multifaceted, multimedia approach is needed – not only what’s on Google, but it would be helpful if politicians could acknowledge the anxiety and make available more mental health resources,” she added.
Dr. Ritchie, who is also vice chair of psychiatry at Georgetown University, Washington, suggested that it is a “simple option [during patient visits] to incorporate a question as to how your patient is being affected by the pandemic into your standard template, together with questions about sleep, appetite, sexual functioning, etc.”
Dr. Ayers said that the “call to action” that he and his colleagues are making is to use their methodology to “know what mental health needs are in the population” and to use existing frameworks and strategies to address them.
The study was supported by a grant from the University of California office of the president and by intramural support from the division of infectious diseases and the Center for Data Driven Health at the Qualcomm Institute, both with the University of California, San Diego. One coauthor was funded by Bill and Melinda Gates through the Global Good Fund. Dr. Ayers owns equity positions in Directing Medicine, Health Watcher, and Good Analytics, companies that advise on the use of digital data for public health surveillance. Dr. Ritchie reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Internet searches regarding acute anxiety reached an all-time high between March and May 2020, new research shows.
Investigators used data collected by Google to monitor the daily percentage of all Internet searches originating in the United States that included the terms “anxiety” or “panic” in combination with “attack” between January 2004 and May 2020.
They found an 11% increase in all acute anxiety queries between March 2020, when President Donald Trump first declared the COVID-19 pandemic a national emergency, and May 2020. This translates into approximately 375,000 more searches than expected.
Most of the increase in inquiries occurred when specific developments in COVID-19 were reported.
“We found record levels of people potentially having panic attacks, as reflected by their online queries since early in the pandemic,” lead author John W. Ayers, PhD, associate adjunct professor of medicine, school of health sciences, University of California, San Diego, said in an interview.
“There are two main take-home messages from our research – one is that we need to think about how to address acute anxiety during COVID-19, and the other is that who is also vice chief of innovation, division of infectious diseases and global public health at the University of California, San Diego.
The study was published online August 24 in JAMA Internal Medicine.
Real-time data
“There has been a lot of speculation about collateral consequences of COVID-19, especially in mental health,” Dr. Ayers said.
Most of the research has been conducted via self-report survey, but these types of surveys may miss individuals who do not participate in the surveys or do not seek care, Dr. Ayers added.
“We need a strategy that can measure behavioral health in real time so we can design interventions to meet these needs,” he said.
He explained that he and his colleagues “looked at one case study – panic attacks – because it is the most prevalent form of mental health problem driven by your surroundings, and it is socially contagious, meaning that when someone you know is having a severe acute anxiety or panic attack, you’re more likely to have one yourself.”
The researchers turned to publicly available nonidentifiable data collected via Google Trends – a feature of Google that shows how frequently a given search term is entered into Google’s search engine, relative to the site’s total search volume, over a specific period.
They monitored all searches containing their keywords over a 15-year period (Jan. 1, 2004–May 4, 2020). Search volumes between March 13, 2020 (when the national emergency was declared) and the last date of available data (May 9, 2020) were compared with the expected search volumes that would have been found had COVID-19 not occurred.
Headline-related spikes
Cumulatively, all acute anxiety searches were 11% higher than expected for the 58-day study period (95% confidence interval, 7%-14%). There was a dramatic increase in searches (375,000), or a total of 3.4 million searches, during that period.
Most of these searches took place between March 16, 2020, and April 14, 2020, when searches were cumulatively 17% higher than expected (95% CI, 13%-22%).
Several COVID-19–related milestones took place during that period.
- First imposition of social distancing guidelines occurred (March 16, 2020).
- The United States surpassed China with the most reported COVID-19 cases (March 26, 2020).
- Extension of social distancing guidelines occurred (March 29, 2020).
- The Centers for Disease Control and Prevention recommended use of face masks (April 3, 2020).
- The United States surpassed Italy for having the most COVID-19–related deaths (April 11, 2020).
The largest spike in acute anxiety queries occurred on March 28, 2020, on which date there were 52% more searches than expected. Queries returned to expected levels on April 15, 2020, and have fallen within expected ranges since then.
Dr. Ayers noted that, although other stressors have affected people in the United States, including electoral and economic issues, “the headlines around COVID-19 were driving the anxiety, and those days with dramatic headlines were associated with large spikes in queries.”
“Our messaging surrounding how COVID-19 is reported may need to change to prevent this,” Dr. Ayers said. “Headlines that hit people in the head by reporting how many people died and bury in the article how we can slow the spread may increase anxiety more than headlines reporting strategies that work right up front.”
He noted that media reporting of suicide has begun to change; there have been fewer sensationalized headlines, and there has been an increase in referrals to suicide hotlines. “We need to be thinking about similar strategies when reporting COVID-19,” said Dr. Ayers.
He also suggested tapping existing resources, such as state suicide hotlines, by training staff to assist persons experiencing acute anxiety and panic attacks.
As an example of this model, the authors point to an Illinois-based hotline, Call4Calm, which helps people cope with acute COVID-19 anxiety.
Google queries concerning panic and anxiety do not yield any links to helplines, although OneBox, a Google feature, provides information to people inquiring about suicide and addiction. “This approach could be used to promote resources about anxiety and panic and COVID-19,” Dr. Ayers suggested.
Call to action
Elspeth Cameron Ritchie, MD, chair of the department of psychiatry, Medstar Washington Hospital Center, said the study’s recommendations were “interesting and worth amplifying “ and that “headlines calling for calm” were “a good suggestion.” She was not involved with the study.
“A multifaceted, multimedia approach is needed – not only what’s on Google, but it would be helpful if politicians could acknowledge the anxiety and make available more mental health resources,” she added.
Dr. Ritchie, who is also vice chair of psychiatry at Georgetown University, Washington, suggested that it is a “simple option [during patient visits] to incorporate a question as to how your patient is being affected by the pandemic into your standard template, together with questions about sleep, appetite, sexual functioning, etc.”
Dr. Ayers said that the “call to action” that he and his colleagues are making is to use their methodology to “know what mental health needs are in the population” and to use existing frameworks and strategies to address them.
The study was supported by a grant from the University of California office of the president and by intramural support from the division of infectious diseases and the Center for Data Driven Health at the Qualcomm Institute, both with the University of California, San Diego. One coauthor was funded by Bill and Melinda Gates through the Global Good Fund. Dr. Ayers owns equity positions in Directing Medicine, Health Watcher, and Good Analytics, companies that advise on the use of digital data for public health surveillance. Dr. Ritchie reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Pregnancy can be ‘a vulnerable time’ for developing mental disorders
Pregnancy and the postpartum period are a “very vulnerable time for mental disorders,” according to Henry A. Nasrallah, MD.
“Those changes that are helping pregnancy can also have psychiatric and psychopathological implications,” Dr. Nasrallah said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
Numerous dramatic changes in physiology, immune functions, cognition, neuroplasticity, and behavior occur during pregnancy, noted Dr. Nasrallah of the University of Cincinnati. For example, the volume of the brain actually decreases during pregnancy, but brain size recovers over the 6 months after delivery. “Clearly, this is a transitional and a transient phenomenon,” he said. “The decrease in brain volume is associated with changes in brain metabolism and an increase in intracellular pH after delivery.”
But these changes can also carry risks for psychiatric disorders, Dr. Nasrallah explained. Changes in the hippocampus, which is “very plastic throughout adulthood,” have been linked to aging, cognition, pregnancy, and motherhood. “The hippocampus is the ‘Grand Central Station’ of memory in the brain, and the hippocampus is affected by neurodegenerative and psychiatric disorders, which disproportionately affect women,” he said at the meeting, presented by Global Academy for Medical Education.
Dr. Nasrallah said the hippocampus has particular susceptibility during pregnancy and in the postpartum period, or in women who have previously been pregnant.
Gender of the fetus can even affect the health of the mother, he added. In women who are pregnant with male fetuses, working memory and spatial ability are higher than in women who are pregnant with female fetuses, Dr. Nasrallah said. This is tied to higher numbers of proinflammatory cytokines present in male fetuses. In female fetuses, there are lower levels of interferon-gamma and interleukin (IL)-12 in the first trimester, and higher levels of IL-1 beta, tumor necrosis factor B, IL-5, and IL-10 in the second trimester.
In particular,
“Cytokine interleukin-10 and interleukin-6 are both increased during psychosis and during depression, so you can see the vulnerability for developing postpartum depression.” Some women “have other genes that make them susceptible for mood disorders, and the pregnancy can push them over the edge,” he said.
If women have bipolar disorder prior to delivery, “they have a very high risk of postpartum depression, possibly because of this immune dysregulation that serves the pregnancy, but unfortunately makes the woman vulnerable for postpartum psychiatric disorders,” Dr. Nasrallah said.
The effects of having children extend into middle age, Dr. Nasrallah said. Research has shown giving birth to more than one to two children can affect a woman’s risk for Alzheimer’s disease and risk for early-onset of the disease. Women who have three or fewer children later in life are also more likely to live longer, he said. In general, a longer reproductive period, duration of breastfeeding, and low number of pregnancies result in better cognition, while younger age at first pregnancy leads to worse cognition.
So-called pregnancy brain causes some cognitive functions to decline, and women may experience trouble concentrating and memory disturbance. “Other functions increase for the sake of the baby,” including a high reaction to threatening stimuli, absent-mindedness, motivation, reward, fear, executive functions, social cognition, salience, and attachment, Dr. Nasrallah said. In some cases, hormone-driven remodeling of the maternal brain can cause postpartum psychosis, which can reduce the anterior cingulate cortex, left parahippocampal gyrus volume, and left superior temporal gyrus volume.
Most changes in the brain, however, appear to be temporary, Dr. Nasrallah noted. Executive function improves 2-6 months after delivery, which includes goal and directed behavior, working memory, inhibitory function, and cognitive flexibility. In the postpartum period, “the gray matter increases in the first 3-4 months, especially in the brain areas that are involved in maternal behavior that includes amygdala, hypothalamus, and prefrontal cortex,” he added. “All of those changes correlate with positive maternal attachment, and so that makes it easier for the mother to bond with the baby.
“Don’t think of it as a negative,” he said. “The decline in brain volume is actually associated with better mothering and increased attachment between the mother and the baby, which is vital for survival of the baby.”
Global Academy and this news organization are owned by the same parent company. Dr. Nasrallah reports no relevant financial disclosures.
Pregnancy and the postpartum period are a “very vulnerable time for mental disorders,” according to Henry A. Nasrallah, MD.
“Those changes that are helping pregnancy can also have psychiatric and psychopathological implications,” Dr. Nasrallah said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
Numerous dramatic changes in physiology, immune functions, cognition, neuroplasticity, and behavior occur during pregnancy, noted Dr. Nasrallah of the University of Cincinnati. For example, the volume of the brain actually decreases during pregnancy, but brain size recovers over the 6 months after delivery. “Clearly, this is a transitional and a transient phenomenon,” he said. “The decrease in brain volume is associated with changes in brain metabolism and an increase in intracellular pH after delivery.”
But these changes can also carry risks for psychiatric disorders, Dr. Nasrallah explained. Changes in the hippocampus, which is “very plastic throughout adulthood,” have been linked to aging, cognition, pregnancy, and motherhood. “The hippocampus is the ‘Grand Central Station’ of memory in the brain, and the hippocampus is affected by neurodegenerative and psychiatric disorders, which disproportionately affect women,” he said at the meeting, presented by Global Academy for Medical Education.
Dr. Nasrallah said the hippocampus has particular susceptibility during pregnancy and in the postpartum period, or in women who have previously been pregnant.
Gender of the fetus can even affect the health of the mother, he added. In women who are pregnant with male fetuses, working memory and spatial ability are higher than in women who are pregnant with female fetuses, Dr. Nasrallah said. This is tied to higher numbers of proinflammatory cytokines present in male fetuses. In female fetuses, there are lower levels of interferon-gamma and interleukin (IL)-12 in the first trimester, and higher levels of IL-1 beta, tumor necrosis factor B, IL-5, and IL-10 in the second trimester.
In particular,
“Cytokine interleukin-10 and interleukin-6 are both increased during psychosis and during depression, so you can see the vulnerability for developing postpartum depression.” Some women “have other genes that make them susceptible for mood disorders, and the pregnancy can push them over the edge,” he said.
If women have bipolar disorder prior to delivery, “they have a very high risk of postpartum depression, possibly because of this immune dysregulation that serves the pregnancy, but unfortunately makes the woman vulnerable for postpartum psychiatric disorders,” Dr. Nasrallah said.
