Depression

The COVID-19 pandemic and resulting lockdown are associated with increased depression and lower levels of life satisfaction – but primarily in specific demographic and socioeconomic groups, new research shows.

A survey of more than 72,000 individuals in the United Kingdom shows that young adults, those in lower-income groups, and those who had been diagnosed with a mental illness were most affected. Interestingly, anxiety increased during the lead-up to the lockdown for the overall group but decreased during the lockdown itself.

A second survey showed that the pandemic triggered poorer mental health among more than 1,400 patients with mental illness or their caregivers. However, individuals found ways of coping despite the increased stress.

Commenting on the findings, David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford (Calif.) University, noted that expectations of a “tidal wave” of mental health problems during the pandemic may have been wide of the mark.

Instead, the pandemic seems to have caused “an exacerbation” of preexisting mental health conditions, Dr. Spiegel said in an interview.

The studies were presented during a dedicated session at the European Psychiatric Association 2020 Congress, which was virtual this year because of COVID-19.
 

Underrepresented groups

The first presentation was given by Daisy Fancourt, PhD, associate professor of psychobiology and epidemiology, University College London. She described the COVID-19 Social Study, which included more than 72,000 individuals.

Participants were recruited via research databases, media communications, and “more targeted sampling at underrepresented groups, including people from low educational backgrounds and low-income households,” Dr. Fancourt noted.

The respondents took part in the study once a week. This resulted in more than 500,000 completed surveys at a rate of between 3,000 and 6,000 responses per day. Sixteen weeks of data have been gathered so far.

The samples were weighted so they “aligned with population proportions in the U.K. for demographic factors such as age, ethnicity, gender, geographical location, and educational attainment,” said Dr. Fancourt.

Results showed that mental health decreased in the lead-up to lockdown, with decreases in happiness and increases in fear, stress, and sadness.

At the start of lockdown, approximately 60% of people reported that they were stressed about COVID-19 itself, whether catching it or becoming seriously ill. During lockdown, there was little change in levels of depression, but anxiety decreased and life satisfaction increased during this period.
 

‘We’re not all in this together’

The lower stress level wasn’t surprising, “because people were at home much more. But what is particularly surprising is that it’s continued to drop even though lockdown easing has now been taking place for a number of weeks,” Dr. Fancourt said.

“A big question is: Has mental health been equally affected across this period? And our data seem to suggest that’s very much not the case,” she added.

After assessing different demographic and socioeconomic groups, the investigators found that participants aged 18-29 years had much higher levels of anxiety, depression, and thoughts of death or self-harm and much lower levels of life satisfaction than older participants.

A similar pattern was found for lower-income groups in comparison with those earning more and for individuals in Black, Asian, and minority ethnic groups, compared with White individuals.

For patients who had been diagnosed with a mental illness, levels of depression, anxiety, and thoughts of death or self-harm, as well as life satisfaction, generally ran parallel to those of the general population, although at a far worse level.

Overall, the results suggest that “we’ve not all been ‘in this together,’ as we heard in some of the media,” Dr. Fancourt said. “In fact, it’s been a very different experience, depending on people’s demographic and socioeconomic characteristics.”
 

Increased loneliness, economic worry

Further analysis into loneliness showed that twice as many respondents described themselves as lonely during the COVID-19 pandemic in comparison with beforehand (18.3% vs. 8.5%).

There was very little improvement in loneliness across the study period, “so whilst it might be higher than normal, we’ve not really seen any reduction, even when there’s been easing of lockdown,” Dr. Fancourt said.

A possible reason could be that some of the most lonely respondents were not able to come out of lockdown because of being in a higher-risk group, she noted.

As with the main findings, loneliness during the pandemic was worse for younger adults as well as for those of low income, those who lived alone, and those who had a mental illness.

The researchers assessed lower socioeconomic position (SEP), which was defined by several indicators: annual household income less than £30,000 (about $38,000), high school or lower education, being unemployed, renting instead of owning one’s own home, or living in overcrowded accommodations

During the COVID-19 epidemic, having a lower SEP was associated with a 50%-100% increased risk of losing work in comparison with having a higher SEP. There was also a 300% increased risk of being unable to pay bills and a 600%-800% increased risk of not being able to access essentials, such as medication or sufficient food.

Interestingly, worrying about potential adversities during the pandemic had a similar impact on anxiety and depression. “In other words, worrying about what might be about to happen seems to be as bad for mental health as those things actually happening,” Dr. Fancourt said.

The majority of participants did not feel in control of their future plans and felt more out of control of their employment and mental health than they did their physical health.

Individuals aged 18-29 years felt least in control over finances, relationships, future plans, and mental health. Those aged 60 years or older were the most likely to report feeling in control on all measures.
 

Puzzling results

Dr. Spiegel described the results as “a little puzzling in some ways.” He noted that the easing of discomfort that participants felt during lockdown suggests that the idea of a lockdown being a terrible thing “is not necessarily the case.”

“People realize that their lives and lifestyles are being threatened, and it can be actually comforting to be doing something, even if what you’re doing is rather uncomfortable and disruptive of life,” said Dr. Spiegel, who was not involved with the research.

The lockdown may have led people “to think a little more deeply about what matters to them in life,” he added.

A big message from the study is that “the most anxious and depressed were young people in their late teens to late 20s,” Dr. Spiegel noted. That’s when individuals are most sociable, when they form their own social networks, and when they look for partners.

“What’s a little scarier is they also had higher levels of thoughts of death and self-harm and less life satisfaction. So I think the consequences of social disruption were most profound in this study for people for whom social life is the most important,” said Dr. Spiegel.

However, Roxane Cohen Silver, PhD, professor of psychological science, medicine, and public health, University of California, Irvine, noted that, despite the large number of participants, the study’s methodology left many questions unanswered.

She explained that to make sound public policy recommendations, “one needs to pay a great deal of attention to the methods that are used in collecting those data.” From the available information, the degree to which the sample is representative and the participation rate are unclear, which leaves the study open to selection bias, despite the weighting the researchers performed to generate the results.

“The methodological soundness of the studies on the mental health effect of COVID are just as important, I believe, as they are when we’re trying to understand the effect of treatment or a drug,” Dr. Cohen Silver said.
 

Relief during the pandemic?

The second presentation was given by Sara Simblett, PhD, department of psychology, King’s College London, who described the Coronavirus Outbreak Psychological Experiences study.

This was a two-part investigation in which 31 semistructured interviews with users of mental health services and carers formed the basis of a qualitative survey. It examined the impact of the pandemic on thoughts, emotions, behaviors, and life situations.

The survey was advertised via social media and mental health charities, yielding a total of 1,402 responses. These included responses from 968 individuals who had experience of a mental health condition. Of these, 266 were currently using mental health services, and 189 were informal carers.

Of those, 46.8% met the case threshold for anxiety, 40.3% met the threshold for depression, and 45.3% were determined to have “low resilience.”

The COVID-19 pandemic triggered poorer mental health in the majority of respondents, at 60.8% among those with a preexisting mental health condition and 64.1% among informal carers.

This was reflected in 95.3% of respondents saying that things were uncertain, 81.3% saying they felt restricted by the pandemic, and 71.9% saying that their day was less structured.

However, the survey also revealed that 79.8% felt relieved during the pandemic, 82.1% said that their memory was “much better,” and 62.9% found it easier to concentrate and make plans.

In addition, many people turned to coping mechanisms; 74.7% looked to religion and spirituality as a source of support, and 64.2% used health and wellness apps.

The COVID-19 Social Study is funded by the Wellcome Trust and the Nuffield Foundation. The Coronavirus Outbreak Psychological Experiences study is a collaboration with the McPin Foundation. The investigators and commentators reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The COVID-19 pandemic and resulting lockdown are associated with increased depression and lower levels of life satisfaction – but primarily in specific demographic and socioeconomic groups, new research shows.

A survey of more than 72,000 individuals in the United Kingdom shows that young adults, those in lower-income groups, and those who had been diagnosed with a mental illness were most affected. Interestingly, anxiety increased during the lead-up to the lockdown for the overall group but decreased during the lockdown itself.

A second survey showed that the pandemic triggered poorer mental health among more than 1,400 patients with mental illness or their caregivers. However, individuals found ways of coping despite the increased stress.

Commenting on the findings, David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford (Calif.) University, noted that expectations of a “tidal wave” of mental health problems during the pandemic may have been wide of the mark.

Instead, the pandemic seems to have caused “an exacerbation” of preexisting mental health conditions, Dr. Spiegel said in an interview.

The studies were presented during a dedicated session at the European Psychiatric Association 2020 Congress, which was virtual this year because of COVID-19.
 

Underrepresented groups

The first presentation was given by Daisy Fancourt, PhD, associate professor of psychobiology and epidemiology, University College London. She described the COVID-19 Social Study, which included more than 72,000 individuals.

Participants were recruited via research databases, media communications, and “more targeted sampling at underrepresented groups, including people from low educational backgrounds and low-income households,” Dr. Fancourt noted.

The respondents took part in the study once a week. This resulted in more than 500,000 completed surveys at a rate of between 3,000 and 6,000 responses per day. Sixteen weeks of data have been gathered so far.

The samples were weighted so they “aligned with population proportions in the U.K. for demographic factors such as age, ethnicity, gender, geographical location, and educational attainment,” said Dr. Fancourt.

Results showed that mental health decreased in the lead-up to lockdown, with decreases in happiness and increases in fear, stress, and sadness.

At the start of lockdown, approximately 60% of people reported that they were stressed about COVID-19 itself, whether catching it or becoming seriously ill. During lockdown, there was little change in levels of depression, but anxiety decreased and life satisfaction increased during this period.
 

‘We’re not all in this together’

The lower stress level wasn’t surprising, “because people were at home much more. But what is particularly surprising is that it’s continued to drop even though lockdown easing has now been taking place for a number of weeks,” Dr. Fancourt said.

“A big question is: Has mental health been equally affected across this period? And our data seem to suggest that’s very much not the case,” she added.

After assessing different demographic and socioeconomic groups, the investigators found that participants aged 18-29 years had much higher levels of anxiety, depression, and thoughts of death or self-harm and much lower levels of life satisfaction than older participants.

A similar pattern was found for lower-income groups in comparison with those earning more and for individuals in Black, Asian, and minority ethnic groups, compared with White individuals.

For patients who had been diagnosed with a mental illness, levels of depression, anxiety, and thoughts of death or self-harm, as well as life satisfaction, generally ran parallel to those of the general population, although at a far worse level.

Overall, the results suggest that “we’ve not all been ‘in this together,’ as we heard in some of the media,” Dr. Fancourt said. “In fact, it’s been a very different experience, depending on people’s demographic and socioeconomic characteristics.”
 

Increased loneliness, economic worry

Further analysis into loneliness showed that twice as many respondents described themselves as lonely during the COVID-19 pandemic in comparison with beforehand (18.3% vs. 8.5%).

There was very little improvement in loneliness across the study period, “so whilst it might be higher than normal, we’ve not really seen any reduction, even when there’s been easing of lockdown,” Dr. Fancourt said.

A possible reason could be that some of the most lonely respondents were not able to come out of lockdown because of being in a higher-risk group, she noted.

As with the main findings, loneliness during the pandemic was worse for younger adults as well as for those of low income, those who lived alone, and those who had a mental illness.

The researchers assessed lower socioeconomic position (SEP), which was defined by several indicators: annual household income less than £30,000 (about $38,000), high school or lower education, being unemployed, renting instead of owning one’s own home, or living in overcrowded accommodations

During the COVID-19 epidemic, having a lower SEP was associated with a 50%-100% increased risk of losing work in comparison with having a higher SEP. There was also a 300% increased risk of being unable to pay bills and a 600%-800% increased risk of not being able to access essentials, such as medication or sufficient food.

Interestingly, worrying about potential adversities during the pandemic had a similar impact on anxiety and depression. “In other words, worrying about what might be about to happen seems to be as bad for mental health as those things actually happening,” Dr. Fancourt said.

The majority of participants did not feel in control of their future plans and felt more out of control of their employment and mental health than they did their physical health.

Individuals aged 18-29 years felt least in control over finances, relationships, future plans, and mental health. Those aged 60 years or older were the most likely to report feeling in control on all measures.
 

Puzzling results

Dr. Spiegel described the results as “a little puzzling in some ways.” He noted that the easing of discomfort that participants felt during lockdown suggests that the idea of a lockdown being a terrible thing “is not necessarily the case.”

“People realize that their lives and lifestyles are being threatened, and it can be actually comforting to be doing something, even if what you’re doing is rather uncomfortable and disruptive of life,” said Dr. Spiegel, who was not involved with the research.

The lockdown may have led people “to think a little more deeply about what matters to them in life,” he added.

A big message from the study is that “the most anxious and depressed were young people in their late teens to late 20s,” Dr. Spiegel noted. That’s when individuals are most sociable, when they form their own social networks, and when they look for partners.

“What’s a little scarier is they also had higher levels of thoughts of death and self-harm and less life satisfaction. So I think the consequences of social disruption were most profound in this study for people for whom social life is the most important,” said Dr. Spiegel.

However, Roxane Cohen Silver, PhD, professor of psychological science, medicine, and public health, University of California, Irvine, noted that, despite the large number of participants, the study’s methodology left many questions unanswered.

She explained that to make sound public policy recommendations, “one needs to pay a great deal of attention to the methods that are used in collecting those data.” From the available information, the degree to which the sample is representative and the participation rate are unclear, which leaves the study open to selection bias, despite the weighting the researchers performed to generate the results.

“The methodological soundness of the studies on the mental health effect of COVID are just as important, I believe, as they are when we’re trying to understand the effect of treatment or a drug,” Dr. Cohen Silver said.
 

Relief during the pandemic?

The second presentation was given by Sara Simblett, PhD, department of psychology, King’s College London, who described the Coronavirus Outbreak Psychological Experiences study.

This was a two-part investigation in which 31 semistructured interviews with users of mental health services and carers formed the basis of a qualitative survey. It examined the impact of the pandemic on thoughts, emotions, behaviors, and life situations.

The survey was advertised via social media and mental health charities, yielding a total of 1,402 responses. These included responses from 968 individuals who had experience of a mental health condition. Of these, 266 were currently using mental health services, and 189 were informal carers.