The effects of having children extend into middle age, Dr. Nasrallah said. Research has shown giving birth to more than one to two children can affect a woman’s risk for Alzheimer’s disease and risk for early-onset of the disease. Women who have three or fewer children later in life are also more likely to live longer, he said. In general, a longer reproductive period, duration of breastfeeding, and low number of pregnancies result in better cognition, while younger age at first pregnancy leads to worse cognition.
So-called pregnancy brain causes some cognitive functions to decline, and women may experience trouble concentrating and memory disturbance. “Other functions increase for the sake of the baby,” including a high reaction to threatening stimuli, absent-mindedness, motivation, reward, fear, executive functions, social cognition, salience, and attachment, Dr. Nasrallah said. In some cases, hormone-driven remodeling of the maternal brain can cause postpartum psychosis, which can reduce the anterior cingulate cortex, left parahippocampal gyrus volume, and left superior temporal gyrus volume.
Most changes in the brain, however, appear to be temporary, Dr. Nasrallah noted. Executive function improves 2-6 months after delivery, which includes goal and directed behavior, working memory, inhibitory function, and cognitive flexibility. In the postpartum period, “the gray matter increases in the first 3-4 months, especially in the brain areas that are involved in maternal behavior that includes amygdala, hypothalamus, and prefrontal cortex,” he added. “All of those changes correlate with positive maternal attachment, and so that makes it easier for the mother to bond with the baby.
“Don’t think of it as a negative,” he said. “The decline in brain volume is actually associated with better mothering and increased attachment between the mother and the baby, which is vital for survival of the baby.”
Global Academy and this news organization are owned by the same parent company. Dr. Nasrallah reports no relevant financial disclosures.
Pregnancy and the postpartum period are a “very vulnerable time for mental disorders,” according to Henry A. Nasrallah, MD.
“Those changes that are helping pregnancy can also have psychiatric and psychopathological implications,” Dr. Nasrallah said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
Numerous dramatic changes in physiology, immune functions, cognition, neuroplasticity, and behavior occur during pregnancy, noted Dr. Nasrallah of the University of Cincinnati. For example, the volume of the brain actually decreases during pregnancy, but brain size recovers over the 6 months after delivery. “Clearly, this is a transitional and a transient phenomenon,” he said. “The decrease in brain volume is associated with changes in brain metabolism and an increase in intracellular pH after delivery.”
But these changes can also carry risks for psychiatric disorders, Dr. Nasrallah explained. Changes in the hippocampus, which is “very plastic throughout adulthood,” have been linked to aging, cognition, pregnancy, and motherhood. “The hippocampus is the ‘Grand Central Station’ of memory in the brain, and the hippocampus is affected by neurodegenerative and psychiatric disorders, which disproportionately affect women,” he said at the meeting, presented by Global Academy for Medical Education.
Dr. Nasrallah said the hippocampus has particular susceptibility during pregnancy and in the postpartum period, or in women who have previously been pregnant.
Gender of the fetus can even affect the health of the mother, he added. In women who are pregnant with male fetuses, working memory and spatial ability are higher than in women who are pregnant with female fetuses, Dr. Nasrallah said. This is tied to higher numbers of proinflammatory cytokines present in male fetuses. In female fetuses, there are lower levels of interferon-gamma and interleukin (IL)-12 in the first trimester, and higher levels of IL-1 beta, tumor necrosis factor B, IL-5, and IL-10 in the second trimester.
In particular,
“Cytokine interleukin-10 and interleukin-6 are both increased during psychosis and during depression, so you can see the vulnerability for developing postpartum depression.” Some women “have other genes that make them susceptible for mood disorders, and the pregnancy can push them over the edge,” he said.
If women have bipolar disorder prior to delivery, “they have a very high risk of postpartum depression, possibly because of this immune dysregulation that serves the pregnancy, but unfortunately makes the woman vulnerable for postpartum psychiatric disorders,” Dr. Nasrallah said.
The effects of having children extend into middle age, Dr. Nasrallah said. Research has shown giving birth to more than one to two children can affect a woman’s risk for Alzheimer’s disease and risk for early-onset of the disease. Women who have three or fewer children later in life are also more likely to live longer, he said. In general, a longer reproductive period, duration of breastfeeding, and low number of pregnancies result in better cognition, while younger age at first pregnancy leads to worse cognition.
So-called pregnancy brain causes some cognitive functions to decline, and women may experience trouble concentrating and memory disturbance. “Other functions increase for the sake of the baby,” including a high reaction to threatening stimuli, absent-mindedness, motivation, reward, fear, executive functions, social cognition, salience, and attachment, Dr. Nasrallah said. In some cases, hormone-driven remodeling of the maternal brain can cause postpartum psychosis, which can reduce the anterior cingulate cortex, left parahippocampal gyrus volume, and left superior temporal gyrus volume.
Most changes in the brain, however, appear to be temporary, Dr. Nasrallah noted. Executive function improves 2-6 months after delivery, which includes goal and directed behavior, working memory, inhibitory function, and cognitive flexibility. In the postpartum period, “the gray matter increases in the first 3-4 months, especially in the brain areas that are involved in maternal behavior that includes amygdala, hypothalamus, and prefrontal cortex,” he added. “All of those changes correlate with positive maternal attachment, and so that makes it easier for the mother to bond with the baby.
“Don’t think of it as a negative,” he said. “The decline in brain volume is actually associated with better mothering and increased attachment between the mother and the baby, which is vital for survival of the baby.”
Global Academy and this news organization are owned by the same parent company. Dr. Nasrallah reports no relevant financial disclosures.
FROM FOCUS ON NEUROPSYCHIATRY 2020
Why are many of my patients doing better during the pandemic?
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
Reflections on life before and during COVID-19
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
COVID-19, school reopenings, and safety: What should we tell parents?
Parents, teachers, children, and adolescents are facing stress and anxiety as K-12 school districts across the country debate whether to return to in-person instruction amid the COVID-19 pandemic. As we approach the opening of schools, the stress and anxiety seem to be heightening.
According to Education Week, which is tracking the reopening plans of public schools across the United States, 21 of the 25 largest school districts are opting to implement remote learning only as their model. I would like to see all of those districts adopt that model until we understand more about this illness, and can prevent and treat it.
Yes, it’s true – I am a psychiatrist – not an infectious disease specialist. And I realize that the American Academy of Pediatrics and the Centers for Disease Control and Prevention have taken nuanced positions on this issue. Their positions make it clear that it is within a child’s best interests – from an educational and social point of view – to attend school in person. Not only is the classroom experience important, but so is the socialization and the exercise. However, when I look at the science on children who have been exposed to the coronavirus, I worry.
For example, a study by Lael M. Yonker, MD, and associates on pediatric SARS-CoV-2 found that the children in days 0-2 of illness have far higher viral loads than adults who have been hospitalized for severe disease. “This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious [multisystem inflammatory syndrome in children],” Dr. Yonker and associates wrote, referring to the illness associated with COVID-19 in children. Their study was published recently in the Journal of Pediatrics (2020 Aug 19. doi: 10.1016/j.jpeds.2020.08.037).
In my state, where positivity rates are fairly low, Gov. Andrew Cuomo admitted in an interview recently that sending children to school in New York City is a “tricky proposition.” At this point, New York City public schools are scheduled to open in mid-September using a hybrid mixture of in-person and remote learning.
And look at what happened several weeks ago in Israel, where schools reopened after the virus was beaten back. At one high school in Jerusalem, just days after the reopening, the virus spread so prolifically to students, teachers, and relatives that the schools had to be closed again. Other countries should not follow Israel’s example, Eli Weizmann, who chairs the team advising Israel’s National Security Council on the pandemic, reportedly told the New York Times. “It was a major failure.”
But I must be honest: I was worried about children returning to school before I heard about the study by Dr. Yonker and associates, Gov. Cuomo’s comments, and what happened in Israel. So far, here in the Northeast, particularly in New York, New Jersey, and Connecticut, we have managed to get COVID-19 under control. Perhaps, in this part of the country, opening classroom education might be feasible – with close monitoring and proper precautions.
But COVID-19 has taken the lives of hundreds of thousands of Americans – more than 176,000 as of this writing. A new model from the University of Washington’s Institute for Health Metrics and Evaluation projects that COVID-19 could lead to more than 300,000 U.S. deaths by Dec. 1. Thankfully, the number of COVID-19–positive children who have died has been low. But they could still pass on the virus to adults.
To get a better understanding of COVID-19, I spoke with Sheryl L. Wulkan, MD, an internist and expert in personal protective equipment (PPE) who has consulted for numerous health care agencies about these issues. Dr. Wulkan said that, in some areas with low infection rates, school openings might be appropriate. However, she said, without proper testing and contact tracing, we are at a loss of controlling the spread.
What we should tell patients, family, and friends
From a psychiatric point of view, how should we advise our patients, family, and friends about sending their children back to school? Is on-site learning better than remote learning? It is. Do our children need the socialization that a school brings? Yes, they do.
Socialization and relating to peers are, indeed, important, but today’s children socialize in many ways beyond attending school – and they have peer friendships and interactions with electronic devices at their disposal.
Can remote learning cause social isolation – an isolation so profound that school is necessary not only for learning but the psyche as well? A meta-analysis of 80 studies that looked at the impact of social isolation and loneliness on adolescents and children who were previously healthy found that the young people “are probably more likely to experience high rates of depression and probably anxiety during and after enforced isolation ends. This may increase as enforced isolation continues,” wrote Maria Elizabeth Loades, PhD, and associates (J Am Acad Child Adolesc Psychiatry. 2020 Jun 3. S0890-8567[20]30337-3).
I am concerned about young people who experience anxiety and depression, and agree with Dr. Loades that we mental health professionals need to be ready to intervene early and provide preventive support. To do this, we should encourage parents to keep us informed about how their children are doing.
So my advice is that, in the absence of a vaccine and an effective treatment like we have for influenza – such as Tamiflu – and effective testing, such the saliva-based test developed by Yale University researchers, if I had school-aged children, I would continue to keep them home from school. Ultimately, however, parents must look at the science and make their decisions based on that. My children are adults with their own children, and only they can make informed decisions about which options are best for their families.
Interestingly, Sanjay Gupta, MD, the neurosurgeon who works as chief medical correspondent of CNN, recently discussed the thought process he and his wife used to determine whether their daughters would return to the classroom. After weighing many factors, including the viral spread in Fulton County, Ga., where they live, the Guptas decided that, at this time, the risks of allowing the girls to return to the classroom outweigh the benefits. “This was not an easy decision, but one that we believe best respects the science, decreases the risk of further spread, and follows the task force criteria,” wrote Dr. Gupta, who is affiliated with Emory University in Atlanta. “After 2 weeks, we will reassess.”
I understand that parents worry about the social and psychological costs of remote learning. And I can only imagine the difficulty of those who must balance homeschooling with working. And frankly, remote learning is not an option for all students. For those less fortunate, substantial governmental aid is important to assist these people and to keep them safe and on their feet until this pandemic is done. Also, those who were under the care of a psychiatrist should continue to receive care during the pandemic. We must be prepared to step in with interventions that can address the suffering that is inevitable, such as the use of targeted cognitive-behavioral therapy.
Public TV as an educational tool
Families with Internet access and those without it could benefit from using public television as a tool.
I would advise educators and the entertainment industry to harness the wonder of TV to develop curricula that can be used to educate children. As we know, Sesame Street proved to be an effective early childhood intervention, particularly for boys (Am Econ J: Applied Economics. 2019;11[1]:318-50). I would like to see programming that goes beyond Sesame Street. Learning from watching this kind of programming would be no substitute for engaging with teachers in real, live classrooms, however.
Children and adolescents will be changed by learning remotely. They will miss their friends, teachers, and other staff members, but their lives will not be ruined. Mental health professionals should be prepared to intervene to address depression, anxiety, and other sequelae and problematic behaviors that could result from social isolation. Schools, businesses, and the economy will again flourish after we get the virus behind us but controlling and eliminating this pandemic need to come first. Let’s keep our children home – to the extent that we can – until we move beyond this pandemic.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
Parents, teachers, children, and adolescents are facing stress and anxiety as K-12 school districts across the country debate whether to return to in-person instruction amid the COVID-19 pandemic. As we approach the opening of schools, the stress and anxiety seem to be heightening.
According to Education Week, which is tracking the reopening plans of public schools across the United States, 21 of the 25 largest school districts are opting to implement remote learning only as their model. I would like to see all of those districts adopt that model until we understand more about this illness, and can prevent and treat it.
Yes, it’s true – I am a psychiatrist – not an infectious disease specialist. And I realize that the American Academy of Pediatrics and the Centers for Disease Control and Prevention have taken nuanced positions on this issue. Their positions make it clear that it is within a child’s best interests – from an educational and social point of view – to attend school in person. Not only is the classroom experience important, but so is the socialization and the exercise. However, when I look at the science on children who have been exposed to the coronavirus, I worry.