Of those, 46.8% met the case threshold for anxiety, 40.3% met the threshold for depression, and 45.3% were determined to have “low resilience.”

The COVID-19 pandemic triggered poorer mental health in the majority of respondents, at 60.8% among those with a preexisting mental health condition and 64.1% among informal carers.

This was reflected in 95.3% of respondents saying that things were uncertain, 81.3% saying they felt restricted by the pandemic, and 71.9% saying that their day was less structured.

However, the survey also revealed that 79.8% felt relieved during the pandemic, 82.1% said that their memory was “much better,” and 62.9% found it easier to concentrate and make plans.

In addition, many people turned to coping mechanisms; 74.7% looked to religion and spirituality as a source of support, and 64.2% used health and wellness apps.

The COVID-19 Social Study is funded by the Wellcome Trust and the Nuffield Foundation. The Coronavirus Outbreak Psychological Experiences study is a collaboration with the McPin Foundation. The investigators and commentators reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The COVID-19 pandemic and resulting lockdown are associated with increased depression and lower levels of life satisfaction – but primarily in specific demographic and socioeconomic groups, new research shows.

A survey of more than 72,000 individuals in the United Kingdom shows that young adults, those in lower-income groups, and those who had been diagnosed with a mental illness were most affected. Interestingly, anxiety increased during the lead-up to the lockdown for the overall group but decreased during the lockdown itself.

A second survey showed that the pandemic triggered poorer mental health among more than 1,400 patients with mental illness or their caregivers. However, individuals found ways of coping despite the increased stress.

Commenting on the findings, David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford (Calif.) University, noted that expectations of a “tidal wave” of mental health problems during the pandemic may have been wide of the mark.

Instead, the pandemic seems to have caused “an exacerbation” of preexisting mental health conditions, Dr. Spiegel said in an interview.

The studies were presented during a dedicated session at the European Psychiatric Association 2020 Congress, which was virtual this year because of COVID-19.
 

Underrepresented groups

The first presentation was given by Daisy Fancourt, PhD, associate professor of psychobiology and epidemiology, University College London. She described the COVID-19 Social Study, which included more than 72,000 individuals.

Participants were recruited via research databases, media communications, and “more targeted sampling at underrepresented groups, including people from low educational backgrounds and low-income households,” Dr. Fancourt noted.

The respondents took part in the study once a week. This resulted in more than 500,000 completed surveys at a rate of between 3,000 and 6,000 responses per day. Sixteen weeks of data have been gathered so far.

The samples were weighted so they “aligned with population proportions in the U.K. for demographic factors such as age, ethnicity, gender, geographical location, and educational attainment,” said Dr. Fancourt.

Results showed that mental health decreased in the lead-up to lockdown, with decreases in happiness and increases in fear, stress, and sadness.

At the start of lockdown, approximately 60% of people reported that they were stressed about COVID-19 itself, whether catching it or becoming seriously ill. During lockdown, there was little change in levels of depression, but anxiety decreased and life satisfaction increased during this period.
 

‘We’re not all in this together’

The lower stress level wasn’t surprising, “because people were at home much more. But what is particularly surprising is that it’s continued to drop even though lockdown easing has now been taking place for a number of weeks,” Dr. Fancourt said.

“A big question is: Has mental health been equally affected across this period? And our data seem to suggest that’s very much not the case,” she added.

After assessing different demographic and socioeconomic groups, the investigators found that participants aged 18-29 years had much higher levels of anxiety, depression, and thoughts of death or self-harm and much lower levels of life satisfaction than older participants.

A similar pattern was found for lower-income groups in comparison with those earning more and for individuals in Black, Asian, and minority ethnic groups, compared with White individuals.

For patients who had been diagnosed with a mental illness, levels of depression, anxiety, and thoughts of death or self-harm, as well as life satisfaction, generally ran parallel to those of the general population, although at a far worse level.

Overall, the results suggest that “we’ve not all been ‘in this together,’ as we heard in some of the media,” Dr. Fancourt said. “In fact, it’s been a very different experience, depending on people’s demographic and socioeconomic characteristics.”
 

Increased loneliness, economic worry

Further analysis into loneliness showed that twice as many respondents described themselves as lonely during the COVID-19 pandemic in comparison with beforehand (18.3% vs. 8.5%).

There was very little improvement in loneliness across the study period, “so whilst it might be higher than normal, we’ve not really seen any reduction, even when there’s been easing of lockdown,” Dr. Fancourt said.

A possible reason could be that some of the most lonely respondents were not able to come out of lockdown because of being in a higher-risk group, she noted.

As with the main findings, loneliness during the pandemic was worse for younger adults as well as for those of low income, those who lived alone, and those who had a mental illness.

The researchers assessed lower socioeconomic position (SEP), which was defined by several indicators: annual household income less than £30,000 (about $38,000), high school or lower education, being unemployed, renting instead of owning one’s own home, or living in overcrowded accommodations

During the COVID-19 epidemic, having a lower SEP was associated with a 50%-100% increased risk of losing work in comparison with having a higher SEP. There was also a 300% increased risk of being unable to pay bills and a 600%-800% increased risk of not being able to access essentials, such as medication or sufficient food.

Interestingly, worrying about potential adversities during the pandemic had a similar impact on anxiety and depression. “In other words, worrying about what might be about to happen seems to be as bad for mental health as those things actually happening,” Dr. Fancourt said.

The majority of participants did not feel in control of their future plans and felt more out of control of their employment and mental health than they did their physical health.

Individuals aged 18-29 years felt least in control over finances, relationships, future plans, and mental health. Those aged 60 years or older were the most likely to report feeling in control on all measures.
 

Puzzling results

Dr. Spiegel described the results as “a little puzzling in some ways.” He noted that the easing of discomfort that participants felt during lockdown suggests that the idea of a lockdown being a terrible thing “is not necessarily the case.”

“People realize that their lives and lifestyles are being threatened, and it can be actually comforting to be doing something, even if what you’re doing is rather uncomfortable and disruptive of life,” said Dr. Spiegel, who was not involved with the research.

The lockdown may have led people “to think a little more deeply about what matters to them in life,” he added.

A big message from the study is that “the most anxious and depressed were young people in their late teens to late 20s,” Dr. Spiegel noted. That’s when individuals are most sociable, when they form their own social networks, and when they look for partners.

“What’s a little scarier is they also had higher levels of thoughts of death and self-harm and less life satisfaction. So I think the consequences of social disruption were most profound in this study for people for whom social life is the most important,” said Dr. Spiegel.

However, Roxane Cohen Silver, PhD, professor of psychological science, medicine, and public health, University of California, Irvine, noted that, despite the large number of participants, the study’s methodology left many questions unanswered.

She explained that to make sound public policy recommendations, “one needs to pay a great deal of attention to the methods that are used in collecting those data.” From the available information, the degree to which the sample is representative and the participation rate are unclear, which leaves the study open to selection bias, despite the weighting the researchers performed to generate the results.

“The methodological soundness of the studies on the mental health effect of COVID are just as important, I believe, as they are when we’re trying to understand the effect of treatment or a drug,” Dr. Cohen Silver said.
 

Relief during the pandemic?

The second presentation was given by Sara Simblett, PhD, department of psychology, King’s College London, who described the Coronavirus Outbreak Psychological Experiences study.

This was a two-part investigation in which 31 semistructured interviews with users of mental health services and carers formed the basis of a qualitative survey. It examined the impact of the pandemic on thoughts, emotions, behaviors, and life situations.

The survey was advertised via social media and mental health charities, yielding a total of 1,402 responses. These included responses from 968 individuals who had experience of a mental health condition. Of these, 266 were currently using mental health services, and 189 were informal carers.

Of those, 46.8% met the case threshold for anxiety, 40.3% met the threshold for depression, and 45.3% were determined to have “low resilience.”

The COVID-19 pandemic triggered poorer mental health in the majority of respondents, at 60.8% among those with a preexisting mental health condition and 64.1% among informal carers.

This was reflected in 95.3% of respondents saying that things were uncertain, 81.3% saying they felt restricted by the pandemic, and 71.9% saying that their day was less structured.

However, the survey also revealed that 79.8% felt relieved during the pandemic, 82.1% said that their memory was “much better,” and 62.9% found it easier to concentrate and make plans.

In addition, many people turned to coping mechanisms; 74.7% looked to religion and spirituality as a source of support, and 64.2% used health and wellness apps.

The COVID-19 Social Study is funded by the Wellcome Trust and the Nuffield Foundation. The Coronavirus Outbreak Psychological Experiences study is a collaboration with the McPin Foundation. The investigators and commentators reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The COVID-19 pandemic has changed life in numerous ways, including use of telehealth services for patients in all specialties. But telepsychiatry is an area not likely to go away even after the pandemic is over, according to Sanjay Gupta, MD.

Jean-philippe WALLET/Getty Images

The use of telepsychiatry has escalated significantly,” said Dr. Gupta, of the DENT Neurologic Institute, in Amherst, N.Y., in a bonus virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

About 90% of clinicians are performing telepsychiatry, Dr. Gupta noted, through methods such as phone consults, email, and video chat. As patients with psychiatric issues grapple with issues related to COVID-19 involving lockdowns, restrictions on travel, and consumption of news, they are presenting with addiction, depression, paranoia, mood lability, and other problems.

One issue immediately facing clinicians is whether to keep patients on long-acting injectables as a way to maintain psychological stability in patients with bipolar disorder, schizophrenia, and alcoholism – something Dr. Gupta and session moderator Henry A. Nasrallah, MD, advocated. “We should never stop the long-acting injectable to switch them to oral medication. Those patients are very likely to relapse,” Dr. Nasrallah said.

During the pandemic, clinicians need to find “safe and novel ways of providing the injection,” and several methods have been pioneered. For example, if a patient with schizophrenia is on lockdown, a nurse can visit monthly or bimonthly to administer an injection, check on the patient’s mental status, and assess whether that patient needs an adjustment to their medication. Other clinics are offering “drive-by” injections to patients who arrive by car, and a nurse wearing a mask and a face shield administers the injection from the car window. Monthly naltrexone also can be administered using one of these methods, and telepsychiatry can be used to monitor patients, Dr. Gupta noted at the meeting, presented by Global Academy for Medical Education.

“In my clinic, what happens is the injection room is set up just next to the door, so they don’t have to walk deep into the clinic,” Dr. Gupta said. “They walk in, go to the left, [and] there’s the injection room. They sit, get an injection, they’re out. It’s kept smooth.”
 

Choosing the right telehealth option

Clinicians should be aware of important regulatory changes that occurred that made widespread telehealth more appealing during the COVID-19 pandemic. Payment parity with in-office visits makes telehealth a viable consideration, while some states have begun offering telehealth licenses to practice across state lines. There is wide variation with regard to which states provide licensure and prescribing privileges for out-of-state clinicians without seeing those patients in person. “The most important thing: The psychiatry service is provided in the state where the patient is located,” Dr. Gupta said. Clinicians should check with that state’s board to figure out specific requirements. “Preferably if you get it in writing, it’s good for you,” he said.

Deciding who the clinician is seeing – consulting with patients or other physicians/clinicians – and what type of visits a clinician will conduct is an important step in transitioning to telepsychiatry. Visits from evaluation through ongoing care are possible through telepsychiatry, or a clinician can opt to see just second opinion visits, Dr. Gupta said. It is also important to consider the technical ability of the patient to do video conferencing.

As HIPAA requirements for privacy have relaxed, clinicians now have an array of teleconferencing options to choose from; platforms such as FaceTime, Doximity, Vidyo, Doxy.me, Zoom, and video chat through EMR are popular options. However, when regular HIPAA requirements are reinstated after the pandemic, clinicians will need to find a compliant platform and sign a business associate agreement to stay within the law.

“Right now, my preferred use is FaceTime,” Dr. Gupta said. “Quick, simple, easy to use. A lot of people have an iPhone, and they know how to do it. I usually have the patient call me and I don’t use my personal iPhone; my clinic has an iPhone.”

How a clinician looks during a telepsychiatry visit is also important. Lighting, position of the camera, and clothing should all be considered. Keep the camera at eye level, test the lighting in the room where the call will take place, and use artificial lighting sources behind a computer, Dr. Gupta said. Other tips for telepsychiatry visits include silencing devices and microphones before a session begins, wearing solid-colored clothes, and having an identification badge visible to the patient. Sessions should be free of background distractions, such as a dog barking or a child interrupting, with the goal of creating an environment where the patient feels free to answer questions.

Contingency planning is a must for video visits, Dr. Gupta said. “I think the simplest thing is to see the patient. But all the stuff that’s the wraparound is really hard, because issues can arise suddenly, and we need to plan.” If a patient has a medical issue or becomes actively suicidal during a session, it is important to know contact information for the local police and crisis services. Clinicians also must plan for technology failure and provide alternative options for continuing the sessions, such as by phone.
 

Selecting patients for telepsychiatry

Not all patients will make the transition to telepsychiatry. “You can’t do telepsychiatry with everyone. It is a risk, so pick and choose,” Dr. Gupta said.

“Safety is a big consideration for conducting a telepsychiatry visit, especially when other health care providers are present. For example, when performing telehealth visits in a clinic, nursing home, or correctional facility, “I feel a lot more comfortable if there’s another health care clinician there,” Dr. Gupta said.

Clinicians may want to avoid a telepsychiatry visit for a patient in their own home for reasons of safety, reliability, and privacy. A longitudinal history with collateral information from friends or relatives can be helpful, but some subtle signs and body language may get missed over video, compared with an in-person visit. “Telepsychiatry can be a barrier at times. If there is substance abuse, we may not smell alcohol. Sometimes you may not see if the patient is using substances. You have to really reconsider if [there] is violence and self-injurious behavior,” he said.

Discussing the pros and cons of telepsychiatry is important to obtaining patient consent. While consent requirements have relaxed under the COVID-19 pandemic, consent should ideally be obtained in writing, but can also be obtained verbally during a crisis. A plan should be developed for what will happen in the case of technology failure. “The patient should also know you’re maintaining privacy, you’re maintaining confidentiality, but there is a risk of hacking,” Dr. Gupta said. “Those things can happen, [and] there are no guarantees.”