For example, a study by Lael M. Yonker, MD, and associates on pediatric SARS-CoV-2 found that the children in days 0-2 of illness have far higher viral loads than adults who have been hospitalized for severe disease. “This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious [multisystem inflammatory syndrome in children],” Dr. Yonker and associates wrote, referring to the illness associated with COVID-19 in children. Their study was published recently in the Journal of Pediatrics (2020 Aug 19. doi: 10.1016/j.jpeds.2020.08.037).
In my state, where positivity rates are fairly low, Gov. Andrew Cuomo admitted in an interview recently that sending children to school in New York City is a “tricky proposition.” At this point, New York City public schools are scheduled to open in mid-September using a hybrid mixture of in-person and remote learning.
And look at what happened several weeks ago in Israel, where schools reopened after the virus was beaten back. At one high school in Jerusalem, just days after the reopening, the virus spread so prolifically to students, teachers, and relatives that the schools had to be closed again. Other countries should not follow Israel’s example, Eli Weizmann, who chairs the team advising Israel’s National Security Council on the pandemic, reportedly told the New York Times. “It was a major failure.”
But I must be honest: I was worried about children returning to school before I heard about the study by Dr. Yonker and associates, Gov. Cuomo’s comments, and what happened in Israel. So far, here in the Northeast, particularly in New York, New Jersey, and Connecticut, we have managed to get COVID-19 under control. Perhaps, in this part of the country, opening classroom education might be feasible – with close monitoring and proper precautions.
But COVID-19 has taken the lives of hundreds of thousands of Americans – more than 176,000 as of this writing. A new model from the University of Washington’s Institute for Health Metrics and Evaluation projects that COVID-19 could lead to more than 300,000 U.S. deaths by Dec. 1. Thankfully, the number of COVID-19–positive children who have died has been low. But they could still pass on the virus to adults.
To get a better understanding of COVID-19, I spoke with Sheryl L. Wulkan, MD, an internist and expert in personal protective equipment (PPE) who has consulted for numerous health care agencies about these issues. Dr. Wulkan said that, in some areas with low infection rates, school openings might be appropriate. However, she said, without proper testing and contact tracing, we are at a loss of controlling the spread.
What we should tell patients, family, and friends
From a psychiatric point of view, how should we advise our patients, family, and friends about sending their children back to school? Is on-site learning better than remote learning? It is. Do our children need the socialization that a school brings? Yes, they do.
Socialization and relating to peers are, indeed, important, but today’s children socialize in many ways beyond attending school – and they have peer friendships and interactions with electronic devices at their disposal.
Can remote learning cause social isolation – an isolation so profound that school is necessary not only for learning but the psyche as well? A meta-analysis of 80 studies that looked at the impact of social isolation and loneliness on adolescents and children who were previously healthy found that the young people “are probably more likely to experience high rates of depression and probably anxiety during and after enforced isolation ends. This may increase as enforced isolation continues,” wrote Maria Elizabeth Loades, PhD, and associates (J Am Acad Child Adolesc Psychiatry. 2020 Jun 3. S0890-8567[20]30337-3).
I am concerned about young people who experience anxiety and depression, and agree with Dr. Loades that we mental health professionals need to be ready to intervene early and provide preventive support. To do this, we should encourage parents to keep us informed about how their children are doing.
So my advice is that, in the absence of a vaccine and an effective treatment like we have for influenza – such as Tamiflu – and effective testing, such the saliva-based test developed by Yale University researchers, if I had school-aged children, I would continue to keep them home from school. Ultimately, however, parents must look at the science and make their decisions based on that. My children are adults with their own children, and only they can make informed decisions about which options are best for their families.
Interestingly, Sanjay Gupta, MD, the neurosurgeon who works as chief medical correspondent of CNN, recently discussed the thought process he and his wife used to determine whether their daughters would return to the classroom. After weighing many factors, including the viral spread in Fulton County, Ga., where they live, the Guptas decided that, at this time, the risks of allowing the girls to return to the classroom outweigh the benefits. “This was not an easy decision, but one that we believe best respects the science, decreases the risk of further spread, and follows the task force criteria,” wrote Dr. Gupta, who is affiliated with Emory University in Atlanta. “After 2 weeks, we will reassess.”
I understand that parents worry about the social and psychological costs of remote learning. And I can only imagine the difficulty of those who must balance homeschooling with working. And frankly, remote learning is not an option for all students. For those less fortunate, substantial governmental aid is important to assist these people and to keep them safe and on their feet until this pandemic is done. Also, those who were under the care of a psychiatrist should continue to receive care during the pandemic. We must be prepared to step in with interventions that can address the suffering that is inevitable, such as the use of targeted cognitive-behavioral therapy.
Public TV as an educational tool
Families with Internet access and those without it could benefit from using public television as a tool.
I would advise educators and the entertainment industry to harness the wonder of TV to develop curricula that can be used to educate children. As we know, Sesame Street proved to be an effective early childhood intervention, particularly for boys (Am Econ J: Applied Economics. 2019;11[1]:318-50). I would like to see programming that goes beyond Sesame Street. Learning from watching this kind of programming would be no substitute for engaging with teachers in real, live classrooms, however.
Children and adolescents will be changed by learning remotely. They will miss their friends, teachers, and other staff members, but their lives will not be ruined. Mental health professionals should be prepared to intervene to address depression, anxiety, and other sequelae and problematic behaviors that could result from social isolation. Schools, businesses, and the economy will again flourish after we get the virus behind us but controlling and eliminating this pandemic need to come first. Let’s keep our children home – to the extent that we can – until we move beyond this pandemic.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
Parents, teachers, children, and adolescents are facing stress and anxiety as K-12 school districts across the country debate whether to return to in-person instruction amid the COVID-19 pandemic. As we approach the opening of schools, the stress and anxiety seem to be heightening.
According to Education Week, which is tracking the reopening plans of public schools across the United States, 21 of the 25 largest school districts are opting to implement remote learning only as their model. I would like to see all of those districts adopt that model until we understand more about this illness, and can prevent and treat it.
Yes, it’s true – I am a psychiatrist – not an infectious disease specialist. And I realize that the American Academy of Pediatrics and the Centers for Disease Control and Prevention have taken nuanced positions on this issue. Their positions make it clear that it is within a child’s best interests – from an educational and social point of view – to attend school in person. Not only is the classroom experience important, but so is the socialization and the exercise. However, when I look at the science on children who have been exposed to the coronavirus, I worry.
For example, a study by Lael M. Yonker, MD, and associates on pediatric SARS-CoV-2 found that the children in days 0-2 of illness have far higher viral loads than adults who have been hospitalized for severe disease. “This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious [multisystem inflammatory syndrome in children],” Dr. Yonker and associates wrote, referring to the illness associated with COVID-19 in children. Their study was published recently in the Journal of Pediatrics (2020 Aug 19. doi: 10.1016/j.jpeds.2020.08.037).
In my state, where positivity rates are fairly low, Gov. Andrew Cuomo admitted in an interview recently that sending children to school in New York City is a “tricky proposition.” At this point, New York City public schools are scheduled to open in mid-September using a hybrid mixture of in-person and remote learning.
And look at what happened several weeks ago in Israel, where schools reopened after the virus was beaten back. At one high school in Jerusalem, just days after the reopening, the virus spread so prolifically to students, teachers, and relatives that the schools had to be closed again. Other countries should not follow Israel’s example, Eli Weizmann, who chairs the team advising Israel’s National Security Council on the pandemic, reportedly told the New York Times. “It was a major failure.”
But I must be honest: I was worried about children returning to school before I heard about the study by Dr. Yonker and associates, Gov. Cuomo’s comments, and what happened in Israel. So far, here in the Northeast, particularly in New York, New Jersey, and Connecticut, we have managed to get COVID-19 under control. Perhaps, in this part of the country, opening classroom education might be feasible – with close monitoring and proper precautions.
But COVID-19 has taken the lives of hundreds of thousands of Americans – more than 176,000 as of this writing. A new model from the University of Washington’s Institute for Health Metrics and Evaluation projects that COVID-19 could lead to more than 300,000 U.S. deaths by Dec. 1. Thankfully, the number of COVID-19–positive children who have died has been low. But they could still pass on the virus to adults.
To get a better understanding of COVID-19, I spoke with Sheryl L. Wulkan, MD, an internist and expert in personal protective equipment (PPE) who has consulted for numerous health care agencies about these issues. Dr. Wulkan said that, in some areas with low infection rates, school openings might be appropriate. However, she said, without proper testing and contact tracing, we are at a loss of controlling the spread.
What we should tell patients, family, and friends
From a psychiatric point of view, how should we advise our patients, family, and friends about sending their children back to school? Is on-site learning better than remote learning? It is. Do our children need the socialization that a school brings? Yes, they do.
Socialization and relating to peers are, indeed, important, but today’s children socialize in many ways beyond attending school – and they have peer friendships and interactions with electronic devices at their disposal.
Can remote learning cause social isolation – an isolation so profound that school is necessary not only for learning but the psyche as well? A meta-analysis of 80 studies that looked at the impact of social isolation and loneliness on adolescents and children who were previously healthy found that the young people “are probably more likely to experience high rates of depression and probably anxiety during and after enforced isolation ends. This may increase as enforced isolation continues,” wrote Maria Elizabeth Loades, PhD, and associates (J Am Acad Child Adolesc Psychiatry. 2020 Jun 3. S0890-8567[20]30337-3).
I am concerned about young people who experience anxiety and depression, and agree with Dr. Loades that we mental health professionals need to be ready to intervene early and provide preventive support. To do this, we should encourage parents to keep us informed about how their children are doing.
So my advice is that, in the absence of a vaccine and an effective treatment like we have for influenza – such as Tamiflu – and effective testing, such the saliva-based test developed by Yale University researchers, if I had school-aged children, I would continue to keep them home from school. Ultimately, however, parents must look at the science and make their decisions based on that. My children are adults with their own children, and only they can make informed decisions about which options are best for their families.
Interestingly, Sanjay Gupta, MD, the neurosurgeon who works as chief medical correspondent of CNN, recently discussed the thought process he and his wife used to determine whether their daughters would return to the classroom. After weighing many factors, including the viral spread in Fulton County, Ga., where they live, the Guptas decided that, at this time, the risks of allowing the girls to return to the classroom outweigh the benefits. “This was not an easy decision, but one that we believe best respects the science, decreases the risk of further spread, and follows the task force criteria,” wrote Dr. Gupta, who is affiliated with Emory University in Atlanta. “After 2 weeks, we will reassess.”
I understand that parents worry about the social and psychological costs of remote learning. And I can only imagine the difficulty of those who must balance homeschooling with working. And frankly, remote learning is not an option for all students. For those less fortunate, substantial governmental aid is important to assist these people and to keep them safe and on their feet until this pandemic is done. Also, those who were under the care of a psychiatrist should continue to receive care during the pandemic. We must be prepared to step in with interventions that can address the suffering that is inevitable, such as the use of targeted cognitive-behavioral therapy.
Public TV as an educational tool
Families with Internet access and those without it could benefit from using public television as a tool.
I would advise educators and the entertainment industry to harness the wonder of TV to develop curricula that can be used to educate children. As we know, Sesame Street proved to be an effective early childhood intervention, particularly for boys (Am Econ J: Applied Economics. 2019;11[1]:318-50). I would like to see programming that goes beyond Sesame Street. Learning from watching this kind of programming would be no substitute for engaging with teachers in real, live classrooms, however.
Children and adolescents will be changed by learning remotely. They will miss their friends, teachers, and other staff members, but their lives will not be ruined. Mental health professionals should be prepared to intervene to address depression, anxiety, and other sequelae and problematic behaviors that could result from social isolation. Schools, businesses, and the economy will again flourish after we get the virus behind us but controlling and eliminating this pandemic need to come first. Let’s keep our children home – to the extent that we can – until we move beyond this pandemic.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
Collaborating with religious communities to promote mental health
Spirituality and religion remain central to the worldview of millions of Americans. According to the Pew Research Center, almost 75% of Americans identify as Christian, Jewish, Muslim, Buddhist, or Hindu.1 As is the case with many Americans,2 the lens of spirituality3 and religion shaped my own worldview since childhood.