If a patient is uncomfortable after beginning telepsychiatry, moving to in-person visits is also an option. “Many times, I do that if I’m not getting a good handle on things,” Dr. Gupta said. Situations where patients insist on in-patient visits over telepsychiatry are rare in his experience, Dr. Gupta noted, and are usually the result of the patient being unfamiliar with the technology. In cases where a patient cannot be talked through a technology barrier, visits can be done in the clinic while taking proper precautions.

“If it is a first-time visit, then I do it in the clinic,” Dr. Gupta said. “They come in, they have a face mask, and we use our group therapy room. The patients sit in a social-distanced fashion. But then, you document why you did this in-person visit like that.”

Documentation during COVID-19 also includes identifying the patient at the first visit, the nature of the visit (teleconference or other), parties present, referencing the pandemic, writing the location of the patient and the clinician, noting the patient’s satisfaction, evaluating the patient’s mental status, and recording what technology was used and any technical issues that were encountered.

Some populations of patients are better suited to telepsychiatry than others. It is more convenient for chronically psychiatrically ill patients in group homes and their staff to communicate through telepsychiatry, Dr. Gupta said. Consultation liaison in hospitals and emergency departments through telepsychiatry can limit the spread of infection, while increased access and convenience occurs as telepsychiatry is implemented in correctional facilities and nursing homes.

“What we are doing now, some of it is here to stay,” Dr. Gupta said.

In situations where a patient needs to switch providers, clinicians should continue to follow that patient until his first patient visit with that new provider. It is also important to set boundaries and apply some level of formality to the telepsychiatry visit, which means seeing the patient in a secure location where he can speak freely and privately.

“The best practices are [to] maintain faith [and] fidelity of the psychiatric assessment,” Dr. Gupta said. “Keep the trust and do your best to maintain patient privacy, because the privacy is not the same as it may be in a face-to-face session when you use televideo.”

Global Academy and this news organization are owned by the same parent company.

Dr. Gupta reported no relevant financial disclosures. Dr. Nasrallah disclosed serving as a consultant for and on the speakers bureaus of several pharmaceutical companies, including Alkermes, Janssen, and Lundbeck. He also disclosed serving on the speakers bureau of Otsuka.

The COVID-19 pandemic has changed life in numerous ways, including use of telehealth services for patients in all specialties. But telepsychiatry is an area not likely to go away even after the pandemic is over, according to Sanjay Gupta, MD.

Jean-philippe WALLET/Getty Images

The use of telepsychiatry has escalated significantly,” said Dr. Gupta, of the DENT Neurologic Institute, in Amherst, N.Y., in a bonus virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

About 90% of clinicians are performing telepsychiatry, Dr. Gupta noted, through methods such as phone consults, email, and video chat. As patients with psychiatric issues grapple with issues related to COVID-19 involving lockdowns, restrictions on travel, and consumption of news, they are presenting with addiction, depression, paranoia, mood lability, and other problems.

One issue immediately facing clinicians is whether to keep patients on long-acting injectables as a way to maintain psychological stability in patients with bipolar disorder, schizophrenia, and alcoholism – something Dr. Gupta and session moderator Henry A. Nasrallah, MD, advocated. “We should never stop the long-acting injectable to switch them to oral medication. Those patients are very likely to relapse,” Dr. Nasrallah said.

During the pandemic, clinicians need to find “safe and novel ways of providing the injection,” and several methods have been pioneered. For example, if a patient with schizophrenia is on lockdown, a nurse can visit monthly or bimonthly to administer an injection, check on the patient’s mental status, and assess whether that patient needs an adjustment to their medication. Other clinics are offering “drive-by” injections to patients who arrive by car, and a nurse wearing a mask and a face shield administers the injection from the car window. Monthly naltrexone also can be administered using one of these methods, and telepsychiatry can be used to monitor patients, Dr. Gupta noted at the meeting, presented by Global Academy for Medical Education.

“In my clinic, what happens is the injection room is set up just next to the door, so they don’t have to walk deep into the clinic,” Dr. Gupta said. “They walk in, go to the left, [and] there’s the injection room. They sit, get an injection, they’re out. It’s kept smooth.”
 

Choosing the right telehealth option

Clinicians should be aware of important regulatory changes that occurred that made widespread telehealth more appealing during the COVID-19 pandemic. Payment parity with in-office visits makes telehealth a viable consideration, while some states have begun offering telehealth licenses to practice across state lines. There is wide variation with regard to which states provide licensure and prescribing privileges for out-of-state clinicians without seeing those patients in person. “The most important thing: The psychiatry service is provided in the state where the patient is located,” Dr. Gupta said. Clinicians should check with that state’s board to figure out specific requirements. “Preferably if you get it in writing, it’s good for you,” he said.

Deciding who the clinician is seeing – consulting with patients or other physicians/clinicians – and what type of visits a clinician will conduct is an important step in transitioning to telepsychiatry. Visits from evaluation through ongoing care are possible through telepsychiatry, or a clinician can opt to see just second opinion visits, Dr. Gupta said. It is also important to consider the technical ability of the patient to do video conferencing.

As HIPAA requirements for privacy have relaxed, clinicians now have an array of teleconferencing options to choose from; platforms such as FaceTime, Doximity, Vidyo, Doxy.me, Zoom, and video chat through EMR are popular options. However, when regular HIPAA requirements are reinstated after the pandemic, clinicians will need to find a compliant platform and sign a business associate agreement to stay within the law.

“Right now, my preferred use is FaceTime,” Dr. Gupta said. “Quick, simple, easy to use. A lot of people have an iPhone, and they know how to do it. I usually have the patient call me and I don’t use my personal iPhone; my clinic has an iPhone.”

How a clinician looks during a telepsychiatry visit is also important. Lighting, position of the camera, and clothing should all be considered. Keep the camera at eye level, test the lighting in the room where the call will take place, and use artificial lighting sources behind a computer, Dr. Gupta said. Other tips for telepsychiatry visits include silencing devices and microphones before a session begins, wearing solid-colored clothes, and having an identification badge visible to the patient. Sessions should be free of background distractions, such as a dog barking or a child interrupting, with the goal of creating an environment where the patient feels free to answer questions.

Contingency planning is a must for video visits, Dr. Gupta said. “I think the simplest thing is to see the patient. But all the stuff that’s the wraparound is really hard, because issues can arise suddenly, and we need to plan.” If a patient has a medical issue or becomes actively suicidal during a session, it is important to know contact information for the local police and crisis services. Clinicians also must plan for technology failure and provide alternative options for continuing the sessions, such as by phone.
 

Selecting patients for telepsychiatry

Not all patients will make the transition to telepsychiatry. “You can’t do telepsychiatry with everyone. It is a risk, so pick and choose,” Dr. Gupta said.

“Safety is a big consideration for conducting a telepsychiatry visit, especially when other health care providers are present. For example, when performing telehealth visits in a clinic, nursing home, or correctional facility, “I feel a lot more comfortable if there’s another health care clinician there,” Dr. Gupta said.

Clinicians may want to avoid a telepsychiatry visit for a patient in their own home for reasons of safety, reliability, and privacy. A longitudinal history with collateral information from friends or relatives can be helpful, but some subtle signs and body language may get missed over video, compared with an in-person visit. “Telepsychiatry can be a barrier at times. If there is substance abuse, we may not smell alcohol. Sometimes you may not see if the patient is using substances. You have to really reconsider if [there] is violence and self-injurious behavior,” he said.

Discussing the pros and cons of telepsychiatry is important to obtaining patient consent. While consent requirements have relaxed under the COVID-19 pandemic, consent should ideally be obtained in writing, but can also be obtained verbally during a crisis. A plan should be developed for what will happen in the case of technology failure. “The patient should also know you’re maintaining privacy, you’re maintaining confidentiality, but there is a risk of hacking,” Dr. Gupta said. “Those things can happen, [and] there are no guarantees.”

If a patient is uncomfortable after beginning telepsychiatry, moving to in-person visits is also an option. “Many times, I do that if I’m not getting a good handle on things,” Dr. Gupta said. Situations where patients insist on in-patient visits over telepsychiatry are rare in his experience, Dr. Gupta noted, and are usually the result of the patient being unfamiliar with the technology. In cases where a patient cannot be talked through a technology barrier, visits can be done in the clinic while taking proper precautions.

“If it is a first-time visit, then I do it in the clinic,” Dr. Gupta said. “They come in, they have a face mask, and we use our group therapy room. The patients sit in a social-distanced fashion. But then, you document why you did this in-person visit like that.”

Documentation during COVID-19 also includes identifying the patient at the first visit, the nature of the visit (teleconference or other), parties present, referencing the pandemic, writing the location of the patient and the clinician, noting the patient’s satisfaction, evaluating the patient’s mental status, and recording what technology was used and any technical issues that were encountered.

Some populations of patients are better suited to telepsychiatry than others. It is more convenient for chronically psychiatrically ill patients in group homes and their staff to communicate through telepsychiatry, Dr. Gupta said. Consultation liaison in hospitals and emergency departments through telepsychiatry can limit the spread of infection, while increased access and convenience occurs as telepsychiatry is implemented in correctional facilities and nursing homes.

“What we are doing now, some of it is here to stay,” Dr. Gupta said.

In situations where a patient needs to switch providers, clinicians should continue to follow that patient until his first patient visit with that new provider. It is also important to set boundaries and apply some level of formality to the telepsychiatry visit, which means seeing the patient in a secure location where he can speak freely and privately.

“The best practices are [to] maintain faith [and] fidelity of the psychiatric assessment,” Dr. Gupta said. “Keep the trust and do your best to maintain patient privacy, because the privacy is not the same as it may be in a face-to-face session when you use televideo.”

Global Academy and this news organization are owned by the same parent company.

Dr. Gupta reported no relevant financial disclosures. Dr. Nasrallah disclosed serving as a consultant for and on the speakers bureaus of several pharmaceutical companies, including Alkermes, Janssen, and Lundbeck. He also disclosed serving on the speakers bureau of Otsuka.

The COVID-19 pandemic has changed life in numerous ways, including use of telehealth services for patients in all specialties. But telepsychiatry is an area not likely to go away even after the pandemic is over, according to Sanjay Gupta, MD.

Jean-philippe WALLET/Getty Images

The use of telepsychiatry has escalated significantly,” said Dr. Gupta, of the DENT Neurologic Institute, in Amherst, N.Y., in a bonus virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

About 90% of clinicians are performing telepsychiatry, Dr. Gupta noted, through methods such as phone consults, email, and video chat. As patients with psychiatric issues grapple with issues related to COVID-19 involving lockdowns, restrictions on travel, and consumption of news, they are presenting with addiction, depression, paranoia, mood lability, and other problems.

One issue immediately facing clinicians is whether to keep patients on long-acting injectables as a way to maintain psychological stability in patients with bipolar disorder, schizophrenia, and alcoholism – something Dr. Gupta and session moderator Henry A. Nasrallah, MD, advocated. “We should never stop the long-acting injectable to switch them to oral medication. Those patients are very likely to relapse,” Dr. Nasrallah said.

During the pandemic, clinicians need to find “safe and novel ways of providing the injection,” and several methods have been pioneered. For example, if a patient with schizophrenia is on lockdown, a nurse can visit monthly or bimonthly to administer an injection, check on the patient’s mental status, and assess whether that patient needs an adjustment to their medication. Other clinics are offering “drive-by” injections to patients who arrive by car, and a nurse wearing a mask and a face shield administers the injection from the car window. Monthly naltrexone also can be administered using one of these methods, and telepsychiatry can be used to monitor patients, Dr. Gupta noted at the meeting, presented by Global Academy for Medical Education.

“In my clinic, what happens is the injection room is set up just next to the door, so they don’t have to walk deep into the clinic,” Dr. Gupta said. “They walk in, go to the left, [and] there’s the injection room. They sit, get an injection, they’re out. It’s kept smooth.”
 

Choosing the right telehealth option

Clinicians should be aware of important regulatory changes that occurred that made widespread telehealth more appealing during the COVID-19 pandemic. Payment parity with in-office visits makes telehealth a viable consideration, while some states have begun offering telehealth licenses to practice across state lines. There is wide variation with regard to which states provide licensure and prescribing privileges for out-of-state clinicians without seeing those patients in person. “The most important thing: The psychiatry service is provided in the state where the patient is located,” Dr. Gupta said. Clinicians should check with that state’s board to figure out specific requirements. “Preferably if you get it in writing, it’s good for you,” he said.

Deciding who the clinician is seeing – consulting with patients or other physicians/clinicians – and what type of visits a clinician will conduct is an important step in transitioning to telepsychiatry. Visits from evaluation through ongoing care are possible through telepsychiatry, or a clinician can opt to see just second opinion visits, Dr. Gupta said. It is also important to consider the technical ability of the patient to do video conferencing.

As HIPAA requirements for privacy have relaxed, clinicians now have an array of teleconferencing options to choose from; platforms such as FaceTime, Doximity, Vidyo, Doxy.me, Zoom, and video chat through EMR are popular options. However, when regular HIPAA requirements are reinstated after the pandemic, clinicians will need to find a compliant platform and sign a business associate agreement to stay within the law.

“Right now, my preferred use is FaceTime,” Dr. Gupta said. “Quick, simple, easy to use. A lot of people have an iPhone, and they know how to do it. I usually have the patient call me and I don’t use my personal iPhone; my clinic has an iPhone.”

How a clinician looks during a telepsychiatry visit is also important. Lighting, position of the camera, and clothing should all be considered. Keep the camera at eye level, test the lighting in the room where the call will take place, and use artificial lighting sources behind a computer, Dr. Gupta said. Other tips for telepsychiatry visits include silencing devices and microphones before a session begins, wearing solid-colored clothes, and having an identification badge visible to the patient. Sessions should be free of background distractions, such as a dog barking or a child interrupting, with the goal of creating an environment where the patient feels free to answer questions.

Contingency planning is a must for video visits, Dr. Gupta said. “I think the simplest thing is to see the patient. But all the stuff that’s the wraparound is really hard, because issues can arise suddenly, and we need to plan.” If a patient has a medical issue or becomes actively suicidal during a session, it is important to know contact information for the local police and crisis services. Clinicians also must plan for technology failure and provide alternative options for continuing the sessions, such as by phone.
 

Selecting patients for telepsychiatry

Not all patients will make the transition to telepsychiatry. “You can’t do telepsychiatry with everyone. It is a risk, so pick and choose,” Dr. Gupta said.

“Safety is a big consideration for conducting a telepsychiatry visit, especially when other health care providers are present. For example, when performing telehealth visits in a clinic, nursing home, or correctional facility, “I feel a lot more comfortable if there’s another health care clinician there,” Dr. Gupta said.

Clinicians may want to avoid a telepsychiatry visit for a patient in their own home for reasons of safety, reliability, and privacy. A longitudinal history with collateral information from friends or relatives can be helpful, but some subtle signs and body language may get missed over video, compared with an in-person visit. “Telepsychiatry can be a barrier at times. If there is substance abuse, we may not smell alcohol. Sometimes you may not see if the patient is using substances. You have to really reconsider if [there] is violence and self-injurious behavior,” he said.

Discussing the pros and cons of telepsychiatry is important to obtaining patient consent. While consent requirements have relaxed under the COVID-19 pandemic, consent should ideally be obtained in writing, but can also be obtained verbally during a crisis. A plan should be developed for what will happen in the case of technology failure. “The patient should also know you’re maintaining privacy, you’re maintaining confidentiality, but there is a risk of hacking,” Dr. Gupta said. “Those things can happen, [and] there are no guarantees.”

If a patient is uncomfortable after beginning telepsychiatry, moving to in-person visits is also an option. “Many times, I do that if I’m not getting a good handle on things,” Dr. Gupta said. Situations where patients insist on in-patient visits over telepsychiatry are rare in his experience, Dr. Gupta noted, and are usually the result of the patient being unfamiliar with the technology. In cases where a patient cannot be talked through a technology barrier, visits can be done in the clinic while taking proper precautions.

“If it is a first-time visit, then I do it in the clinic,” Dr. Gupta said. “They come in, they have a face mask, and we use our group therapy room. The patients sit in a social-distanced fashion. But then, you document why you did this in-person visit like that.”

Documentation during COVID-19 also includes identifying the patient at the first visit, the nature of the visit (teleconference or other), parties present, referencing the pandemic, writing the location of the patient and the clinician, noting the patient’s satisfaction, evaluating the patient’s mental status, and recording what technology was used and any technical issues that were encountered.

Some populations of patients are better suited to telepsychiatry than others. It is more convenient for chronically psychiatrically ill patients in group homes and their staff to communicate through telepsychiatry, Dr. Gupta said. Consultation liaison in hospitals and emergency departments through telepsychiatry can limit the spread of infection, while increased access and convenience occurs as telepsychiatry is implemented in correctional facilities and nursing homes.

“What we are doing now, some of it is here to stay,” Dr. Gupta said.

In situations where a patient needs to switch providers, clinicians should continue to follow that patient until his first patient visit with that new provider. It is also important to set boundaries and apply some level of formality to the telepsychiatry visit, which means seeing the patient in a secure location where he can speak freely and privately.

“The best practices are [to] maintain faith [and] fidelity of the psychiatric assessment,” Dr. Gupta said. “Keep the trust and do your best to maintain patient privacy, because the privacy is not the same as it may be in a face-to-face session when you use televideo.”

Global Academy and this news organization are owned by the same parent company.

Dr. Gupta reported no relevant financial disclosures. Dr. Nasrallah disclosed serving as a consultant for and on the speakers bureaus of several pharmaceutical companies, including Alkermes, Janssen, and Lundbeck. He also disclosed serving on the speakers bureau of Otsuka.

For patients with psychotic depression, response to treatment, remission rates, and cognitive improvement are better following electroconvulsive therapy (ECT) than for patients with nonpsychotic depression, results from a new study suggest.

However, findings from another study suggest that at least some of these differences may be because psychotic patients are referred for ECT earlier in the disease course.

Both studies were presented at the European Psychiatric Association 2020 Congress, which was held online this year because of the COVID-19 pandemic.
 

Limited, old evidence

The first study was led by Christopher Yi Wen Chan, MD, Institute of Mental Health, Singapore. The investigators stated that they have “often observed” superior remission rates with ECT in psychotic versus nonpsychotic depression. However, the evidence base is “limited and mostly more than 10 years old.”

They conducted a retrospective case-control study that included 160 patients – 50 with psychotic depression, and 110 with nonpsychotic depression. All patients had a primary diagnosis of unipolar major depressive disorder and underwent ECT at a tertiary psychiatric institute between January 2016 and January 2018.

Baseline characteristics of the two groups were similar, although patients with psychosis were more likely to have had an involuntary hospital admission and to have had higher baseline scores on the Montreal Cognitive Assessment (MoCA) and Clinical Global Impression–Severity scale (CGI-S) than nonpsychotic patients.

Response rates to ECT were significantly higher for the patients with psychotic depression than for those with nonpsychotic depression (79% vs. 51%; P = .009), as were remission rates (71% vs. 36%; P = .001).

Both groups showed significant improvement following ECT in Montgomery-Åsberg Depression Rating Scale, CGI, and quality-of-life scores.

However, only the participants with psychotic depression showed a significant improvement in MoCA total score (P = .038), as well as on attention (P = .024), language (P = .008), and orientation (P = .021) subdomains.
 

Psychotic depression markers?

For the second study, a team led by Aida De Arriba Arnau, MD, Centro de Investigación Biomédica en Red de Salud Mental, Barcelona, Spain, retrospectively analyzed 66 patients with depression who had received ECT. Of these, 26 had psychotic depression, and 40 had nonpsychotic depression.

Response rates were again higher in patients with psychotic vs nonpsychotic depression (92.3% vs. 85.0%). A similar number of sessions was needed to achieve a response.

Improvements in Hamilton Depression Rating Scale scores were significant between the two groups from the start of treatment, although the difference became nonsignificant at week 6.

Arriba Arnau said that there were some notable differences between patients with psychotic depression and those with nonpsychotic depression. For example, the former had “poor functionality, shorter episode duration, and less pharmacological resistance before receiving ECT,” she said.

“So we hypothesized that they might be referred more promptly to ECT treatment,” she added.

The psychotic depression group was significantly older than the group with nonpsychotic depression, at an average of 67.81 years vs 58.96 years.

They also “showed more illness severity and cognitive disturbances at baseline and ... required less anesthetic doses and higher initial stimulus intensity,» Arriba Arnau noted.

“All these features could be the markers of psychotic depression as an entity,” she said. However, the potential impact of age on these differences should be “further studied.”

She added that other aspects, such as age at onset and number of previous episodes, were similar between the groups.
 

Confirmatory data

Commenting on the findings for Medscape Medical News, Georgios Petrides, MD, associate professor of psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, New York, noted that differences in response to ECT between patients with psychotic depression and those with nonpsychotic depression are “well known.”

However, “it’s actually good to present more data that confirm what people are doing in clinical practice,” said Petrides, who was not involved with the research.

Petrides noted that some guidelines recommend ECT as first-line treatment for psychotic depression.

“For nonpsychotic depression, we’d try medications, psychotherapy, and everything else first,” he said. He noted that the current results are “a good replication of what is known so far.”

As to why ECT should be more effective for patients with psychotic depression, he said, “A lot of people think that the biology of psychotic depression is different from the biology of nonpsychotic depression.”

Many things that ECT “corrects” are disturbed in psychotic depression, including cortisol homeostasis, which is thought to be affected via the hypothalamic-pituitary-adrenal axis, Petrides added.

That ECT is more effective in psychotic depression is an “indirect point of evidence” to support that theory.

One aspect that has traditionally dogged the use of ECT has been the stigma that surrounds the procedure, Petrides noted. That’s “always an issue, but it’s getting less and less over time,” he said.

He added that ECT is extremely safe and that it is associated with the “lowest mortality for any procedure performed under general anesthesia,” which helps to reduce the stigma around it, he noted.

The study authors and Petrides have reported no relevant financial relationships.

This article first appeared on Medscape.com.

For patients with psychotic depression, response to treatment, remission rates, and cognitive improvement are better following electroconvulsive therapy (ECT) than for patients with nonpsychotic depression, results from a new study suggest.

However, findings from another study suggest that at least some of these differences may be because psychotic patients are referred for ECT earlier in the disease course.

Both studies were presented at the European Psychiatric Association 2020 Congress, which was held online this year because of the COVID-19 pandemic.
 

Limited, old evidence

The first study was led by Christopher Yi Wen Chan, MD, Institute of Mental Health, Singapore. The investigators stated that they have “often observed” superior remission rates with ECT in psychotic versus nonpsychotic depression. However, the evidence base is “limited and mostly more than 10 years old.”

They conducted a retrospective case-control study that included 160 patients – 50 with psychotic depression, and 110 with nonpsychotic depression. All patients had a primary diagnosis of unipolar major depressive disorder and underwent ECT at a tertiary psychiatric institute between January 2016 and January 2018.

Baseline characteristics of the two groups were similar, although patients with psychosis were more likely to have had an involuntary hospital admission and to have had higher baseline scores on the Montreal Cognitive Assessment (MoCA) and Clinical Global Impression–Severity scale (CGI-S) than nonpsychotic patients.

Response rates to ECT were significantly higher for the patients with psychotic depression than for those with nonpsychotic depression (79% vs. 51%; P = .009), as were remission rates (71% vs. 36%; P = .001).

Both groups showed significant improvement following ECT in Montgomery-Åsberg Depression Rating Scale, CGI, and quality-of-life scores.

However, only the participants with psychotic depression showed a significant improvement in MoCA total score (P = .038), as well as on attention (P = .024), language (P = .008), and orientation (P = .021) subdomains.
 

Psychotic depression markers?

For the second study, a team led by Aida De Arriba Arnau, MD, Centro de Investigación Biomédica en Red de Salud Mental, Barcelona, Spain, retrospectively analyzed 66 patients with depression who had received ECT. Of these, 26 had psychotic depression, and 40 had nonpsychotic depression.

Response rates were again higher in patients with psychotic vs nonpsychotic depression (92.3% vs. 85.0%). A similar number of sessions was needed to achieve a response.

Improvements in Hamilton Depression Rating Scale scores were significant between the two groups from the start of treatment, although the difference became nonsignificant at week 6.

Arriba Arnau said that there were some notable differences between patients with psychotic depression and those with nonpsychotic depression. For example, the former had “poor functionality, shorter episode duration, and less pharmacological resistance before receiving ECT,” she said.

“So we hypothesized that they might be referred more promptly to ECT treatment,” she added.

The psychotic depression group was significantly older than the group with nonpsychotic depression, at an average of 67.81 years vs 58.96 years.

They also “showed more illness severity and cognitive disturbances at baseline and ... required less anesthetic doses and higher initial stimulus intensity,» Arriba Arnau noted.

“All these features could be the markers of psychotic depression as an entity,” she said. However, the potential impact of age on these differences should be “further studied.”

She added that other aspects, such as age at onset and number of previous episodes, were similar between the groups.
 

Confirmatory data

Commenting on the findings for Medscape Medical News, Georgios Petrides, MD, associate professor of psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, New York, noted that differences in response to ECT between patients with psychotic depression and those with nonpsychotic depression are “well known.”

However, “it’s actually good to present more data that confirm what people are doing in clinical practice,” said Petrides, who was not involved with the research.

Petrides noted that some guidelines recommend ECT as first-line treatment for psychotic depression.

“For nonpsychotic depression, we’d try medications, psychotherapy, and everything else first,” he said. He noted that the current results are “a good replication of what is known so far.”

As to why ECT should be more effective for patients with psychotic depression, he said, “A lot of people think that the biology of psychotic depression is different from the biology of nonpsychotic depression.”

Many things that ECT “corrects” are disturbed in psychotic depression, including cortisol homeostasis, which is thought to be affected via the hypothalamic-pituitary-adrenal axis, Petrides added.

That ECT is more effective in psychotic depression is an “indirect point of evidence” to support that theory.

One aspect that has traditionally dogged the use of ECT has been the stigma that surrounds the procedure, Petrides noted. That’s “always an issue, but it’s getting less and less over time,” he said.

He added that ECT is extremely safe and that it is associated with the “lowest mortality for any procedure performed under general anesthesia,” which helps to reduce the stigma around it, he noted.

The study authors and Petrides have reported no relevant financial relationships.

This article first appeared on Medscape.com.

For patients with psychotic depression, response to treatment, remission rates, and cognitive improvement are better following electroconvulsive therapy (ECT) than for patients with nonpsychotic depression, results from a new study suggest.

However, findings from another study suggest that at least some of these differences may be because psychotic patients are referred for ECT earlier in the disease course.

Both studies were presented at the European Psychiatric Association 2020 Congress, which was held online this year because of the COVID-19 pandemic.
 

Limited, old evidence

The first study was led by Christopher Yi Wen Chan, MD, Institute of Mental Health, Singapore. The investigators stated that they have “often observed” superior remission rates with ECT in psychotic versus nonpsychotic depression. However, the evidence base is “limited and mostly more than 10 years old.”

They conducted a retrospective case-control study that included 160 patients – 50 with psychotic depression, and 110 with nonpsychotic depression. All patients had a primary diagnosis of unipolar major depressive disorder and underwent ECT at a tertiary psychiatric institute between January 2016 and January 2018.

Baseline characteristics of the two groups were similar, although patients with psychosis were more likely to have had an involuntary hospital admission and to have had higher baseline scores on the Montreal Cognitive Assessment (MoCA) and Clinical Global Impression–Severity scale (CGI-S) than nonpsychotic patients.

Response rates to ECT were significantly higher for the patients with psychotic depression than for those with nonpsychotic depression (79% vs. 51%; P = .009), as were remission rates (71% vs. 36%; P = .001).

Both groups showed significant improvement following ECT in Montgomery-Åsberg Depression Rating Scale, CGI, and quality-of-life scores.

However, only the participants with psychotic depression showed a significant improvement in MoCA total score (P = .038), as well as on attention (P = .024), language (P = .008), and orientation (P = .021) subdomains.
 

Psychotic depression markers?

For the second study, a team led by Aida De Arriba Arnau, MD, Centro de Investigación Biomédica en Red de Salud Mental, Barcelona, Spain, retrospectively analyzed 66 patients with depression who had received ECT. Of these, 26 had psychotic depression, and 40 had nonpsychotic depression.