Growing up in a Christian household, many of my family’s discussions centered on bolstering our spiritual health. I grew to internalize the notion that spiritual health relates to a sense of self, a sense of purpose, and a connection to God, nature, and others. Religious texts such as the Bible, Quran, and Torah share principles aimed at developing believers’ spiritual health. However, the intricacies of mental health remain entirely foreign within many faith communities. In these communities, unfamiliarity with mental health topics seemingly leads to the conflation of spiritual health and mental health.4
Within faith communities, I often hear the phrase, “You can’t worry and pray at the same time.” This commonly used expression encourages people of faith to lean on their spiritual health in times of uncertainty. The perceived dichotomy between worry and prayer represents the theology of sole reliance on spiritual coping skills, such as prayer, when feelings of anxiety and other psychological stressors arise. Because of “pray it away” doctrines and ongoing stigma related to mental health, many of our spiritually minded patients are more likely to seek counsel from religious leaders than they are from mental health clinicians in times of psychological distress.5,6
About 54% of U.S. adults identify as religious, and 75% think of themselves as spiritual.7 This intrapersonal conflict between religious/spiritual health and mental health raises an important question:
Engaging with the community
In a recent virtual talk titled, “Dealing with Depression: Faith, Meds, and Therapy,” I openly discussed varying aspects of mental health and mental illness with approximately 70 women at my church in Philadelphia. Before this presentation, there had never been a leadership-sponsored conversation within the church to discuss spiritual health and mental health as separate but highly interconnected entities.
Throughout the nearly 2-hour session, I used biblical and biological principles to explain the differences between spiritual health and mental health, strategies to recognize signs and symptoms of depression, and treatment options for depression. After the formal presentation, a 45-minute question-and-answer session followed in which some members shared their own experiences with mental illness.
Two major themes emerged as central points of discussion during our time of open dialogue. First, several women shared the spiritual and clinical avenues they used to access support in times of psychological distress. There was a general tone of agreement among attendees that spiritual health and mental health are, in fact, different. Second, the presentation opened the door for attendees, previously unfamiliar with mental health services, to ask questions about connecting with the appropriate resources to receive mental health treatment. The subject of seeking psychiatric care for mental health challenges was, at least in part, demystified and brought to the forefront of the attendees’ minds.
Studies show that many faith-based communities are more likely to seek counsel for psychological distress from religious leaders than from mental health professionals. In this vein, my recent community engagement highlighted to me ways that we can readily reach spiritually and religiously minded patients who otherwise would not receive the psychiatric care that they need. Psychiatrists can play an integral role in bridging the gap in psychiatric care for faith-based persons through outreach to and collaboration with religious communities.
Opportunities for collaboration
In collaboration with religious leaders, psychiatrists can actively support the mental health of spiritually and religiously minded patients through several low-effort, but potentially high-yield, initiatives. Notably, many of my suggested interventions do not require significant, if any, infrastructural changes to the health care system or worship communities. As psychiatrists, we can collaborate with faith leaders as follows:
1. More regularly assess the role of religion and spirituality in our patients’ daily lives to better meet their spiritual and mental health needs.
2. Better use existing chaplain services to provide spiritual support for hospitalized patients.
3. Present information about mental health – in-person, virtually, or in written form – to religious communities through talks, discussions, popular religious publications, social media platforms, and webinars.
4. Amplify existing mental health guides for faith leaders (i.e., the American Psychiatric Association’s guidebook Mental Health: A Guide for Faith Leaders),8 thereby encouraging church leaders and staff to become better informed about common mental health conditions.
5. Collaborate with places of worship to offer psychiatric and psychological services to their members.
This sort of engagement with religious communities is the collective role of community-oriented psychiatrists, not just psychiatrists who ascribe to religious or spiritual beliefs. We ought to remain mindful of the spiritual distress that many spiritual and religious patients feel when they experience mental illness,9 particularly in light of the distress caused by the coronavirus pandemic.10 But first, we must become comfortable with asking our patients about their religious or spiritual affiliations using tools such as the Cultural Formulation Interview.11 The more we recognize the role of spirituality in our patients’ lives, the better equipped we become to help patients identify and seek treatment for mental illness without the distress of their feeling spiritually deficient.
Dr. Jordan is a psychiatry resident physician in Philadelphia. She has no conflicts of interest.
References
1. Religious Landscape Study. pewforum.org.
2. U.S. Religion Census Census: Religious Congregations and Membership Study. Association of Religion Data Archives. 2010. doi: 10.17605/OSF.IO/9AMDJ.
3. J Med Ethics Hist Med. 2018 Apr 9;11:3.
4. The Dimensions of Health: Conceptual Models. Sudbury, Mass.: Jones & Bartlett, 2010.
5. J Res Christ Educ. 2014;23(2):176-86.
6. Health Serv Res. 2003 Apr;38(2):647-73.
7. “More Americans say they’re spiritual but not religious.” pewresearch.org. 2017 Sep 6.
8. Mental Health: A Guide for Faith Leaders. Washington: American Psychiatric Association Foundation, 2018.
9. Mental Health by the Numbers. NAMI: National Alliance on Mental Illness. 2019.
10. “Most Americans say coronavirus outbreak has impacted their lives. Pew Research Center. pewsocialtrends.org. 2020 Mar 30.
11. DSM-5 Handbook on the Cultural Formulation Interview. Washington: American Psychiatric Association Publishing, 2016.
Spirituality and religion remain central to the worldview of millions of Americans. According to the Pew Research Center, almost 75% of Americans identify as Christian, Jewish, Muslim, Buddhist, or Hindu.1 As is the case with many Americans,2 the lens of spirituality3 and religion shaped my own worldview since childhood.
Growing up in a Christian household, many of my family’s discussions centered on bolstering our spiritual health. I grew to internalize the notion that spiritual health relates to a sense of self, a sense of purpose, and a connection to God, nature, and others. Religious texts such as the Bible, Quran, and Torah share principles aimed at developing believers’ spiritual health. However, the intricacies of mental health remain entirely foreign within many faith communities. In these communities, unfamiliarity with mental health topics seemingly leads to the conflation of spiritual health and mental health.4
Within faith communities, I often hear the phrase, “You can’t worry and pray at the same time.” This commonly used expression encourages people of faith to lean on their spiritual health in times of uncertainty. The perceived dichotomy between worry and prayer represents the theology of sole reliance on spiritual coping skills, such as prayer, when feelings of anxiety and other psychological stressors arise. Because of “pray it away” doctrines and ongoing stigma related to mental health, many of our spiritually minded patients are more likely to seek counsel from religious leaders than they are from mental health clinicians in times of psychological distress.5,6
About 54% of U.S. adults identify as religious, and 75% think of themselves as spiritual.7 This intrapersonal conflict between religious/spiritual health and mental health raises an important question:
Engaging with the community
In a recent virtual talk titled, “Dealing with Depression: Faith, Meds, and Therapy,” I openly discussed varying aspects of mental health and mental illness with approximately 70 women at my church in Philadelphia. Before this presentation, there had never been a leadership-sponsored conversation within the church to discuss spiritual health and mental health as separate but highly interconnected entities.
Throughout the nearly 2-hour session, I used biblical and biological principles to explain the differences between spiritual health and mental health, strategies to recognize signs and symptoms of depression, and treatment options for depression. After the formal presentation, a 45-minute question-and-answer session followed in which some members shared their own experiences with mental illness.
Two major themes emerged as central points of discussion during our time of open dialogue. First, several women shared the spiritual and clinical avenues they used to access support in times of psychological distress. There was a general tone of agreement among attendees that spiritual health and mental health are, in fact, different. Second, the presentation opened the door for attendees, previously unfamiliar with mental health services, to ask questions about connecting with the appropriate resources to receive mental health treatment. The subject of seeking psychiatric care for mental health challenges was, at least in part, demystified and brought to the forefront of the attendees’ minds.
Studies show that many faith-based communities are more likely to seek counsel for psychological distress from religious leaders than from mental health professionals. In this vein, my recent community engagement highlighted to me ways that we can readily reach spiritually and religiously minded patients who otherwise would not receive the psychiatric care that they need. Psychiatrists can play an integral role in bridging the gap in psychiatric care for faith-based persons through outreach to and collaboration with religious communities.
Opportunities for collaboration
In collaboration with religious leaders, psychiatrists can actively support the mental health of spiritually and religiously minded patients through several low-effort, but potentially high-yield, initiatives. Notably, many of my suggested interventions do not require significant, if any, infrastructural changes to the health care system or worship communities. As psychiatrists, we can collaborate with faith leaders as follows:
1. More regularly assess the role of religion and spirituality in our patients’ daily lives to better meet their spiritual and mental health needs.
2. Better use existing chaplain services to provide spiritual support for hospitalized patients.
3. Present information about mental health – in-person, virtually, or in written form – to religious communities through talks, discussions, popular religious publications, social media platforms, and webinars.
4. Amplify existing mental health guides for faith leaders (i.e., the American Psychiatric Association’s guidebook Mental Health: A Guide for Faith Leaders),8 thereby encouraging church leaders and staff to become better informed about common mental health conditions.
5. Collaborate with places of worship to offer psychiatric and psychological services to their members.
This sort of engagement with religious communities is the collective role of community-oriented psychiatrists, not just psychiatrists who ascribe to religious or spiritual beliefs. We ought to remain mindful of the spiritual distress that many spiritual and religious patients feel when they experience mental illness,9 particularly in light of the distress caused by the coronavirus pandemic.10 But first, we must become comfortable with asking our patients about their religious or spiritual affiliations using tools such as the Cultural Formulation Interview.11 The more we recognize the role of spirituality in our patients’ lives, the better equipped we become to help patients identify and seek treatment for mental illness without the distress of their feeling spiritually deficient.
Dr. Jordan is a psychiatry resident physician in Philadelphia. She has no conflicts of interest.
References
1. Religious Landscape Study. pewforum.org.
2. U.S. Religion Census Census: Religious Congregations and Membership Study. Association of Religion Data Archives. 2010. doi: 10.17605/OSF.IO/9AMDJ.
3. J Med Ethics Hist Med. 2018 Apr 9;11:3.
4. The Dimensions of Health: Conceptual Models. Sudbury, Mass.: Jones & Bartlett, 2010.
5. J Res Christ Educ. 2014;23(2):176-86.
6. Health Serv Res. 2003 Apr;38(2):647-73.
7. “More Americans say they’re spiritual but not religious.” pewresearch.org. 2017 Sep 6.
8. Mental Health: A Guide for Faith Leaders. Washington: American Psychiatric Association Foundation, 2018.
9. Mental Health by the Numbers. NAMI: National Alliance on Mental Illness. 2019.
10. “Most Americans say coronavirus outbreak has impacted their lives. Pew Research Center. pewsocialtrends.org. 2020 Mar 30.
11. DSM-5 Handbook on the Cultural Formulation Interview. Washington: American Psychiatric Association Publishing, 2016.
Spirituality and religion remain central to the worldview of millions of Americans. According to the Pew Research Center, almost 75% of Americans identify as Christian, Jewish, Muslim, Buddhist, or Hindu.1 As is the case with many Americans,2 the lens of spirituality3 and religion shaped my own worldview since childhood.
Growing up in a Christian household, many of my family’s discussions centered on bolstering our spiritual health. I grew to internalize the notion that spiritual health relates to a sense of self, a sense of purpose, and a connection to God, nature, and others. Religious texts such as the Bible, Quran, and Torah share principles aimed at developing believers’ spiritual health. However, the intricacies of mental health remain entirely foreign within many faith communities. In these communities, unfamiliarity with mental health topics seemingly leads to the conflation of spiritual health and mental health.4
Within faith communities, I often hear the phrase, “You can’t worry and pray at the same time.” This commonly used expression encourages people of faith to lean on their spiritual health in times of uncertainty. The perceived dichotomy between worry and prayer represents the theology of sole reliance on spiritual coping skills, such as prayer, when feelings of anxiety and other psychological stressors arise. Because of “pray it away” doctrines and ongoing stigma related to mental health, many of our spiritually minded patients are more likely to seek counsel from religious leaders than they are from mental health clinicians in times of psychological distress.5,6
About 54% of U.S. adults identify as religious, and 75% think of themselves as spiritual.7 This intrapersonal conflict between religious/spiritual health and mental health raises an important question:
Engaging with the community
In a recent virtual talk titled, “Dealing with Depression: Faith, Meds, and Therapy,” I openly discussed varying aspects of mental health and mental illness with approximately 70 women at my church in Philadelphia. Before this presentation, there had never been a leadership-sponsored conversation within the church to discuss spiritual health and mental health as separate but highly interconnected entities.
Throughout the nearly 2-hour session, I used biblical and biological principles to explain the differences between spiritual health and mental health, strategies to recognize signs and symptoms of depression, and treatment options for depression. After the formal presentation, a 45-minute question-and-answer session followed in which some members shared their own experiences with mental illness.
Two major themes emerged as central points of discussion during our time of open dialogue. First, several women shared the spiritual and clinical avenues they used to access support in times of psychological distress. There was a general tone of agreement among attendees that spiritual health and mental health are, in fact, different. Second, the presentation opened the door for attendees, previously unfamiliar with mental health services, to ask questions about connecting with the appropriate resources to receive mental health treatment. The subject of seeking psychiatric care for mental health challenges was, at least in part, demystified and brought to the forefront of the attendees’ minds.