Response rates were again higher in patients with psychotic vs nonpsychotic depression (92.3% vs. 85.0%). A similar number of sessions was needed to achieve a response.

Improvements in Hamilton Depression Rating Scale scores were significant between the two groups from the start of treatment, although the difference became nonsignificant at week 6.

Arriba Arnau said that there were some notable differences between patients with psychotic depression and those with nonpsychotic depression. For example, the former had “poor functionality, shorter episode duration, and less pharmacological resistance before receiving ECT,” she said.

“So we hypothesized that they might be referred more promptly to ECT treatment,” she added.

The psychotic depression group was significantly older than the group with nonpsychotic depression, at an average of 67.81 years vs 58.96 years.

They also “showed more illness severity and cognitive disturbances at baseline and ... required less anesthetic doses and higher initial stimulus intensity,» Arriba Arnau noted.

“All these features could be the markers of psychotic depression as an entity,” she said. However, the potential impact of age on these differences should be “further studied.”

She added that other aspects, such as age at onset and number of previous episodes, were similar between the groups.
 

Confirmatory data

Commenting on the findings for Medscape Medical News, Georgios Petrides, MD, associate professor of psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, New York, noted that differences in response to ECT between patients with psychotic depression and those with nonpsychotic depression are “well known.”

However, “it’s actually good to present more data that confirm what people are doing in clinical practice,” said Petrides, who was not involved with the research.

Petrides noted that some guidelines recommend ECT as first-line treatment for psychotic depression.

“For nonpsychotic depression, we’d try medications, psychotherapy, and everything else first,” he said. He noted that the current results are “a good replication of what is known so far.”

As to why ECT should be more effective for patients with psychotic depression, he said, “A lot of people think that the biology of psychotic depression is different from the biology of nonpsychotic depression.”

Many things that ECT “corrects” are disturbed in psychotic depression, including cortisol homeostasis, which is thought to be affected via the hypothalamic-pituitary-adrenal axis, Petrides added.

That ECT is more effective in psychotic depression is an “indirect point of evidence” to support that theory.

One aspect that has traditionally dogged the use of ECT has been the stigma that surrounds the procedure, Petrides noted. That’s “always an issue, but it’s getting less and less over time,” he said.

He added that ECT is extremely safe and that it is associated with the “lowest mortality for any procedure performed under general anesthesia,” which helps to reduce the stigma around it, he noted.

The study authors and Petrides have reported no relevant financial relationships.

This article first appeared on Medscape.com.

A growing number of psychiatrists in the United States no longer accept insurance and will only see patients who can pay upfront, out-of-pocket for office visits, a new trends analysis shows.

Ivy Benjenk, BSN, MPH, and Jie Chen, PhD, from the University of Maryland, College Park, wrote that psychiatrists may be more likely than other specialties to adopt a self-pay-only model because of low insurance reimbursement rates, particularly for psychotherapy, as well as a demand for psychiatric services that outstrips supply.

There is a “limited supply” of psychiatrists in the United States and a “great deal of administrative hoops that go into accepting insurance for pretty minimal payment. So it makes some sense for psychiatrists to move entirely into the self-pay market,” Ms. Benjenk said in an interview.

The study was published online July 15 in JAMA Psychiatry.
 

Barrier to care

To explore patterns in self-payment for office-based psychiatric services and changes over time, the researchers analyzed data from 2007 to 2016 from the National Ambulatory Medical Care Survey, a nationally representative survey of physicians who were not federally employed, were office based, and were primarily engaged in direct patient care.

Of 15,790 psychiatrist visits, 3445 (21.8%) were self-paid by patients, compared with 4336 of 119,749 primary care clinician visits (3.6%).

Of the 750 psychiatrists in the sample, 146 (19.5%) were reimbursed predominantly by self-payment, compared with 69 of 4,294 primary care clinicians (1.6%).

The percentage of self-paid psychiatrist office visits has trended upward (from 18.5% in 2007-2009 to 26.7% in 2014-2016), whereas the percentage of self-paid primary care visits has trended downward (from 4.1% in 2007-2009 to 2.8% in 2014-2016).

The percentage of psychiatrists who work in predominantly self-pay practices has also trended upward (from 16.4% in 2007-2009 to 26.4% in 2014-2016), whereas the percentage of primary care clinicians who work in predominantly self-pay practices has not changed significantly (from 1.5% to 1.7%).

Psychiatrists who are reimbursed predominantly by self-payment were more likely to work in solo practices than group practices. Most self-pay psychiatry patients were White men.

Self-pay visits lasted longer than visits paid for by a third party (average duration, 38.3 min vs. 28.8 min; P < .001). Self-pay patients also made more visits to their psychiatrist than patients with third-party payers (mean, 18.3 visits vs. 9.4 visits in preceding 12 months; P < .001).

Ms. Benjenk and Dr. Chen wrote that self-pay psychiatry is a “hurdle many patients cannot surmount,” even if a portion of that payment is eventually paid by insurance.

“Either they have to pay out-of-pocket entirely or try to bill their insurance after the fact. It’s a lot of work to try to get an insurance company to pay for something after the fact. I couldn’t imagine someone who’s depressed or having some other psychiatric comorbidities actually go through the rigmarole of getting that done,” Ms. Benjenk said.

Ms. Benjenk believes that, with COVID-19 and a large shift to telepsychiatry, more psychiatrists might be interested in accepting insurance because they may be able to see more patients in a day.

“With telehealth, psychiatrists also can practice anywhere in their state, so that opens up a whole new pool of patients. And it’s cost saving; they don’t have to travel to an office, worry about office space or about no-shows, and there can be less lag time between appointments,” Ms. Benjenk said.

The study had no specific funding. Ms. Benjenk and Dr. Chen disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

A growing number of psychiatrists in the United States no longer accept insurance and will only see patients who can pay upfront, out-of-pocket for office visits, a new trends analysis shows.

Ivy Benjenk, BSN, MPH, and Jie Chen, PhD, from the University of Maryland, College Park, wrote that psychiatrists may be more likely than other specialties to adopt a self-pay-only model because of low insurance reimbursement rates, particularly for psychotherapy, as well as a demand for psychiatric services that outstrips supply.

There is a “limited supply” of psychiatrists in the United States and a “great deal of administrative hoops that go into accepting insurance for pretty minimal payment. So it makes some sense for psychiatrists to move entirely into the self-pay market,” Ms. Benjenk said in an interview.

The study was published online July 15 in JAMA Psychiatry.
 

Barrier to care

To explore patterns in self-payment for office-based psychiatric services and changes over time, the researchers analyzed data from 2007 to 2016 from the National Ambulatory Medical Care Survey, a nationally representative survey of physicians who were not federally employed, were office based, and were primarily engaged in direct patient care.

Of 15,790 psychiatrist visits, 3445 (21.8%) were self-paid by patients, compared with 4336 of 119,749 primary care clinician visits (3.6%).

Of the 750 psychiatrists in the sample, 146 (19.5%) were reimbursed predominantly by self-payment, compared with 69 of 4,294 primary care clinicians (1.6%).

The percentage of self-paid psychiatrist office visits has trended upward (from 18.5% in 2007-2009 to 26.7% in 2014-2016), whereas the percentage of self-paid primary care visits has trended downward (from 4.1% in 2007-2009 to 2.8% in 2014-2016).

The percentage of psychiatrists who work in predominantly self-pay practices has also trended upward (from 16.4% in 2007-2009 to 26.4% in 2014-2016), whereas the percentage of primary care clinicians who work in predominantly self-pay practices has not changed significantly (from 1.5% to 1.7%).

Psychiatrists who are reimbursed predominantly by self-payment were more likely to work in solo practices than group practices. Most self-pay psychiatry patients were White men.

Self-pay visits lasted longer than visits paid for by a third party (average duration, 38.3 min vs. 28.8 min; P < .001). Self-pay patients also made more visits to their psychiatrist than patients with third-party payers (mean, 18.3 visits vs. 9.4 visits in preceding 12 months; P < .001).

Ms. Benjenk and Dr. Chen wrote that self-pay psychiatry is a “hurdle many patients cannot surmount,” even if a portion of that payment is eventually paid by insurance.

“Either they have to pay out-of-pocket entirely or try to bill their insurance after the fact. It’s a lot of work to try to get an insurance company to pay for something after the fact. I couldn’t imagine someone who’s depressed or having some other psychiatric comorbidities actually go through the rigmarole of getting that done,” Ms. Benjenk said.

Ms. Benjenk believes that, with COVID-19 and a large shift to telepsychiatry, more psychiatrists might be interested in accepting insurance because they may be able to see more patients in a day.

“With telehealth, psychiatrists also can practice anywhere in their state, so that opens up a whole new pool of patients. And it’s cost saving; they don’t have to travel to an office, worry about office space or about no-shows, and there can be less lag time between appointments,” Ms. Benjenk said.

The study had no specific funding. Ms. Benjenk and Dr. Chen disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

A growing number of psychiatrists in the United States no longer accept insurance and will only see patients who can pay upfront, out-of-pocket for office visits, a new trends analysis shows.

Ivy Benjenk, BSN, MPH, and Jie Chen, PhD, from the University of Maryland, College Park, wrote that psychiatrists may be more likely than other specialties to adopt a self-pay-only model because of low insurance reimbursement rates, particularly for psychotherapy, as well as a demand for psychiatric services that outstrips supply.

There is a “limited supply” of psychiatrists in the United States and a “great deal of administrative hoops that go into accepting insurance for pretty minimal payment. So it makes some sense for psychiatrists to move entirely into the self-pay market,” Ms. Benjenk said in an interview.

The study was published online July 15 in JAMA Psychiatry.
 

Barrier to care

To explore patterns in self-payment for office-based psychiatric services and changes over time, the researchers analyzed data from 2007 to 2016 from the National Ambulatory Medical Care Survey, a nationally representative survey of physicians who were not federally employed, were office based, and were primarily engaged in direct patient care.

Of 15,790 psychiatrist visits, 3445 (21.8%) were self-paid by patients, compared with 4336 of 119,749 primary care clinician visits (3.6%).

Of the 750 psychiatrists in the sample, 146 (19.5%) were reimbursed predominantly by self-payment, compared with 69 of 4,294 primary care clinicians (1.6%).

The percentage of self-paid psychiatrist office visits has trended upward (from 18.5% in 2007-2009 to 26.7% in 2014-2016), whereas the percentage of self-paid primary care visits has trended downward (from 4.1% in 2007-2009 to 2.8% in 2014-2016).

The percentage of psychiatrists who work in predominantly self-pay practices has also trended upward (from 16.4% in 2007-2009 to 26.4% in 2014-2016), whereas the percentage of primary care clinicians who work in predominantly self-pay practices has not changed significantly (from 1.5% to 1.7%).

Psychiatrists who are reimbursed predominantly by self-payment were more likely to work in solo practices than group practices. Most self-pay psychiatry patients were White men.

Self-pay visits lasted longer than visits paid for by a third party (average duration, 38.3 min vs. 28.8 min; P < .001). Self-pay patients also made more visits to their psychiatrist than patients with third-party payers (mean, 18.3 visits vs. 9.4 visits in preceding 12 months; P < .001).

Ms. Benjenk and Dr. Chen wrote that self-pay psychiatry is a “hurdle many patients cannot surmount,” even if a portion of that payment is eventually paid by insurance.

“Either they have to pay out-of-pocket entirely or try to bill their insurance after the fact. It’s a lot of work to try to get an insurance company to pay for something after the fact. I couldn’t imagine someone who’s depressed or having some other psychiatric comorbidities actually go through the rigmarole of getting that done,” Ms. Benjenk said.

Ms. Benjenk believes that, with COVID-19 and a large shift to telepsychiatry, more psychiatrists might be interested in accepting insurance because they may be able to see more patients in a day.

“With telehealth, psychiatrists also can practice anywhere in their state, so that opens up a whole new pool of patients. And it’s cost saving; they don’t have to travel to an office, worry about office space or about no-shows, and there can be less lag time between appointments,” Ms. Benjenk said.

The study had no specific funding. Ms. Benjenk and Dr. Chen disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Key clinical point: Vitamin D supplementation may reduce negative emotions in patients with major depressive disorder (MDD).

Major finding: Vitamin D supplementation reduced negative emotions at doses of ≤4,000 IU/day (Hedges' g = −0.2311; P = .0008). In the sub-group analysis, the effects were significant in patients with serum levels of 25(OH)D ≤50 nmol/L (P = .0028), but not in those with levels >50 nmol/L (P = .0507).

Study details: Systematic review and meta-analysis of 25 randomized controlled trials (n = 7,534) comparing the effects of vitamin D and the placebo on negative emotions in patients with MDD.

Disclosures: No funding information was identified. The authors declared no conflicts of interest.

Citation: Cheng YC et al. Depress Anxiety. 2020 May 04. doi: 10.1002/da.23025.

Key clinical point: Vitamin D supplementation may reduce negative emotions in patients with major depressive disorder (MDD).

Major finding: Vitamin D supplementation reduced negative emotions at doses of ≤4,000 IU/day (Hedges' g = −0.2311; P = .0008). In the sub-group analysis, the effects were significant in patients with serum levels of 25(OH)D ≤50 nmol/L (P = .0028), but not in those with levels >50 nmol/L (P = .0507).

Study details: Systematic review and meta-analysis of 25 randomized controlled trials (n = 7,534) comparing the effects of vitamin D and the placebo on negative emotions in patients with MDD.

Disclosures: No funding information was identified. The authors declared no conflicts of interest.

Citation: Cheng YC et al. Depress Anxiety. 2020 May 04. doi: 10.1002/da.23025.

Key clinical point: Vitamin D supplementation may reduce negative emotions in patients with major depressive disorder (MDD).

Major finding: Vitamin D supplementation reduced negative emotions at doses of ≤4,000 IU/day (Hedges' g = −0.2311; P = .0008). In the sub-group analysis, the effects were significant in patients with serum levels of 25(OH)D ≤50 nmol/L (P = .0028), but not in those with levels >50 nmol/L (P = .0507).

Study details: Systematic review and meta-analysis of 25 randomized controlled trials (n = 7,534) comparing the effects of vitamin D and the placebo on negative emotions in patients with MDD.

Disclosures: No funding information was identified. The authors declared no conflicts of interest.

Citation: Cheng YC et al. Depress Anxiety. 2020 May 04. doi: 10.1002/da.23025.

Key clinical point: Patients with major depressive disorder (MDD) having suicidal ideation (SI) show poorer performance in verbal learning domain.

Major finding: The SI vs. non-SI group performed worse in the domain of verbal learning at baseline (mean verbal learning scores, 39.7 vs. 42.2; P = .036). Other cognitive domains had no significant differences between the groups (speed of processing, working memory, and visual learning; P greater than .005 for all).

Study details: The data come from a longitudinal, 4-week open-label trial of patients with MDD (SI group, n = 130 and non-SI group, n = 175).

Disclosures: This study was funded by the National Natural Science Foundation of China, the National Key Research and Development Program of China, Guangdong Basic and Applied Basic Research Foundation, Science and Technology Department of Guangdong Province major science and technology, the International Communication Foundation Science and Technology Commission of Shanghai Municipality, Guangzhou Municipal Psychiatric Disease Clinical Transformation Laboratory, and Key Laboratory for Innovation platform Plan, Science, and Technology Program of Guangzhou, China. The authors declared no conflicts of interest.

Citation: Lan X et al. J Affect Disord. 2020 Apr 30. doi: 10.1016/j.jad.2020.03.141.

Key clinical point: Patients with major depressive disorder (MDD) having suicidal ideation (SI) show poorer performance in verbal learning domain.

Major finding: The SI vs. non-SI group performed worse in the domain of verbal learning at baseline (mean verbal learning scores, 39.7 vs. 42.2; P = .036). Other cognitive domains had no significant differences between the groups (speed of processing, working memory, and visual learning; P greater than .005 for all).

Study details: The data come from a longitudinal, 4-week open-label trial of patients with MDD (SI group, n = 130 and non-SI group, n = 175).

Disclosures: This study was funded by the National Natural Science Foundation of China, the National Key Research and Development Program of China, Guangdong Basic and Applied Basic Research Foundation, Science and Technology Department of Guangdong Province major science and technology, the International Communication Foundation Science and Technology Commission of Shanghai Municipality, Guangzhou Municipal Psychiatric Disease Clinical Transformation Laboratory, and Key Laboratory for Innovation platform Plan, Science, and Technology Program of Guangzhou, China. The authors declared no conflicts of interest.

Citation: Lan X et al. J Affect Disord. 2020 Apr 30. doi: 10.1016/j.jad.2020.03.141.

Key clinical point: Patients with major depressive disorder (MDD) having suicidal ideation (SI) show poorer performance in verbal learning domain.

Major finding: The SI vs. non-SI group performed worse in the domain of verbal learning at baseline (mean verbal learning scores, 39.7 vs. 42.2; P = .036). Other cognitive domains had no significant differences between the groups (speed of processing, working memory, and visual learning; P greater than .005 for all).

Study details: The data come from a longitudinal, 4-week open-label trial of patients with MDD (SI group, n = 130 and non-SI group, n = 175).

Disclosures: This study was funded by the National Natural Science Foundation of China, the National Key Research and Development Program of China, Guangdong Basic and Applied Basic Research Foundation, Science and Technology Department of Guangdong Province major science and technology, the International Communication Foundation Science and Technology Commission of Shanghai Municipality, Guangzhou Municipal Psychiatric Disease Clinical Transformation Laboratory, and Key Laboratory for Innovation platform Plan, Science, and Technology Program of Guangzhou, China. The authors declared no conflicts of interest.

Citation: Lan X et al. J Affect Disord. 2020 Apr 30. doi: 10.1016/j.jad.2020.03.141.

A history of repetitive hits to the head (RHI), even without noticeable symptoms, is linked to a significantly increased risk of depression and poorer cognition later in life, new research shows.

“We found that a history of exposure to [repetitive hits to the head] from contact sports, military service, or physical abuse, as well as a history of TBI (traumatic brain injury), corresponded to more symptoms of later life depression and worse cognitive function,” lead author Michael Alosco, PhD, associate professor of neurology and codirector of the Boston University Alzheimer’s Disease Center Clinical Core, told Medscape Medical News.

He added that the findings underscore the importance of assessing repetitive head impacts (RHI).

The study was published online June 26 in Neurology.
 

Largest study to date

It is well known that sustaining a TBI is associated with worse later life cognition or mood problems, said Alosco. However, in the current research the investigators hypothesized that RHI may be a key driver of some of these outcomes, Alosco said.

Previous studies have been small or have only examined male former football players.

“What’s unique about our study is that we focused on a history of RHIs, and it is the largest study of its kind, incorporating over 30,000 males and females with different types of exposure to these RHIs.”

The researchers used data from the Brain Health Registry, an internet-based registry that longitudinally monitors cognition and functioning of participants (age 40 years and older).

Participants completed the Ohio State University TBI Identification Method (OSU TBI-ID) and answered a yes/no question: “Have you ever had a period of time in which you experienced multiple, repeated impacts to your head (eg, history of abuse, contact sports, military duty)?”

Participants also completed the Geriatric Depression Scale (GDS-15), the CogState Battery (CBB), and the Lumos Labs NeuroCognitive Performance Tests (NCPT). Demographic information included age, sex, race/ethnicity, and level of education.
 

Negative synergistic effect

Of the total sample (N = 13,323, mean age 62 years, 72.5% female, 88.6% White) 725 participants (5%) reported exposure to RHI, with contact sports as the most common cause, followed by physical abuse and then military duty; about 55% (7277 participants) reported TBI.

The researchers noted that 44.4% of those exposed to RHI and 70.3% of those who reported TBI were female. However, those with a history of contact sports were predominantly male and those reporting a history of abuse were predominantly women.

Among study participants who completed the GDS-15, 16.4% reported symptoms of depression, similar to rates reported among community-dwelling older adults.

Compared to the unexposed group, participants who reported TBI with loss of consciousness (LOC) and participants who reported TBI without LOC both had higher scores on the GDS-15 (beta = 0.75 [95% CI, 0.59-0.91] and beta = 0.43 [95% CI, 0.31-0.54], respectively).

A history of RHI was associated with an even higher depression score (beta = 1.24 [95% CI, 0.36-2.12).

Depression increased in tandem with increased exposure, with the lowest GDS-15 scores found in the unexposed group and subsequent increases in scores as exposure to RHI was introduced and TBI severity increased. The GDS scores were highest in those who had RHI plus TBI with LOC.

Participants with a history of RHI and/or TBI also had worse scores on tests of memory, learning, processing speed, and reaction time, compared with unexposed participants.

In particular, TBI with LOC had the most neuropsychological associations.

TBI without LOC had a negative effect on CogState tests measuring Identification and processing speed (beta = 0.004 [95% CI, 0-0.01] and beta = 0.004 [95% CI, 0.0002-0.01], respectively), whereas RHI predicted a worse processing speed score (beta = .02 [95% CI, 0.01-0.05]).

The presence of both RHI and TBI (with or without LOC) had a “synergistic negative effect” on neuropsychological performance, with a “consistent statistically significant finding” for worse neuropsychological test performance for those who had RHI and TBI with LOC, compared with those who had not sustained RHI.

Alosco said the findings highlight the need for clinicians to educate and inform parents/guardians of kids playing (or considering playing) contact sports about the research and potential risks associated with these activities.

“We have to ask the question: ‘Does it make sense to expose ourselves to these repeated hits to the heads?’ If we want to prevent long-term problems, one way is not to expose [people] to these hits. Everyone takes risks in life with everything, but the more we can understand and mitigate the risks, the better,” Alosco said.
 

“A significant contribution”

Commenting on the findings for Medscape Medical News, Temitayo Oyegbile-Chidi, MD, PhD, a pediatric neurologist with Health Peak Inc, McLean, Virginia, and a member of the American Academy of Neurology, said the study “makes a significant contribution to the literature, as neurologists who specialized in TBI have long yearned to understand the long-term effects of repeated head impact on the brain and cognition.”

Clinicians should “inquire about a history of prior head impacts on all our patients, regardless of age, especially if they are experiencing or showing signs of unexpected cognitive dysfunction or mental health concerns,” said Oyegbile-Chidi, who was not involved with the study.

For those who have sustained single or repeated head impacts with or without associated LOC in the past, “it is important … to keep in mind that depression and cognitive dysfunction may persist or present even many years after the impact was sustained,” she added.

The study was supported by a grant from the National Institutes of Health. Alosco has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Oyegbile-Chidi has disclosed no relevant financial relationships.

A history of repetitive hits to the head (RHI), even without noticeable symptoms, is linked to a significantly increased risk of depression and poorer cognition later in life, new research shows.

“We found that a history of exposure to [repetitive hits to the head] from contact sports, military service, or physical abuse, as well as a history of TBI (traumatic brain injury), corresponded to more symptoms of later life depression and worse cognitive function,” lead author Michael Alosco, PhD, associate professor of neurology and codirector of the Boston University Alzheimer’s Disease Center Clinical Core, told Medscape Medical News.

He added that the findings underscore the importance of assessing repetitive head impacts (RHI).

The study was published online June 26 in Neurology.
 

Largest study to date

It is well known that sustaining a TBI is associated with worse later life cognition or mood problems, said Alosco. However, in the current research the investigators hypothesized that RHI may be a key driver of some of these outcomes, Alosco said.

Previous studies have been small or have only examined male former football players.

“What’s unique about our study is that we focused on a history of RHIs, and it is the largest study of its kind, incorporating over 30,000 males and females with different types of exposure to these RHIs.”

The researchers used data from the Brain Health Registry, an internet-based registry that longitudinally monitors cognition and functioning of participants (age 40 years and older).

Participants completed the Ohio State University TBI Identification Method (OSU TBI-ID) and answered a yes/no question: “Have you ever had a period of time in which you experienced multiple, repeated impacts to your head (eg, history of abuse, contact sports, military duty)?”

Participants also completed the Geriatric Depression Scale (GDS-15), the CogState Battery (CBB), and the Lumos Labs NeuroCognitive Performance Tests (NCPT). Demographic information included age, sex, race/ethnicity, and level of education.
 

Negative synergistic effect

Of the total sample (N = 13,323, mean age 62 years, 72.5% female, 88.6% White) 725 participants (5%) reported exposure to RHI, with contact sports as the most common cause, followed by physical abuse and then military duty; about 55% (7277 participants) reported TBI.

The researchers noted that 44.4% of those exposed to RHI and 70.3% of those who reported TBI were female. However, those with a history of contact sports were predominantly male and those reporting a history of abuse were predominantly women.

Among study participants who completed the GDS-15, 16.4% reported symptoms of depression, similar to rates reported among community-dwelling older adults.

Compared to the unexposed group, participants who reported TBI with loss of consciousness (LOC) and participants who reported TBI without LOC both had higher scores on the GDS-15 (beta = 0.75 [95% CI, 0.59-0.91] and beta = 0.43 [95% CI, 0.31-0.54], respectively).

A history of RHI was associated with an even higher depression score (beta = 1.24 [95% CI, 0.36-2.12).

Depression increased in tandem with increased exposure, with the lowest GDS-15 scores found in the unexposed group and subsequent increases in scores as exposure to RHI was introduced and TBI severity increased. The GDS scores were highest in those who had RHI plus TBI with LOC.

Participants with a history of RHI and/or TBI also had worse scores on tests of memory, learning, processing speed, and reaction time, compared with unexposed participants.

In particular, TBI with LOC had the most neuropsychological associations.

TBI without LOC had a negative effect on CogState tests measuring Identification and processing speed (beta = 0.004 [95% CI, 0-0.01] and beta = 0.004 [95% CI, 0.0002-0.01], respectively), whereas RHI predicted a worse processing speed score (beta = .02 [95% CI, 0.01-0.05]).

The presence of both RHI and TBI (with or without LOC) had a “synergistic negative effect” on neuropsychological performance, with a “consistent statistically significant finding” for worse neuropsychological test performance for those who had RHI and TBI with LOC, compared with those who had not sustained RHI.

Alosco said the findings highlight the need for clinicians to educate and inform parents/guardians of kids playing (or considering playing) contact sports about the research and potential risks associated with these activities.

“We have to ask the question: ‘Does it make sense to expose ourselves to these repeated hits to the heads?’ If we want to prevent long-term problems, one way is not to expose [people] to these hits. Everyone takes risks in life with everything, but the more we can understand and mitigate the risks, the better,” Alosco said.
 

“A significant contribution”

Commenting on the findings for Medscape Medical News, Temitayo Oyegbile-Chidi, MD, PhD, a pediatric neurologist with Health Peak Inc, McLean, Virginia, and a member of the American Academy of Neurology, said the study “makes a significant contribution to the literature, as neurologists who specialized in TBI have long yearned to understand the long-term effects of repeated head impact on the brain and cognition.”

Clinicians should “inquire about a history of prior head impacts on all our patients, regardless of age, especially if they are experiencing or showing signs of unexpected cognitive dysfunction or mental health concerns,” said Oyegbile-Chidi, who was not involved with the study.

For those who have sustained single or repeated head impacts with or without associated LOC in the past, “it is important … to keep in mind that depression and cognitive dysfunction may persist or present even many years after the impact was sustained,” she added.

The study was supported by a grant from the National Institutes of Health. Alosco has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Oyegbile-Chidi has disclosed no relevant financial relationships.

A history of repetitive hits to the head (RHI), even without noticeable symptoms, is linked to a significantly increased risk of depression and poorer cognition later in life, new research shows.

“We found that a history of exposure to [repetitive hits to the head] from contact sports, military service, or physical abuse, as well as a history of TBI (traumatic brain injury), corresponded to more symptoms of later life depression and worse cognitive function,” lead author Michael Alosco, PhD, associate professor of neurology and codirector of the Boston University Alzheimer’s Disease Center Clinical Core, told Medscape Medical News.

He added that the findings underscore the importance of assessing repetitive head impacts (RHI).

The study was published online June 26 in Neurology.
 

Largest study to date

It is well known that sustaining a TBI is associated with worse later life cognition or mood problems, said Alosco. However, in the current research the investigators hypothesized that RHI may be a key driver of some of these outcomes, Alosco said.

Previous studies have been small or have only examined male former football players.