Studies show that many faith-based communities are more likely to seek counsel for psychological distress from religious leaders than from mental health professionals. In this vein, my recent community engagement highlighted to me ways that we can readily reach spiritually and religiously minded patients who otherwise would not receive the psychiatric care that they need. Psychiatrists can play an integral role in bridging the gap in psychiatric care for faith-based persons through outreach to and collaboration with religious communities.
Opportunities for collaboration
In collaboration with religious leaders, psychiatrists can actively support the mental health of spiritually and religiously minded patients through several low-effort, but potentially high-yield, initiatives. Notably, many of my suggested interventions do not require significant, if any, infrastructural changes to the health care system or worship communities. As psychiatrists, we can collaborate with faith leaders as follows:
1. More regularly assess the role of religion and spirituality in our patients’ daily lives to better meet their spiritual and mental health needs.
2. Better use existing chaplain services to provide spiritual support for hospitalized patients.
3. Present information about mental health – in-person, virtually, or in written form – to religious communities through talks, discussions, popular religious publications, social media platforms, and webinars.
4. Amplify existing mental health guides for faith leaders (i.e., the American Psychiatric Association’s guidebook Mental Health: A Guide for Faith Leaders),8 thereby encouraging church leaders and staff to become better informed about common mental health conditions.
5. Collaborate with places of worship to offer psychiatric and psychological services to their members.
This sort of engagement with religious communities is the collective role of community-oriented psychiatrists, not just psychiatrists who ascribe to religious or spiritual beliefs. We ought to remain mindful of the spiritual distress that many spiritual and religious patients feel when they experience mental illness,9 particularly in light of the distress caused by the coronavirus pandemic.10 But first, we must become comfortable with asking our patients about their religious or spiritual affiliations using tools such as the Cultural Formulation Interview.11 The more we recognize the role of spirituality in our patients’ lives, the better equipped we become to help patients identify and seek treatment for mental illness without the distress of their feeling spiritually deficient.
Dr. Jordan is a psychiatry resident physician in Philadelphia. She has no conflicts of interest.
References
1. Religious Landscape Study. pewforum.org.
2. U.S. Religion Census Census: Religious Congregations and Membership Study. Association of Religion Data Archives. 2010. doi: 10.17605/OSF.IO/9AMDJ.
3. J Med Ethics Hist Med. 2018 Apr 9;11:3.
4. The Dimensions of Health: Conceptual Models. Sudbury, Mass.: Jones & Bartlett, 2010.
5. J Res Christ Educ. 2014;23(2):176-86.
6. Health Serv Res. 2003 Apr;38(2):647-73.
7. “More Americans say they’re spiritual but not religious.” pewresearch.org. 2017 Sep 6.
8. Mental Health: A Guide for Faith Leaders. Washington: American Psychiatric Association Foundation, 2018.
9. Mental Health by the Numbers. NAMI: National Alliance on Mental Illness. 2019.
10. “Most Americans say coronavirus outbreak has impacted their lives. Pew Research Center. pewsocialtrends.org. 2020 Mar 30.
11. DSM-5 Handbook on the Cultural Formulation Interview. Washington: American Psychiatric Association Publishing, 2016.
COVID-19: Optimizing therapeutic strategies for children, adolescents with ADHD
Recently, the Yakima Health District (YHD), in collaboration with the Washington State Department of Health, issued dramatic revisions to its educational curriculum, opting for exclusively remote learning as an important next step in COVID-19 containment measures.
The newly implemented “enhanced” distance-learning paradigm has garnered considerable national attention. Even more noteworthy is how YHD addressed those with language barriers and learning differences such as ADHD as a “priority group”; these individuals are exempt from the newly implemented measures, and small instructional groups of no more than five “at-risk” students will be directly supervised by specialized educators.1,2 To overcome these new unprecedented challenges from the coronavirus pandemic, especially from the perspective of distance education and mental health for susceptible groups such as those with ADHD, it is of utmost importance to explore various programs of interest, as well as the targeted therapies being considered during this crisis.
From a therapeutic standpoint, individuals with learning differences are more likely to play catch-up with their age-matched peers. This puts them at significant risk for developmental delays with symptoms manifesting as disruptive behavioral issues. This is why ongoing parental guidance, coupled with a paradoxically stimulating environment, is critical for children and adolescents with ADHD.3 Accumulating evidence, based on a myriad of studies, demonstrates that childhood treatment with ADHD stimulants reduces the incidence of future substance use, as well as that of other negative outcomes.4,5
Therapeutic strategies that work
“The new normal” has forced unique challenges on clinicians for mitigating distress by novel means of health care delivery. Given the paucity of research exploring the interactions of individuals with ADHD within the context of COVID-19, Take for example, the suggested guidelines from the European ADHD Guidelines Group (EAGG) – such as the following:
- Telecommunications in general, and telepsychiatry in particular, should function as the primary mode of health care delivery to fulfill societal standards of physical distancing.
- Children and adolescents with ADHD should be designated as a “priority group” with respect to monitoring initiatives by educators in a school setting, be it virtual or otherwise.
- Implementation of behavioral strategies by parent or guardian to address psychological well-being and reduce the presence of comorbid behavioral conditions (such as oppositional defiant disorder).
In addition to the aforementioned guidance, EAGG maintains that individuals with ADHD may be initiated on medications after the completion of a baseline examination; if the patients in question are already on a treatment regimen, they should proceed with it as indicated. Interruptions to therapy are not ideal because patients are then subjected to health-related stressors of COVID-19. Reasonable regulations concerning access to medications, without unnecessary delays, undoubtedly will facilitate patient needs, allowing for a smooth transition in day-to-day activities. The family, as a cohesive unit, may benefit from reeducation because it contributes toward the therapeutic process. Neurofeedback, coping skills, and cognitive restructuring training are potential modalities that can augment medications.
Although it may seem counterintuitive, parents or caregivers should resist the urge to increase the medication dose during an outbreak with the intended goal of diminishing the psychosocial burden of ADHD symptomatology. Likewise, unless indicated by a specialist, antipsychotics and/or hypnotics should not be introduced for addressing behavioral dysregulation (such as agitation) during the confinement period.
Historically, numerous clinicians have suggested that patients undergo a routine cardiovascular examination and EKG before being prescribed psychostimulants (the rationale for this recommendation is that sympathomimetics unduly affect blood pressure and heart rate).6,7 However, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) eventually amended their previous stance by releasing a joint statement in which they deemed a baseline EKG necessary only in ADHD patients with preexisting cardiac risk. For all other patients, the use of EKGs was entirely contingent on physician discretion. However, given the nature of safety precautions for COVID-19, it is prudent to discourage or delay in-person cardiovascular examination/monitoring protocols altogether, especially in those patients without known heart conditions.
Another area of concern is sleep dysfunction, which might exist as an untoward effect of ADHD medication intake or because of the presence of COVID-19 psychosocial stressors. However, clinicians advise that unnecessary psychopharmacology (such as hypnotics or melatonin) be avoided. Instead, conservative lifestyle measures should be enacted, emphasizing the role of proper sleep hygiene in maintaining optimal behavioral health. Despite setbacks to in-person appointments, patients are expected to continue their pharmacotherapy with “parent-focused” ADHD interventions taking a primary role in facilitating compliance through remote monitoring.
ADMiRE, a tertiary-level, dedicated ADHD intervention program from South Dublin, Ireland, has identified several roadblocks with respect to streamlining health care for individuals with ADHD during the confinement period. The proposed resolution to these issues, some of which are derived from EAGG guidelines, might have universal applications elsewhere, thereby facilitating the development of therapeutic services of interest. ADMiRE has noted a correspondence between the guidelines established by EAGG and that of the Canadian ADHD Resource Alliance (CADDRA), including minimal in-person interactions (in favor of virtual teleconferencing) and a cardiovascular screen can be performed in lieu of baseline cardiac auscultation. Moreover, in the event that the patient is a low cardiac risk candidate for ADHD treatment, monitoring protocols may be continued from a home setting. However, if a physical examination is indicated, CADDRA recommends the use of precautionary PPE before commencing ADHD pharmacotherapy.
One of the most significant hurdles is that of school closures because teacher feedback for baseline behavior was traditionally instrumental in dictating patient medical management (for example, for titration schedule). It is expected that, for the time being, this role will be supplanted by parental reports. As well as disclosing information on behavioral dysregulation, family members should be trained to relay critical information about the development of stimulant-induced cardiovascular symptoms – namely, dyspnea, chest pain, and/or palpitations. Furthermore, as primary caregivers, parents should harbor a certain degree of emotional sensitivity because their mood state may influence the child’s overall behavioral course in terms of symptom exacerbation.8
Toward adopting an integrated model for care
Developing an effective assessment plan for patients with ADHD often proves to be a challenging task for clinicians, perhaps even more so in environments that enforce social distancing and limited physical contact by default. As a neurodevelopmental disorder from childhood, the symptoms (including inattention, hyperactivity, and/or impulsivity) of ADHD do not arise in a vacuum – comorbid conditions include mood and anxiety disorders, which are complicated further by a background risk for substance use and self-medicating tendencies.9 Unfortunately, the pandemic has limited the breadth of non-COVID doctors visits, which hinders the overall diagnostic and monitoring process for identifiable comorbid conditions, such as autism spectrum disorder, intellectual disability, oppositional defiant and conduct disorders, and so on.10 Since ADHD symptoms cannot be treated by pharmacotherapy or behavioral interventions alone, our team advocates that families provide additional emotional support and continuous encouragement during these uncertain times.
ADHD and the self-medication hypothesis
The Khantzian self-medication hypothesis posits that a drug seeker may subconsciously gravitate toward a particular agent only to discover a sense of relief concerning inner turmoil or restlessness after use. Observations support the notion that individuals with undiagnosed ADHD have sought cocaine or even recreational designer drugs (such as methylenedioxypyrovalerone, or “bath salts”).11 Given the similar mechanism of action between cocaine, methylenedioxypyrovalerone, and prescribed psychostimulants such as methylphenidate, the results are hardly surprising because these agents all work on the brain’s “reward center” (for example, the nucleus accumbens) by invoking dopamine release. Aside from the aforementioned self-medication hypothesis, “downers” such as Xanax recently have experienced a prescription spike during the outbreak. While there isn’t an immediate cause for concern of Xanax abuse in ADHD individuals, the potential for addiction is certainly real, especially when taking into account comorbid anxiety disorder or sleep dysfunction.
Because of limited resources and precautionary guidelines, clinicians are at a considerable disadvantage in terms of formulating a comprehensive diagnostic and treatment plan for children and adolescents with ADHD. This situation is further compounded by the recent closure of schools and the lack of feedback with respect to baseline behavior from teachers and specialized educators. This is why it is imperative for primary caregivers to closely monitor children with ADHD for developing changes in behavioral patterns (for example, mood or anxiety issues and drug-seeking or disruptive behavior) and work with health care professionals.
References
1. “Distance learning strongly recommended for all Yakima county schools.” NBC Right Now. 2020 Aug 5.
2. Retka J. “Enhanced” remote learning in Yakima county schools? What that means for students this fall. Yakima Herald-Republic. 2020 Aug 8.
3. Armstrong T. “To empower! Not Control! A holistic approach to ADHD.” American Institute for Learning and Development. 1998.
4. J Child Psychol Psychiatry. 2014 Aug;55(8):878-85.
5. Ir J Psychol Med. 2020 May 21:1-22.
6. Lancet Child Adolesc Health. 2020 Jun;4(6):412-4.
7. O’Keefe L. AAP News. 2008 Jun;29(6):1.
8. Asian J Psychiatr. 2020 Jun;51:102077.
9. Current Psychiatry. 2015 Dec;14(12):e3-4.
10. Encephale. 2020 Jun 7;46(3S):S85-92.
11. Current Psychiatry. 2014 Dec; 3(12): e3-4.
Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Zaid Ulhaq Choudhry is a research assistant at the IMCHF. He has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clini-cal research at the IMCHF and is Mr. Choudhry’s father. He has no disclosures.
Recently, the Yakima Health District (YHD), in collaboration with the Washington State Department of Health, issued dramatic revisions to its educational curriculum, opting for exclusively remote learning as an important next step in COVID-19 containment measures.
The newly implemented “enhanced” distance-learning paradigm has garnered considerable national attention. Even more noteworthy is how YHD addressed those with language barriers and learning differences such as ADHD as a “priority group”; these individuals are exempt from the newly implemented measures, and small instructional groups of no more than five “at-risk” students will be directly supervised by specialized educators.1,2 To overcome these new unprecedented challenges from the coronavirus pandemic, especially from the perspective of distance education and mental health for susceptible groups such as those with ADHD, it is of utmost importance to explore various programs of interest, as well as the targeted therapies being considered during this crisis.