“What’s unique about our study is that we focused on a history of RHIs, and it is the largest study of its kind, incorporating over 30,000 males and females with different types of exposure to these RHIs.”

The researchers used data from the Brain Health Registry, an internet-based registry that longitudinally monitors cognition and functioning of participants (age 40 years and older).

Participants completed the Ohio State University TBI Identification Method (OSU TBI-ID) and answered a yes/no question: “Have you ever had a period of time in which you experienced multiple, repeated impacts to your head (eg, history of abuse, contact sports, military duty)?”

Participants also completed the Geriatric Depression Scale (GDS-15), the CogState Battery (CBB), and the Lumos Labs NeuroCognitive Performance Tests (NCPT). Demographic information included age, sex, race/ethnicity, and level of education.
 

Negative synergistic effect

Of the total sample (N = 13,323, mean age 62 years, 72.5% female, 88.6% White) 725 participants (5%) reported exposure to RHI, with contact sports as the most common cause, followed by physical abuse and then military duty; about 55% (7277 participants) reported TBI.

The researchers noted that 44.4% of those exposed to RHI and 70.3% of those who reported TBI were female. However, those with a history of contact sports were predominantly male and those reporting a history of abuse were predominantly women.

Among study participants who completed the GDS-15, 16.4% reported symptoms of depression, similar to rates reported among community-dwelling older adults.

Compared to the unexposed group, participants who reported TBI with loss of consciousness (LOC) and participants who reported TBI without LOC both had higher scores on the GDS-15 (beta = 0.75 [95% CI, 0.59-0.91] and beta = 0.43 [95% CI, 0.31-0.54], respectively).

A history of RHI was associated with an even higher depression score (beta = 1.24 [95% CI, 0.36-2.12).

Depression increased in tandem with increased exposure, with the lowest GDS-15 scores found in the unexposed group and subsequent increases in scores as exposure to RHI was introduced and TBI severity increased. The GDS scores were highest in those who had RHI plus TBI with LOC.

Participants with a history of RHI and/or TBI also had worse scores on tests of memory, learning, processing speed, and reaction time, compared with unexposed participants.

In particular, TBI with LOC had the most neuropsychological associations.

TBI without LOC had a negative effect on CogState tests measuring Identification and processing speed (beta = 0.004 [95% CI, 0-0.01] and beta = 0.004 [95% CI, 0.0002-0.01], respectively), whereas RHI predicted a worse processing speed score (beta = .02 [95% CI, 0.01-0.05]).

The presence of both RHI and TBI (with or without LOC) had a “synergistic negative effect” on neuropsychological performance, with a “consistent statistically significant finding” for worse neuropsychological test performance for those who had RHI and TBI with LOC, compared with those who had not sustained RHI.

Alosco said the findings highlight the need for clinicians to educate and inform parents/guardians of kids playing (or considering playing) contact sports about the research and potential risks associated with these activities.

“We have to ask the question: ‘Does it make sense to expose ourselves to these repeated hits to the heads?’ If we want to prevent long-term problems, one way is not to expose [people] to these hits. Everyone takes risks in life with everything, but the more we can understand and mitigate the risks, the better,” Alosco said.
 

“A significant contribution”

Commenting on the findings for Medscape Medical News, Temitayo Oyegbile-Chidi, MD, PhD, a pediatric neurologist with Health Peak Inc, McLean, Virginia, and a member of the American Academy of Neurology, said the study “makes a significant contribution to the literature, as neurologists who specialized in TBI have long yearned to understand the long-term effects of repeated head impact on the brain and cognition.”

Clinicians should “inquire about a history of prior head impacts on all our patients, regardless of age, especially if they are experiencing or showing signs of unexpected cognitive dysfunction or mental health concerns,” said Oyegbile-Chidi, who was not involved with the study.

For those who have sustained single or repeated head impacts with or without associated LOC in the past, “it is important … to keep in mind that depression and cognitive dysfunction may persist or present even many years after the impact was sustained,” she added.

The study was supported by a grant from the National Institutes of Health. Alosco has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Oyegbile-Chidi has disclosed no relevant financial relationships.

Ms. Jones brings her 15-year-old daughter, Angela, to the resident clinic. Angela is becoming increasingly anxious, withdrawn, and difficult to manage. As part of the initial interview, the resident, Dr. Sota, asks about the sociocultural background of the family. Ms. Jones is African American and recently began a relationship with a white man. Her daughter, Angela, is biracial; her biological father is white and has moved out of state with little ongoing contact with Angela and her mother.

At interview, Angela expresses a lot of anger at her mother, her biological father, and her new “stepfather.” Ms. Jones says: “I do not want Angela growing up as an ‘angry black woman.’ ” When asked for an explanation, she stated that she doesn’t want her daughter to be stereotyped, to be perceived as an angry black person. “She needs to fit in with our new life. She has lots of opportunities if only she would take them.”

Dr. Sota recognizes that Angela’s struggle, and perhaps also the struggle of Ms. Jones, has a component of internalized racism. How should Dr. Sota proceed? Dr. Sota puts herself in Angela’s shoes: How does Angela see herself? Angela has light brown skin, and Dr. Sota wonders whether Angela wants to present as white or whether asserting her black heritage is important.

The term internalized racism (IR) first appeared in the 1980s. IR was compared to the oppression of black people in the 1800s: “The slavery that captures the mind and incarcerates the motivation, perception, aspiration, and identity in a web of anti-self images, generating a personal and collective self destruction, is more cruel than the shackles on the wrists and ankles.”¹ According to Susanne Lipsky,² IR “in African Americans manifests as internalizing stereotypes, mistrusting the self and other Blacks, and narrows one’s view of authentic Black culture.”

IR refers to the internalization and acceptance of the dominant white culture’s actions and beliefs, while rejecting one’s own cultural background. There is a long history of negative cultural representations of African Americans in popular American culture, and IR has a detrimental impact on the emotional well-being of African Americans.³

IR is associated with poorer metabolic health⁴ and psychological distress, depression and anxiety,^5-8 and decreased self-esteem.⁹ However, protective processes can reduce one’s response to risk and can be developed through the psychotherapeutic relationship.
 

Interventions at an individual, family, or community levels

Angela: Tell me about yourself: What type of person are you? How do you identify? How do you feel about yourself/your appearance/your language?

Tell me about your friends/family? What interests do you have?

“Tell me more” questions can reveal conflicted feelings, etc., even if Angela does not answer. A good therapist can talk about IR; even if Angela does not bring it up, it is important for the therapist to find language suitable for the age of the patient.

Dr. Sota has some luck with Angela, who nods her head but says little. Dr. Sota then turns to Ms. Jones and asks whether she can answer these questions, too, and rephrases the questions for an adult. Interviewing parents in the presence of their children gives Dr. Sota and Angela an idea of what is permitted to talk about in the family.

A therapist can also note other permissions in the family: How do Angela and her mother use language? Do they claim or reject words and phrases such as “angry black woman” and choose, instead, to use language to “fit in” with the dominant white culture?

Dr. Sota notices that Ms. Jones presents herself as keen to fit in with her new future husband’s life. She wants Angela to do likewise. Dr. Sota notices that Angela vacillates between wanting to claim her black identity and having to navigate what that means in this family (not a good thing) – and wanting to assimilate into white culture. Her peers fall into two separate groups: a set of black friends and a set of white friends. Her mother prefers that she see her white friends, mistrusting her black friends.

Dr. Sota’s supervisor suggests that she introduce IR more forcefully because this seems to be a major course of conflict for Angela and encourage a frank discussion between mother and daughter. Dr. Sota starts the next session in the following way: “I noticed last week that the way you each identify yourselves is quite different. Ms. Jones, you want Angela to ‘fit in’ and perhaps just embrace white culture, whereas Angela, perhaps you vacillate between a white identity and a black identity?”

The following questions can help Dr. Sota elicit IR:

• What information about yourself would you like others to know – about your heritage, country of origin, family, class background, and so on?
• What makes you proud about being a member of this group, and what do you love about other members of this group?
• What has been hard about being a member of this group, and what don’t you like about others in this group?
• What were your early life experiences with people in this group? How were you treated? How did you feel about others in your group when you were young?

At a community level, family workshops support positive cultural identities that strengthen family functioning and reducing behavioral health risks. In a study of 575 urban American Indian (AI) families from diverse tribal backgrounds, the AI families who participated in such a workshop had significant increases in their ethnic identity, improved sense of spirituality, and a more positive cultural identification. The workshops provided culturally adaptive parenting interventions.¹⁰

IR is a serious determinant of both physical and mental health. Assessment of IR can be done using rating scales, such as the Nadanolitization Scale¹¹ or the Internalized Racial Oppression Scale.¹² IR also can also be assessed using a more formalized interview guide, such as the DSM-5 Cultural Formulation Interview (CFI).¹³ This 16-question interview guide helps behavioral health providers better understand the way service users and their social networks (e.g., families, friends) understand what is happening to them and why, as well as the barriers they experience, such as racism, discrimination, stigma, and financial stressors.

Individuals’ cultures and experiences have a profound impact on their understanding of their symptoms and their engagement in care. The American Psychiatric Association considers it to be part of mental health providers’ duty of care to engage all individuals in culturally relevant conversations about their past experiences and care expectations. More relevant, I submit that you cannot treat someone without having made this inquiry. A cultural assessment improves understanding but also shifts power relationships between providers and patients. The DSM-5 CFI and training guides are widely available and provide additional information for those who want to improve their cultural literacy.
 

Conclusion

Internalized racism is the component of racism that is the most difficult to discern. Psychiatrists and mental health professionals are uniquely poised to address IR, and any subsequent internal conflict and identity difficulties. Each program, office, and clinic can easily find the resources to do this through the APA. If you would like help providing education, contact me at [email protected].
 

References

1. Akbar N. J Black Studies. 1984. doi: 10.11771002193478401400401.

2. Lipsky S. Internalized Racism. Seattle: Rational Island Publishers, 1987.

3. Williams DR and Mohammed SA. Am Behav Sci. 2013 May 8. doi: 10.1177/00027642134873340.

4. DeLilly CR and Flaskerud JH. Issues Ment Health Nurs. 2012 Nov;33(11):804-11.

5. Molina KM and James D. Group Process Intergroup Relat. 2016 Jul;19(4):439-61.

6. Szymanski D and Obiri O. Couns Psychologist. 2011;39(3):438-62.

7. Carter RT et al. J Multicul Couns Dev. 2017 Oct 5;45(4):232-59.

8. Mouzon DM and McLean JS. Ethn Health. 2017 Feb;22(1):36-48.

9. Szymanski DM and Gupta A. J Couns Psychol. 2009;56(1):110-18.

10. Kulis SS et al. Cultural Diversity and Ethnic Minority Psychol. 2019. doi: 10.1037/cpd000315.

11. Taylor J and Grundy C. “Measuring black internalization of white stereotypes about African Americans: The Nadanolization Scale.” In: Jones RL, ed. Handbook of Tests and Measurements of Black Populations. Hampton, Va.: Cobb & Henry, 1996.

12. Bailey T-K M et al. J Couns Psychol. 2011 Oct;58(4):481-93.

13. American Psychiatric Association. Cultural Formulation Interview. DSM-5. American Psychiatric Association Publishing: Arlington, Va. 2013.



Various aspects about the case described above have been changed to protect the clinician’s and patients’ identities. Thanks to the following individuals for their contributions to this article: Suzanne Huberty, MD, and Shiona Heru, JD.
 

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest to disclose.




 

Ms. Jones brings her 15-year-old daughter, Angela, to the resident clinic. Angela is becoming increasingly anxious, withdrawn, and difficult to manage. As part of the initial interview, the resident, Dr. Sota, asks about the sociocultural background of the family. Ms. Jones is African American and recently began a relationship with a white man. Her daughter, Angela, is biracial; her biological father is white and has moved out of state with little ongoing contact with Angela and her mother.

At interview, Angela expresses a lot of anger at her mother, her biological father, and her new “stepfather.” Ms. Jones says: “I do not want Angela growing up as an ‘angry black woman.’ ” When asked for an explanation, she stated that she doesn’t want her daughter to be stereotyped, to be perceived as an angry black person. “She needs to fit in with our new life. She has lots of opportunities if only she would take them.”

Dr. Sota recognizes that Angela’s struggle, and perhaps also the struggle of Ms. Jones, has a component of internalized racism. How should Dr. Sota proceed? Dr. Sota puts herself in Angela’s shoes: How does Angela see herself? Angela has light brown skin, and Dr. Sota wonders whether Angela wants to present as white or whether asserting her black heritage is important.

The term internalized racism (IR) first appeared in the 1980s. IR was compared to the oppression of black people in the 1800s: “The slavery that captures the mind and incarcerates the motivation, perception, aspiration, and identity in a web of anti-self images, generating a personal and collective self destruction, is more cruel than the shackles on the wrists and ankles.”¹ According to Susanne Lipsky,² IR “in African Americans manifests as internalizing stereotypes, mistrusting the self and other Blacks, and narrows one’s view of authentic Black culture.”

IR refers to the internalization and acceptance of the dominant white culture’s actions and beliefs, while rejecting one’s own cultural background. There is a long history of negative cultural representations of African Americans in popular American culture, and IR has a detrimental impact on the emotional well-being of African Americans.³

IR is associated with poorer metabolic health⁴ and psychological distress, depression and anxiety,^5-8 and decreased self-esteem.⁹ However, protective processes can reduce one’s response to risk and can be developed through the psychotherapeutic relationship.
 

Interventions at an individual, family, or community levels

Angela: Tell me about yourself: What type of person are you? How do you identify? How do you feel about yourself/your appearance/your language?

Tell me about your friends/family? What interests do you have?

“Tell me more” questions can reveal conflicted feelings, etc., even if Angela does not answer. A good therapist can talk about IR; even if Angela does not bring it up, it is important for the therapist to find language suitable for the age of the patient.

Dr. Sota has some luck with Angela, who nods her head but says little. Dr. Sota then turns to Ms. Jones and asks whether she can answer these questions, too, and rephrases the questions for an adult. Interviewing parents in the presence of their children gives Dr. Sota and Angela an idea of what is permitted to talk about in the family.

A therapist can also note other permissions in the family: How do Angela and her mother use language? Do they claim or reject words and phrases such as “angry black woman” and choose, instead, to use language to “fit in” with the dominant white culture?