From a therapeutic standpoint, individuals with learning differences are more likely to play catch-up with their age-matched peers. This puts them at significant risk for developmental delays with symptoms manifesting as disruptive behavioral issues. This is why ongoing parental guidance, coupled with a paradoxically stimulating environment, is critical for children and adolescents with ADHD.3 Accumulating evidence, based on a myriad of studies, demonstrates that childhood treatment with ADHD stimulants reduces the incidence of future substance use, as well as that of other negative outcomes.4,5
Therapeutic strategies that work
“The new normal” has forced unique challenges on clinicians for mitigating distress by novel means of health care delivery. Given the paucity of research exploring the interactions of individuals with ADHD within the context of COVID-19, Take for example, the suggested guidelines from the European ADHD Guidelines Group (EAGG) – such as the following:
- Telecommunications in general, and telepsychiatry in particular, should function as the primary mode of health care delivery to fulfill societal standards of physical distancing.
- Children and adolescents with ADHD should be designated as a “priority group” with respect to monitoring initiatives by educators in a school setting, be it virtual or otherwise.
- Implementation of behavioral strategies by parent or guardian to address psychological well-being and reduce the presence of comorbid behavioral conditions (such as oppositional defiant disorder).
In addition to the aforementioned guidance, EAGG maintains that individuals with ADHD may be initiated on medications after the completion of a baseline examination; if the patients in question are already on a treatment regimen, they should proceed with it as indicated. Interruptions to therapy are not ideal because patients are then subjected to health-related stressors of COVID-19. Reasonable regulations concerning access to medications, without unnecessary delays, undoubtedly will facilitate patient needs, allowing for a smooth transition in day-to-day activities. The family, as a cohesive unit, may benefit from reeducation because it contributes toward the therapeutic process. Neurofeedback, coping skills, and cognitive restructuring training are potential modalities that can augment medications.
Although it may seem counterintuitive, parents or caregivers should resist the urge to increase the medication dose during an outbreak with the intended goal of diminishing the psychosocial burden of ADHD symptomatology. Likewise, unless indicated by a specialist, antipsychotics and/or hypnotics should not be introduced for addressing behavioral dysregulation (such as agitation) during the confinement period.
Historically, numerous clinicians have suggested that patients undergo a routine cardiovascular examination and EKG before being prescribed psychostimulants (the rationale for this recommendation is that sympathomimetics unduly affect blood pressure and heart rate).6,7 However, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) eventually amended their previous stance by releasing a joint statement in which they deemed a baseline EKG necessary only in ADHD patients with preexisting cardiac risk. For all other patients, the use of EKGs was entirely contingent on physician discretion. However, given the nature of safety precautions for COVID-19, it is prudent to discourage or delay in-person cardiovascular examination/monitoring protocols altogether, especially in those patients without known heart conditions.
Another area of concern is sleep dysfunction, which might exist as an untoward effect of ADHD medication intake or because of the presence of COVID-19 psychosocial stressors. However, clinicians advise that unnecessary psychopharmacology (such as hypnotics or melatonin) be avoided. Instead, conservative lifestyle measures should be enacted, emphasizing the role of proper sleep hygiene in maintaining optimal behavioral health. Despite setbacks to in-person appointments, patients are expected to continue their pharmacotherapy with “parent-focused” ADHD interventions taking a primary role in facilitating compliance through remote monitoring.
ADMiRE, a tertiary-level, dedicated ADHD intervention program from South Dublin, Ireland, has identified several roadblocks with respect to streamlining health care for individuals with ADHD during the confinement period. The proposed resolution to these issues, some of which are derived from EAGG guidelines, might have universal applications elsewhere, thereby facilitating the development of therapeutic services of interest. ADMiRE has noted a correspondence between the guidelines established by EAGG and that of the Canadian ADHD Resource Alliance (CADDRA), including minimal in-person interactions (in favor of virtual teleconferencing) and a cardiovascular screen can be performed in lieu of baseline cardiac auscultation. Moreover, in the event that the patient is a low cardiac risk candidate for ADHD treatment, monitoring protocols may be continued from a home setting. However, if a physical examination is indicated, CADDRA recommends the use of precautionary PPE before commencing ADHD pharmacotherapy.
One of the most significant hurdles is that of school closures because teacher feedback for baseline behavior was traditionally instrumental in dictating patient medical management (for example, for titration schedule). It is expected that, for the time being, this role will be supplanted by parental reports. As well as disclosing information on behavioral dysregulation, family members should be trained to relay critical information about the development of stimulant-induced cardiovascular symptoms – namely, dyspnea, chest pain, and/or palpitations. Furthermore, as primary caregivers, parents should harbor a certain degree of emotional sensitivity because their mood state may influence the child’s overall behavioral course in terms of symptom exacerbation.8
Toward adopting an integrated model for care
Developing an effective assessment plan for patients with ADHD often proves to be a challenging task for clinicians, perhaps even more so in environments that enforce social distancing and limited physical contact by default. As a neurodevelopmental disorder from childhood, the symptoms (including inattention, hyperactivity, and/or impulsivity) of ADHD do not arise in a vacuum – comorbid conditions include mood and anxiety disorders, which are complicated further by a background risk for substance use and self-medicating tendencies.9 Unfortunately, the pandemic has limited the breadth of non-COVID doctors visits, which hinders the overall diagnostic and monitoring process for identifiable comorbid conditions, such as autism spectrum disorder, intellectual disability, oppositional defiant and conduct disorders, and so on.10 Since ADHD symptoms cannot be treated by pharmacotherapy or behavioral interventions alone, our team advocates that families provide additional emotional support and continuous encouragement during these uncertain times.
ADHD and the self-medication hypothesis
The Khantzian self-medication hypothesis posits that a drug seeker may subconsciously gravitate toward a particular agent only to discover a sense of relief concerning inner turmoil or restlessness after use. Observations support the notion that individuals with undiagnosed ADHD have sought cocaine or even recreational designer drugs (such as methylenedioxypyrovalerone, or “bath salts”).11 Given the similar mechanism of action between cocaine, methylenedioxypyrovalerone, and prescribed psychostimulants such as methylphenidate, the results are hardly surprising because these agents all work on the brain’s “reward center” (for example, the nucleus accumbens) by invoking dopamine release. Aside from the aforementioned self-medication hypothesis, “downers” such as Xanax recently have experienced a prescription spike during the outbreak. While there isn’t an immediate cause for concern of Xanax abuse in ADHD individuals, the potential for addiction is certainly real, especially when taking into account comorbid anxiety disorder or sleep dysfunction.
Because of limited resources and precautionary guidelines, clinicians are at a considerable disadvantage in terms of formulating a comprehensive diagnostic and treatment plan for children and adolescents with ADHD. This situation is further compounded by the recent closure of schools and the lack of feedback with respect to baseline behavior from teachers and specialized educators. This is why it is imperative for primary caregivers to closely monitor children with ADHD for developing changes in behavioral patterns (for example, mood or anxiety issues and drug-seeking or disruptive behavior) and work with health care professionals.
References
1. “Distance learning strongly recommended for all Yakima county schools.” NBC Right Now. 2020 Aug 5.
2. Retka J. “Enhanced” remote learning in Yakima county schools? What that means for students this fall. Yakima Herald-Republic. 2020 Aug 8.
3. Armstrong T. “To empower! Not Control! A holistic approach to ADHD.” American Institute for Learning and Development. 1998.
4. J Child Psychol Psychiatry. 2014 Aug;55(8):878-85.
5. Ir J Psychol Med. 2020 May 21:1-22.
6. Lancet Child Adolesc Health. 2020 Jun;4(6):412-4.
7. O’Keefe L. AAP News. 2008 Jun;29(6):1.
8. Asian J Psychiatr. 2020 Jun;51:102077.
9. Current Psychiatry. 2015 Dec;14(12):e3-4.
10. Encephale. 2020 Jun 7;46(3S):S85-92.
11. Current Psychiatry. 2014 Dec; 3(12): e3-4.
Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Zaid Ulhaq Choudhry is a research assistant at the IMCHF. He has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clini-cal research at the IMCHF and is Mr. Choudhry’s father. He has no disclosures.
Recently, the Yakima Health District (YHD), in collaboration with the Washington State Department of Health, issued dramatic revisions to its educational curriculum, opting for exclusively remote learning as an important next step in COVID-19 containment measures.
The newly implemented “enhanced” distance-learning paradigm has garnered considerable national attention. Even more noteworthy is how YHD addressed those with language barriers and learning differences such as ADHD as a “priority group”; these individuals are exempt from the newly implemented measures, and small instructional groups of no more than five “at-risk” students will be directly supervised by specialized educators.1,2 To overcome these new unprecedented challenges from the coronavirus pandemic, especially from the perspective of distance education and mental health for susceptible groups such as those with ADHD, it is of utmost importance to explore various programs of interest, as well as the targeted therapies being considered during this crisis.
From a therapeutic standpoint, individuals with learning differences are more likely to play catch-up with their age-matched peers. This puts them at significant risk for developmental delays with symptoms manifesting as disruptive behavioral issues. This is why ongoing parental guidance, coupled with a paradoxically stimulating environment, is critical for children and adolescents with ADHD.3 Accumulating evidence, based on a myriad of studies, demonstrates that childhood treatment with ADHD stimulants reduces the incidence of future substance use, as well as that of other negative outcomes.4,5
Therapeutic strategies that work
“The new normal” has forced unique challenges on clinicians for mitigating distress by novel means of health care delivery. Given the paucity of research exploring the interactions of individuals with ADHD within the context of COVID-19, Take for example, the suggested guidelines from the European ADHD Guidelines Group (EAGG) – such as the following:
- Telecommunications in general, and telepsychiatry in particular, should function as the primary mode of health care delivery to fulfill societal standards of physical distancing.
- Children and adolescents with ADHD should be designated as a “priority group” with respect to monitoring initiatives by educators in a school setting, be it virtual or otherwise.
- Implementation of behavioral strategies by parent or guardian to address psychological well-being and reduce the presence of comorbid behavioral conditions (such as oppositional defiant disorder).
In addition to the aforementioned guidance, EAGG maintains that individuals with ADHD may be initiated on medications after the completion of a baseline examination; if the patients in question are already on a treatment regimen, they should proceed with it as indicated. Interruptions to therapy are not ideal because patients are then subjected to health-related stressors of COVID-19. Reasonable regulations concerning access to medications, without unnecessary delays, undoubtedly will facilitate patient needs, allowing for a smooth transition in day-to-day activities. The family, as a cohesive unit, may benefit from reeducation because it contributes toward the therapeutic process. Neurofeedback, coping skills, and cognitive restructuring training are potential modalities that can augment medications.
Although it may seem counterintuitive, parents or caregivers should resist the urge to increase the medication dose during an outbreak with the intended goal of diminishing the psychosocial burden of ADHD symptomatology. Likewise, unless indicated by a specialist, antipsychotics and/or hypnotics should not be introduced for addressing behavioral dysregulation (such as agitation) during the confinement period.
Historically, numerous clinicians have suggested that patients undergo a routine cardiovascular examination and EKG before being prescribed psychostimulants (the rationale for this recommendation is that sympathomimetics unduly affect blood pressure and heart rate).6,7 However, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) eventually amended their previous stance by releasing a joint statement in which they deemed a baseline EKG necessary only in ADHD patients with preexisting cardiac risk. For all other patients, the use of EKGs was entirely contingent on physician discretion. However, given the nature of safety precautions for COVID-19, it is prudent to discourage or delay in-person cardiovascular examination/monitoring protocols altogether, especially in those patients without known heart conditions.
Another area of concern is sleep dysfunction, which might exist as an untoward effect of ADHD medication intake or because of the presence of COVID-19 psychosocial stressors. However, clinicians advise that unnecessary psychopharmacology (such as hypnotics or melatonin) be avoided. Instead, conservative lifestyle measures should be enacted, emphasizing the role of proper sleep hygiene in maintaining optimal behavioral health. Despite setbacks to in-person appointments, patients are expected to continue their pharmacotherapy with “parent-focused” ADHD interventions taking a primary role in facilitating compliance through remote monitoring.
ADMiRE, a tertiary-level, dedicated ADHD intervention program from South Dublin, Ireland, has identified several roadblocks with respect to streamlining health care for individuals with ADHD during the confinement period. The proposed resolution to these issues, some of which are derived from EAGG guidelines, might have universal applications elsewhere, thereby facilitating the development of therapeutic services of interest. ADMiRE has noted a correspondence between the guidelines established by EAGG and that of the Canadian ADHD Resource Alliance (CADDRA), including minimal in-person interactions (in favor of virtual teleconferencing) and a cardiovascular screen can be performed in lieu of baseline cardiac auscultation. Moreover, in the event that the patient is a low cardiac risk candidate for ADHD treatment, monitoring protocols may be continued from a home setting. However, if a physical examination is indicated, CADDRA recommends the use of precautionary PPE before commencing ADHD pharmacotherapy.
One of the most significant hurdles is that of school closures because teacher feedback for baseline behavior was traditionally instrumental in dictating patient medical management (for example, for titration schedule). It is expected that, for the time being, this role will be supplanted by parental reports. As well as disclosing information on behavioral dysregulation, family members should be trained to relay critical information about the development of stimulant-induced cardiovascular symptoms – namely, dyspnea, chest pain, and/or palpitations. Furthermore, as primary caregivers, parents should harbor a certain degree of emotional sensitivity because their mood state may influence the child’s overall behavioral course in terms of symptom exacerbation.8
Toward adopting an integrated model for care
Developing an effective assessment plan for patients with ADHD often proves to be a challenging task for clinicians, perhaps even more so in environments that enforce social distancing and limited physical contact by default. As a neurodevelopmental disorder from childhood, the symptoms (including inattention, hyperactivity, and/or impulsivity) of ADHD do not arise in a vacuum – comorbid conditions include mood and anxiety disorders, which are complicated further by a background risk for substance use and self-medicating tendencies.9 Unfortunately, the pandemic has limited the breadth of non-COVID doctors visits, which hinders the overall diagnostic and monitoring process for identifiable comorbid conditions, such as autism spectrum disorder, intellectual disability, oppositional defiant and conduct disorders, and so on.10 Since ADHD symptoms cannot be treated by pharmacotherapy or behavioral interventions alone, our team advocates that families provide additional emotional support and continuous encouragement during these uncertain times.
ADHD and the self-medication hypothesis
The Khantzian self-medication hypothesis posits that a drug seeker may subconsciously gravitate toward a particular agent only to discover a sense of relief concerning inner turmoil or restlessness after use. Observations support the notion that individuals with undiagnosed ADHD have sought cocaine or even recreational designer drugs (such as methylenedioxypyrovalerone, or “bath salts”).11 Given the similar mechanism of action between cocaine, methylenedioxypyrovalerone, and prescribed psychostimulants such as methylphenidate, the results are hardly surprising because these agents all work on the brain’s “reward center” (for example, the nucleus accumbens) by invoking dopamine release. Aside from the aforementioned self-medication hypothesis, “downers” such as Xanax recently have experienced a prescription spike during the outbreak. While there isn’t an immediate cause for concern of Xanax abuse in ADHD individuals, the potential for addiction is certainly real, especially when taking into account comorbid anxiety disorder or sleep dysfunction.
Because of limited resources and precautionary guidelines, clinicians are at a considerable disadvantage in terms of formulating a comprehensive diagnostic and treatment plan for children and adolescents with ADHD. This situation is further compounded by the recent closure of schools and the lack of feedback with respect to baseline behavior from teachers and specialized educators. This is why it is imperative for primary caregivers to closely monitor children with ADHD for developing changes in behavioral patterns (for example, mood or anxiety issues and drug-seeking or disruptive behavior) and work with health care professionals.
References
1. “Distance learning strongly recommended for all Yakima county schools.” NBC Right Now. 2020 Aug 5.
2. Retka J. “Enhanced” remote learning in Yakima county schools? What that means for students this fall. Yakima Herald-Republic. 2020 Aug 8.
3. Armstrong T. “To empower! Not Control! A holistic approach to ADHD.” American Institute for Learning and Development. 1998.
4. J Child Psychol Psychiatry. 2014 Aug;55(8):878-85.
5. Ir J Psychol Med. 2020 May 21:1-22.
6. Lancet Child Adolesc Health. 2020 Jun;4(6):412-4.
7. O’Keefe L. AAP News. 2008 Jun;29(6):1.
8. Asian J Psychiatr. 2020 Jun;51:102077.
9. Current Psychiatry. 2015 Dec;14(12):e3-4.
10. Encephale. 2020 Jun 7;46(3S):S85-92.
11. Current Psychiatry. 2014 Dec; 3(12): e3-4.
Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Zaid Ulhaq Choudhry is a research assistant at the IMCHF. He has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clini-cal research at the IMCHF and is Mr. Choudhry’s father. He has no disclosures.
The transitions of COVID-19
When I was preparing for the recent birth of my baby, I anticipated a period of transition for myself. As a reproductive psychiatrist, I have treated many women during the perinatal and postpartum periods, and have a unique appreciation for the life changes that accompany birth. What I did not expect, however, was the world transitioning with me.
“The new normal” is an economic phrase that describes the COVID-19 era. The pandemic has engendered economic instability, collapsed industries, challenged health care systems, and has led to many deaths worldwide. The COVID-19 pandemic also has been associated with overall increases in anxiety and depression.1 Emerging research suggests that frontline medical workers are especially at risk for developing psychological distress.2
COVID-19 has also created immense challenges for families. Because of concern for the spread of the virus, schools have been suspended, older grandparents isolated, and many parents continue to work remotely. For families in psychiatric care, this time has also been a time of change. Telepsychiatry might be more accessible, but the transition has been an adjustment for patients and clinicians.
As psychiatrists, how do we best treat families during this time? What are some ways to support our psychiatric colleagues? How do we ensure our own emotional well-being amid the tremendous changes occurring around us?
Background of interpersonal psychotherapy
Interpersonal psychotherapy (IPT) is a form of psychotherapy designed to treat depression following periods of transition. Its main goals include improving interpersonal connection and reducing psychological distress. Originally developed in the 1970s by Gerald Klerman, MD; Myrna Weissman, PhD; and Eugene Paykel, MD, IPT is a structured, time-limited form of psychotherapy.3
Conceptualizing depression as a treatable illness, Pim Cuijpers, PhD, and associates summarized the division of IPT into three phases.4 The initial phase involves history taking, forming an alliance, and choosing an interpersonal focus for treatment. The middle phase focuses on applying interpersonal problem-specific therapeutic techniques. The concluding phase of treatment involves consolidation of gains as well as formulating contingency plans for relapse of symptoms. Over the course of treatment, an IPT clinician focuses on life transitions and emphasizes that isolation and antagonistic relationships increase an individual’s vulnerability for a depressive episode.3
Randomized, controlled trials support IPT’s efficacy as a treatment for depression. Research also suggests it can possibly prevent the development of depression.4 Although IPT initially was designed as an individual form of psychotherapy, it has been adapted to both family and group contexts.5,6 IPT is also an empirically valid form of psychotherapy for postpartum depression.7
Interpersonal psychotherapy for families
Given IPT’s role for treating depression following times of transition, clinicians should consider adapting interpersonal psychotherapy to family treatment during this time. Addressing social isolation, managing complex family relationships, and monitoring the family’s overall emotional health should be prioritized. Families under quarantine or who are grieving the death of family members may especially benefit from improved interpersonal connection. Consistent with the IPT model, contingency plans for the family should also be explored to prepare for potential future waves of the pandemic.
In addition to supporting and strengthening families, psychiatrists can use IPT themes to identify positive changes for families tied to COVID-19. Despite its difficulties, the stay-at-home order provided some families a unique chance to slow down and adapt a more relaxed routine. Busy families were suddenly given the opportunity to spend more time with one another. Although many older grandparents were isolated, creative uses of technology provided a chance for grandparents to remain an integral part of family life. Psychiatrists can assist families in transitioning back to previous schedules, while also exploring ways to incorporate the positive changes gained during this time.
Interpersonal psychotherapy for psychiatrists
An interpersonal focus could also be helpful for clinicians to adapt to changes in psychiatric practice. Many clinicians have been thrust into telepsychiatry practice, some with little to no preparation. Because of the trauma associated with frontline work, some psychiatrists have expanded their patient panel to treat physician colleagues. For consult-liaison psychiatrists, the possible neuropsychiatric effects of COVID-19 are new symptoms to consider when evaluating patients in a medical hospital setting.8 Fundamentally, modern day psychiatrists have never encountered a pandemic nor attempted to treat its psychological implications. Prioritizing seeking support from colleagues and caring for one’s personal relationships are helpful tools for clinicians to maintain their own emotional health during this challenging period.
Personal reflection
When I reflect on my baby’s recent birth, I recognize the importance of interpersonal relationships. COVID-19 developed shortly after I gave birth, during the initial haze of the newborn period. Initially, I felt overwhelmed by the many transitions and emotions that were occurring simultaneously. However, as I began to prioritize socialization for myself and my family (albeit creatively at times while socially distancing), I witnessed its positive effects on my emotional well-being and recognized its value in managing times of transition.
Using IPT for families, colleagues, and ourselves
As general psychiatrists, there are several ways to utilize IPT-related themes during this time:
- Connect with families: Although families may recognize they are struggling emotionally, some may find it difficult to navigate the sea of mental health resources. This is particularly true when a family’s financial situation is also stressed. Reaching out to local religious services and community medical resources or inquiring about the mental health of other family members are ways for psychiatrists to engage more families in mental health treatment.
- Reach out to colleagues: Psychiatrists are not immune to developing psychiatric disorders,and it is important to support each other.9 This is also an unusual time when psychiatrists are treating symptoms in patients that they themselves may be also experiencing. Supporting help groups and hot lines, reaching out to colleagues who appear to be struggling and addressing interpersonal conflicts within one’s practice are crucial practices for psychiatrists during this time.
- Explore within ourselves: Evaluating our own interpersonal relationships as well as areas for improvement are critical skills to maintain our own emotional well-being. Setting aside time to connect with friends in a nonclinical setting and prioritizing our family connections are helpful tools. In addition, exploring our reactions to past life transitions could improve our own level of insight into our response to COVID-19.
Conclusion
Conceptualizing COVID-19 as a period of transition and using IPT themes are helpful tools to mitigate the potential adverse psychological effects of COVID-19 on families. Similarly, they can also be helpful in supporting our colleagues and helping ourselves cope during this difficult period.
References
1. Qiu J et al. Gen Psychiatr. 2020 Mar 6;33(2):e100213.
2. Gautam M et al. Psychosomatics. 2020 Apr 20. doi: 10.1016/j.psym.2020.04.009.
3. Markowitz JC, Weissman MM. Clin Psychol Psychother. 2012 Mar-Apr;19(2):99-105.
4. Cuijpers P et al. Am J Psychiatry. 2016 Jul;173(7):680-7.
5. Dietz LJ et al. J Am Acad Child Adolesc Psychiatry. 2015 Mar;54(3):191-9.
6. Verdeli H et al. Child Adolesc Psychiatr Clin N Am. 2008 Jul;17(3):605-24.
7. Stuart S. Clin Psychol Psychother. 2012 Mar-Apr;19(2):134-40.
8. Rogers JP et al. Lancet Psychiatry. 2020 Jul;7(7):611-27.
9. Korkeila JA et al. Scand J Public Health. 2003;31(2):85-91.
Dr. Reinstein is a psychiatry attending at Zucker Hillside Hospital, New York. Her clinical interests include reproductive psychiatry and family therapy, with a specific focus on maternal mental health. She is one of the recipients of the 4th Annual Resident Recognition Award for Excellence in Family Oriented Care. Dr. Reinstein has no conflicts of interest. Alison M. Heru, MD, the Families in Psychiatry columnist, invited Dr. Reinstein to address this topic.
When I was preparing for the recent birth of my baby, I anticipated a period of transition for myself. As a reproductive psychiatrist, I have treated many women during the perinatal and postpartum periods, and have a unique appreciation for the life changes that accompany birth. What I did not expect, however, was the world transitioning with me.
“The new normal” is an economic phrase that describes the COVID-19 era. The pandemic has engendered economic instability, collapsed industries, challenged health care systems, and has led to many deaths worldwide. The COVID-19 pandemic also has been associated with overall increases in anxiety and depression.1 Emerging research suggests that frontline medical workers are especially at risk for developing psychological distress.2
COVID-19 has also created immense challenges for families. Because of concern for the spread of the virus, schools have been suspended, older grandparents isolated, and many parents continue to work remotely. For families in psychiatric care, this time has also been a time of change. Telepsychiatry might be more accessible, but the transition has been an adjustment for patients and clinicians.
As psychiatrists, how do we best treat families during this time? What are some ways to support our psychiatric colleagues? How do we ensure our own emotional well-being amid the tremendous changes occurring around us?
Background of interpersonal psychotherapy
Interpersonal psychotherapy (IPT) is a form of psychotherapy designed to treat depression following periods of transition. Its main goals include improving interpersonal connection and reducing psychological distress. Originally developed in the 1970s by Gerald Klerman, MD; Myrna Weissman, PhD; and Eugene Paykel, MD, IPT is a structured, time-limited form of psychotherapy.3
Conceptualizing depression as a treatable illness, Pim Cuijpers, PhD, and associates summarized the division of IPT into three phases.4 The initial phase involves history taking, forming an alliance, and choosing an interpersonal focus for treatment. The middle phase focuses on applying interpersonal problem-specific therapeutic techniques. The concluding phase of treatment involves consolidation of gains as well as formulating contingency plans for relapse of symptoms. Over the course of treatment, an IPT clinician focuses on life transitions and emphasizes that isolation and antagonistic relationships increase an individual’s vulnerability for a depressive episode.3
Randomized, controlled trials support IPT’s efficacy as a treatment for depression. Research also suggests it can possibly prevent the development of depression.4 Although IPT initially was designed as an individual form of psychotherapy, it has been adapted to both family and group contexts.5,6 IPT is also an empirically valid form of psychotherapy for postpartum depression.7
Interpersonal psychotherapy for families
Given IPT’s role for treating depression following times of transition, clinicians should consider adapting interpersonal psychotherapy to family treatment during this time. Addressing social isolation, managing complex family relationships, and monitoring the family’s overall emotional health should be prioritized. Families under quarantine or who are grieving the death of family members may especially benefit from improved interpersonal connection. Consistent with the IPT model, contingency plans for the family should also be explored to prepare for potential future waves of the pandemic.
In addition to supporting and strengthening families, psychiatrists can use IPT themes to identify positive changes for families tied to COVID-19. Despite its difficulties, the stay-at-home order provided some families a unique chance to slow down and adapt a more relaxed routine. Busy families were suddenly given the opportunity to spend more time with one another. Although many older grandparents were isolated, creative uses of technology provided a chance for grandparents to remain an integral part of family life. Psychiatrists can assist families in transitioning back to previous schedules, while also exploring ways to incorporate the positive changes gained during this time.
Interpersonal psychotherapy for psychiatrists
An interpersonal focus could also be helpful for clinicians to adapt to changes in psychiatric practice. Many clinicians have been thrust into telepsychiatry practice, some with little to no preparation. Because of the trauma associated with frontline work, some psychiatrists have expanded their patient panel to treat physician colleagues. For consult-liaison psychiatrists, the possible neuropsychiatric effects of COVID-19 are new symptoms to consider when evaluating patients in a medical hospital setting.8 Fundamentally, modern day psychiatrists have never encountered a pandemic nor attempted to treat its psychological implications. Prioritizing seeking support from colleagues and caring for one’s personal relationships are helpful tools for clinicians to maintain their own emotional health during this challenging period.
Personal reflection
When I reflect on my baby’s recent birth, I recognize the importance of interpersonal relationships. COVID-19 developed shortly after I gave birth, during the initial haze of the newborn period. Initially, I felt overwhelmed by the many transitions and emotions that were occurring simultaneously. However, as I began to prioritize socialization for myself and my family (albeit creatively at times while socially distancing), I witnessed its positive effects on my emotional well-being and recognized its value in managing times of transition.
Using IPT for families, colleagues, and ourselves
As general psychiatrists, there are several ways to utilize IPT-related themes during this time:
- Connect with families: Although families may recognize they are struggling emotionally, some may find it difficult to navigate the sea of mental health resources. This is particularly true when a family’s financial situation is also stressed. Reaching out to local religious services and community medical resources or inquiring about the mental health of other family members are ways for psychiatrists to engage more families in mental health treatment.
- Reach out to colleagues: Psychiatrists are not immune to developing psychiatric disorders,and it is important to support each other.9 This is also an unusual time when psychiatrists are treating symptoms in patients that they themselves may be also experiencing. Supporting help groups and hot lines, reaching out to colleagues who appear to be struggling and addressing interpersonal conflicts within one’s practice are crucial practices for psychiatrists during this time.
- Explore within ourselves: Evaluating our own interpersonal relationships as well as areas for improvement are critical skills to maintain our own emotional well-being. Setting aside time to connect with friends in a nonclinical setting and prioritizing our family connections are helpful tools. In addition, exploring our reactions to past life transitions could improve our own level of insight into our response to COVID-19.
Conclusion
Conceptualizing COVID-19 as a period of transition and using IPT themes are helpful tools to mitigate the potential adverse psychological effects of COVID-19 on families. Similarly, they can also be helpful in supporting our colleagues and helping ourselves cope during this difficult period.
References
1. Qiu J et al. Gen Psychiatr. 2020 Mar 6;33(2):e100213.
2. Gautam M et al. Psychosomatics. 2020 Apr 20. doi: 10.1016/j.psym.2020.04.009.
3. Markowitz JC, Weissman MM. Clin Psychol Psychother. 2012 Mar-Apr;19(2):99-105.
4. Cuijpers P et al. Am J Psychiatry. 2016 Jul;173(7):680-7.
5. Dietz LJ et al. J Am Acad Child Adolesc Psychiatry. 2015 Mar;54(3):191-9.
6. Verdeli H et al. Child Adolesc Psychiatr Clin N Am. 2008 Jul;17(3):605-24.
7. Stuart S. Clin Psychol Psychother. 2012 Mar-Apr;19(2):134-40.
8. Rogers JP et al. Lancet Psychiatry. 2020 Jul;7(7):611-27.
9. Korkeila JA et al. Scand J Public Health. 2003;31(2):85-91.
Dr. Reinstein is a psychiatry attending at Zucker Hillside Hospital, New York. Her clinical interests include reproductive psychiatry and family therapy, with a specific focus on maternal mental health. She is one of the recipients of the 4th Annual Resident Recognition Award for Excellence in Family Oriented Care. Dr. Reinstein has no conflicts of interest. Alison M. Heru, MD, the Families in Psychiatry columnist, invited Dr. Reinstein to address this topic.
When I was preparing for the recent birth of my baby, I anticipated a period of transition for myself. As a reproductive psychiatrist, I have treated many women during the perinatal and postpartum periods, and have a unique appreciation for the life changes that accompany birth. What I did not expect, however, was the world transitioning with me.
“The new normal” is an economic phrase that describes the COVID-19 era. The pandemic has engendered economic instability, collapsed industries, challenged health care systems, and has led to many deaths worldwide. The COVID-19 pandemic also has been associated with overall increases in anxiety and depression.1 Emerging research suggests that frontline medical workers are especially at risk for developing psychological distress.2
COVID-19 has also created immense challenges for families. Because of concern for the spread of the virus, schools have been suspended, older grandparents isolated, and many parents continue to work remotely. For families in psychiatric care, this time has also been a time of change. Telepsychiatry might be more accessible, but the transition has been an adjustment for patients and clinicians.
As psychiatrists, how do we best treat families during this time? What are some ways to support our psychiatric colleagues? How do we ensure our own emotional well-being amid the tremendous changes occurring around us?
Background of interpersonal psychotherapy
Interpersonal psychotherapy (IPT) is a form of psychotherapy designed to treat depression following periods of transition. Its main goals include improving interpersonal connection and reducing psychological distress. Originally developed in the 1970s by Gerald Klerman, MD; Myrna Weissman, PhD; and Eugene Paykel, MD, IPT is a structured, time-limited form of psychotherapy.3
Conceptualizing depression as a treatable illness, Pim Cuijpers, PhD, and associates summarized the division of IPT into three phases.4 The initial phase involves history taking, forming an alliance, and choosing an interpersonal focus for treatment. The middle phase focuses on applying interpersonal problem-specific therapeutic techniques. The concluding phase of treatment involves consolidation of gains as well as formulating contingency plans for relapse of symptoms. Over the course of treatment, an IPT clinician focuses on life transitions and emphasizes that isolation and antagonistic relationships increase an individual’s vulnerability for a depressive episode.3
Randomized, controlled trials support IPT’s efficacy as a treatment for depression. Research also suggests it can possibly prevent the development of depression.4 Although IPT initially was designed as an individual form of psychotherapy, it has been adapted to both family and group contexts.5,6 IPT is also an empirically valid form of psychotherapy for postpartum depression.7
Interpersonal psychotherapy for families
Given IPT’s role for treating depression following times of transition, clinicians should consider adapting interpersonal psychotherapy to family treatment during this time. Addressing social isolation, managing complex family relationships, and monitoring the family’s overall emotional health should be prioritized. Families under quarantine or who are grieving the death of family members may especially benefit from improved interpersonal connection. Consistent with the IPT model, contingency plans for the family should also be explored to prepare for potential future waves of the pandemic.
In addition to supporting and strengthening families, psychiatrists can use IPT themes to identify positive changes for families tied to COVID-19. Despite its difficulties, the stay-at-home order provided some families a unique chance to slow down and adapt a more relaxed routine. Busy families were suddenly given the opportunity to spend more time with one another. Although many older grandparents were isolated, creative uses of technology provided a chance for grandparents to remain an integral part of family life. Psychiatrists can assist families in transitioning back to previous schedules, while also exploring ways to incorporate the positive changes gained during this time.
Interpersonal psychotherapy for psychiatrists
An interpersonal focus could also be helpful for clinicians to adapt to changes in psychiatric practice. Many clinicians have been thrust into telepsychiatry practice, some with little to no preparation. Because of the trauma associated with frontline work, some psychiatrists have expanded their patient panel to treat physician colleagues. For consult-liaison psychiatrists, the possible neuropsychiatric effects of COVID-19 are new symptoms to consider when evaluating patients in a medical hospital setting.8 Fundamentally, modern day psychiatrists have never encountered a pandemic nor attempted to treat its psychological implications. Prioritizing seeking support from colleagues and caring for one’s personal relationships are helpful tools for clinicians to maintain their own emotional health during this challenging period.
Personal reflection
When I reflect on my baby’s recent birth, I recognize the importance of interpersonal relationships. COVID-19 developed shortly after I gave birth, during the initial haze of the newborn period. Initially, I felt overwhelmed by the many transitions and emotions that were occurring simultaneously. However, as I began to prioritize socialization for myself and my family (albeit creatively at times while socially distancing), I witnessed its positive effects on my emotional well-being and recognized its value in managing times of transition.
Using IPT for families, colleagues, and ourselves
As general psychiatrists, there are several ways to utilize IPT-related themes during this time:
- Connect with families: Although families may recognize they are struggling emotionally, some may find it difficult to navigate the sea of mental health resources. This is particularly true when a family’s financial situation is also stressed. Reaching out to local religious services and community medical resources or inquiring about the mental health of other family members are ways for psychiatrists to engage more families in mental health treatment.
- Reach out to colleagues: Psychiatrists are not immune to developing psychiatric disorders,and it is important to support each other.9 This is also an unusual time when psychiatrists are treating symptoms in patients that they themselves may be also experiencing. Supporting help groups and hot lines, reaching out to colleagues who appear to be struggling and addressing interpersonal conflicts within one’s practice are crucial practices for psychiatrists during this time.
- Explore within ourselves: Evaluating our own interpersonal relationships as well as areas for improvement are critical skills to maintain our own emotional well-being. Setting aside time to connect with friends in a nonclinical setting and prioritizing our family connections are helpful tools. In addition, exploring our reactions to past life transitions could improve our own level of insight into our response to COVID-19.
Conclusion
Conceptualizing COVID-19 as a period of transition and using IPT themes are helpful tools to mitigate the potential adverse psychological effects of COVID-19 on families. Similarly, they can also be helpful in supporting our colleagues and helping ourselves cope during this difficult period.
References
1. Qiu J et al. Gen Psychiatr. 2020 Mar 6;33(2):e100213.
2. Gautam M et al. Psychosomatics. 2020 Apr 20. doi: 10.1016/j.psym.2020.04.009.
3. Markowitz JC, Weissman MM. Clin Psychol Psychother. 2012 Mar-Apr;19(2):99-105.
4. Cuijpers P et al. Am J Psychiatry. 2016 Jul;173(7):680-7.
5. Dietz LJ et al. J Am Acad Child Adolesc Psychiatry. 2015 Mar;54(3):191-9.
6. Verdeli H et al. Child Adolesc Psychiatr Clin N Am. 2008 Jul;17(3):605-24.
7. Stuart S. Clin Psychol Psychother. 2012 Mar-Apr;19(2):134-40.
8. Rogers JP et al. Lancet Psychiatry. 2020 Jul;7(7):611-27.
9. Korkeila JA et al. Scand J Public Health. 2003;31(2):85-91.
Dr. Reinstein is a psychiatry attending at Zucker Hillside Hospital, New York. Her clinical interests include reproductive psychiatry and family therapy, with a specific focus on maternal mental health. She is one of the recipients of the 4th Annual Resident Recognition Award for Excellence in Family Oriented Care. Dr. Reinstein has no conflicts of interest. Alison M. Heru, MD, the Families in Psychiatry columnist, invited Dr. Reinstein to address this topic.