Dr. Sota notices that Ms. Jones presents herself as keen to fit in with her new future husband’s life. She wants Angela to do likewise. Dr. Sota notices that Angela vacillates between wanting to claim her black identity and having to navigate what that means in this family (not a good thing) – and wanting to assimilate into white culture. Her peers fall into two separate groups: a set of black friends and a set of white friends. Her mother prefers that she see her white friends, mistrusting her black friends.

Dr. Sota’s supervisor suggests that she introduce IR more forcefully because this seems to be a major course of conflict for Angela and encourage a frank discussion between mother and daughter. Dr. Sota starts the next session in the following way: “I noticed last week that the way you each identify yourselves is quite different. Ms. Jones, you want Angela to ‘fit in’ and perhaps just embrace white culture, whereas Angela, perhaps you vacillate between a white identity and a black identity?”

The following questions can help Dr. Sota elicit IR:

• What information about yourself would you like others to know – about your heritage, country of origin, family, class background, and so on?
• What makes you proud about being a member of this group, and what do you love about other members of this group?
• What has been hard about being a member of this group, and what don’t you like about others in this group?
• What were your early life experiences with people in this group? How were you treated? How did you feel about others in your group when you were young?

At a community level, family workshops support positive cultural identities that strengthen family functioning and reducing behavioral health risks. In a study of 575 urban American Indian (AI) families from diverse tribal backgrounds, the AI families who participated in such a workshop had significant increases in their ethnic identity, improved sense of spirituality, and a more positive cultural identification. The workshops provided culturally adaptive parenting interventions.¹⁰

IR is a serious determinant of both physical and mental health. Assessment of IR can be done using rating scales, such as the Nadanolitization Scale¹¹ or the Internalized Racial Oppression Scale.¹² IR also can also be assessed using a more formalized interview guide, such as the DSM-5 Cultural Formulation Interview (CFI).¹³ This 16-question interview guide helps behavioral health providers better understand the way service users and their social networks (e.g., families, friends) understand what is happening to them and why, as well as the barriers they experience, such as racism, discrimination, stigma, and financial stressors.

Individuals’ cultures and experiences have a profound impact on their understanding of their symptoms and their engagement in care. The American Psychiatric Association considers it to be part of mental health providers’ duty of care to engage all individuals in culturally relevant conversations about their past experiences and care expectations. More relevant, I submit that you cannot treat someone without having made this inquiry. A cultural assessment improves understanding but also shifts power relationships between providers and patients. The DSM-5 CFI and training guides are widely available and provide additional information for those who want to improve their cultural literacy.
 

Conclusion

Internalized racism is the component of racism that is the most difficult to discern. Psychiatrists and mental health professionals are uniquely poised to address IR, and any subsequent internal conflict and identity difficulties. Each program, office, and clinic can easily find the resources to do this through the APA. If you would like help providing education, contact me at [email protected].
 

References

1. Akbar N. J Black Studies. 1984. doi: 10.11771002193478401400401.

2. Lipsky S. Internalized Racism. Seattle: Rational Island Publishers, 1987.

3. Williams DR and Mohammed SA. Am Behav Sci. 2013 May 8. doi: 10.1177/00027642134873340.

4. DeLilly CR and Flaskerud JH. Issues Ment Health Nurs. 2012 Nov;33(11):804-11.

5. Molina KM and James D. Group Process Intergroup Relat. 2016 Jul;19(4):439-61.

6. Szymanski D and Obiri O. Couns Psychologist. 2011;39(3):438-62.

7. Carter RT et al. J Multicul Couns Dev. 2017 Oct 5;45(4):232-59.

8. Mouzon DM and McLean JS. Ethn Health. 2017 Feb;22(1):36-48.

9. Szymanski DM and Gupta A. J Couns Psychol. 2009;56(1):110-18.

10. Kulis SS et al. Cultural Diversity and Ethnic Minority Psychol. 2019. doi: 10.1037/cpd000315.

11. Taylor J and Grundy C. “Measuring black internalization of white stereotypes about African Americans: The Nadanolization Scale.” In: Jones RL, ed. Handbook of Tests and Measurements of Black Populations. Hampton, Va.: Cobb & Henry, 1996.

12. Bailey T-K M et al. J Couns Psychol. 2011 Oct;58(4):481-93.

13. American Psychiatric Association. Cultural Formulation Interview. DSM-5. American Psychiatric Association Publishing: Arlington, Va. 2013.



Various aspects about the case described above have been changed to protect the clinician’s and patients’ identities. Thanks to the following individuals for their contributions to this article: Suzanne Huberty, MD, and Shiona Heru, JD.
 

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest to disclose.




 

Ms. Jones brings her 15-year-old daughter, Angela, to the resident clinic. Angela is becoming increasingly anxious, withdrawn, and difficult to manage. As part of the initial interview, the resident, Dr. Sota, asks about the sociocultural background of the family. Ms. Jones is African American and recently began a relationship with a white man. Her daughter, Angela, is biracial; her biological father is white and has moved out of state with little ongoing contact with Angela and her mother.

At interview, Angela expresses a lot of anger at her mother, her biological father, and her new “stepfather.” Ms. Jones says: “I do not want Angela growing up as an ‘angry black woman.’ ” When asked for an explanation, she stated that she doesn’t want her daughter to be stereotyped, to be perceived as an angry black person. “She needs to fit in with our new life. She has lots of opportunities if only she would take them.”

Dr. Sota recognizes that Angela’s struggle, and perhaps also the struggle of Ms. Jones, has a component of internalized racism. How should Dr. Sota proceed? Dr. Sota puts herself in Angela’s shoes: How does Angela see herself? Angela has light brown skin, and Dr. Sota wonders whether Angela wants to present as white or whether asserting her black heritage is important.

The term internalized racism (IR) first appeared in the 1980s. IR was compared to the oppression of black people in the 1800s: “The slavery that captures the mind and incarcerates the motivation, perception, aspiration, and identity in a web of anti-self images, generating a personal and collective self destruction, is more cruel than the shackles on the wrists and ankles.”¹ According to Susanne Lipsky,² IR “in African Americans manifests as internalizing stereotypes, mistrusting the self and other Blacks, and narrows one’s view of authentic Black culture.”

IR refers to the internalization and acceptance of the dominant white culture’s actions and beliefs, while rejecting one’s own cultural background. There is a long history of negative cultural representations of African Americans in popular American culture, and IR has a detrimental impact on the emotional well-being of African Americans.³

IR is associated with poorer metabolic health⁴ and psychological distress, depression and anxiety,^5-8 and decreased self-esteem.⁹ However, protective processes can reduce one’s response to risk and can be developed through the psychotherapeutic relationship.
 

Interventions at an individual, family, or community levels

Angela: Tell me about yourself: What type of person are you? How do you identify? How do you feel about yourself/your appearance/your language?

Tell me about your friends/family? What interests do you have?

“Tell me more” questions can reveal conflicted feelings, etc., even if Angela does not answer. A good therapist can talk about IR; even if Angela does not bring it up, it is important for the therapist to find language suitable for the age of the patient.

Dr. Sota has some luck with Angela, who nods her head but says little. Dr. Sota then turns to Ms. Jones and asks whether she can answer these questions, too, and rephrases the questions for an adult. Interviewing parents in the presence of their children gives Dr. Sota and Angela an idea of what is permitted to talk about in the family.

A therapist can also note other permissions in the family: How do Angela and her mother use language? Do they claim or reject words and phrases such as “angry black woman” and choose, instead, to use language to “fit in” with the dominant white culture?

Dr. Sota notices that Ms. Jones presents herself as keen to fit in with her new future husband’s life. She wants Angela to do likewise. Dr. Sota notices that Angela vacillates between wanting to claim her black identity and having to navigate what that means in this family (not a good thing) – and wanting to assimilate into white culture. Her peers fall into two separate groups: a set of black friends and a set of white friends. Her mother prefers that she see her white friends, mistrusting her black friends.

Dr. Sota’s supervisor suggests that she introduce IR more forcefully because this seems to be a major course of conflict for Angela and encourage a frank discussion between mother and daughter. Dr. Sota starts the next session in the following way: “I noticed last week that the way you each identify yourselves is quite different. Ms. Jones, you want Angela to ‘fit in’ and perhaps just embrace white culture, whereas Angela, perhaps you vacillate between a white identity and a black identity?”

The following questions can help Dr. Sota elicit IR:

• What information about yourself would you like others to know – about your heritage, country of origin, family, class background, and so on?
• What makes you proud about being a member of this group, and what do you love about other members of this group?
• What has been hard about being a member of this group, and what don’t you like about others in this group?
• What were your early life experiences with people in this group? How were you treated? How did you feel about others in your group when you were young?

At a community level, family workshops support positive cultural identities that strengthen family functioning and reducing behavioral health risks. In a study of 575 urban American Indian (AI) families from diverse tribal backgrounds, the AI families who participated in such a workshop had significant increases in their ethnic identity, improved sense of spirituality, and a more positive cultural identification. The workshops provided culturally adaptive parenting interventions.¹⁰

IR is a serious determinant of both physical and mental health. Assessment of IR can be done using rating scales, such as the Nadanolitization Scale¹¹ or the Internalized Racial Oppression Scale.¹² IR also can also be assessed using a more formalized interview guide, such as the DSM-5 Cultural Formulation Interview (CFI).¹³ This 16-question interview guide helps behavioral health providers better understand the way service users and their social networks (e.g., families, friends) understand what is happening to them and why, as well as the barriers they experience, such as racism, discrimination, stigma, and financial stressors.

Individuals’ cultures and experiences have a profound impact on their understanding of their symptoms and their engagement in care. The American Psychiatric Association considers it to be part of mental health providers’ duty of care to engage all individuals in culturally relevant conversations about their past experiences and care expectations. More relevant, I submit that you cannot treat someone without having made this inquiry. A cultural assessment improves understanding but also shifts power relationships between providers and patients. The DSM-5 CFI and training guides are widely available and provide additional information for those who want to improve their cultural literacy.
 

Conclusion

Internalized racism is the component of racism that is the most difficult to discern. Psychiatrists and mental health professionals are uniquely poised to address IR, and any subsequent internal conflict and identity difficulties. Each program, office, and clinic can easily find the resources to do this through the APA. If you would like help providing education, contact me at [email protected].
 

References

1. Akbar N. J Black Studies. 1984. doi: 10.11771002193478401400401.

2. Lipsky S. Internalized Racism. Seattle: Rational Island Publishers, 1987.

3. Williams DR and Mohammed SA. Am Behav Sci. 2013 May 8. doi: 10.1177/00027642134873340.

4. DeLilly CR and Flaskerud JH. Issues Ment Health Nurs. 2012 Nov;33(11):804-11.

5. Molina KM and James D. Group Process Intergroup Relat. 2016 Jul;19(4):439-61.

6. Szymanski D and Obiri O. Couns Psychologist. 2011;39(3):438-62.

7. Carter RT et al. J Multicul Couns Dev. 2017 Oct 5;45(4):232-59.

8. Mouzon DM and McLean JS. Ethn Health. 2017 Feb;22(1):36-48.

9. Szymanski DM and Gupta A. J Couns Psychol. 2009;56(1):110-18.

10. Kulis SS et al. Cultural Diversity and Ethnic Minority Psychol. 2019. doi: 10.1037/cpd000315.

11. Taylor J and Grundy C. “Measuring black internalization of white stereotypes about African Americans: The Nadanolization Scale.” In: Jones RL, ed. Handbook of Tests and Measurements of Black Populations. Hampton, Va.: Cobb & Henry, 1996.

12. Bailey T-K M et al. J Couns Psychol. 2011 Oct;58(4):481-93.

13. American Psychiatric Association. Cultural Formulation Interview. DSM-5. American Psychiatric Association Publishing: Arlington, Va. 2013.



Various aspects about the case described above have been changed to protect the clinician’s and patients’ identities. Thanks to the following individuals for their contributions to this article: Suzanne Huberty, MD, and Shiona Heru, JD.
 

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest to disclose.




 

International medical graduates (IMGs) constitute more than 24% of the total percentage of active physicians, 30% of active psychiatrists, and 33% of psychiatry residents in the United States.¹ IMGs serve in various medical specialties and provide medical care to socioeconomically disadvantaged patients in underserved communities.² Evidence suggests that patient outcomes among elderly patients admitted in U.S. hospitals for those treated by IMGs were on par with outcomes of U.S. graduates. Moreover, patients who were treated by IMGs had a lower mortality rates.³

IMGs trained in the United States make considerable contributions to psychiatry and have been very successful as educators, researchers, and leaders. Over the last 3 decades, for example, three American Psychiatric Association (APA) presidents and one past president of the American Academy of Child and Adolescent Psychiatry were IMGs. Many of them also hold department chair positions at many academic institutions.^4,5

In short, IMGs are an important part of the U.S. health care system – particularly in psychiatry.

In addition to participating in psychiatry residency programs, IMG physicians are heavily represented in subspecialties, including geriatric psychiatry (45%), addiction psychiatry (42%), child and adolescent psychiatry (36%), psychosomatic medicine (32%), and forensic psychiatry (25%).⁶ IMG trainees face multiple challenges that begin as they transition to psychiatry residency in the United States, including understanding the American health care system, electronic medical records and documentation, and evidence-based medicine. In addition, they need to adapt to cultural changes, and work on language barriers, communication skills, and social isolation.^7,8 Training programs account for these challenges and proactively take essential steps to facilitate the transition of IMGs into the U.S. system.^9,10

As training programs prepare for the new academic year starting from July 2020 and continue to provide educational experiences to current trainees, the COVID-19 pandemic has brought additional challenges for the training programs. The gravity of the novel coronavirus pandemic continues to deepen, causing immense fear and uncertainty globally. An APA poll of more than 1,000 adults conducted early in the pandemic showed that about 40% of Americans were anxious about becoming seriously ill or dying with COVID-19. Nearly half of the respondents (48%) were anxious about the possibility of getting COVID-19, and even more (62%) were anxious about the possibility of their loved ones getting infected by this virus. Also, one-third of Americans reported a serious impact on their mental health.

Furthermore, the ailing economy and increasing unemployment are raising financial concerns for individuals and families. This pandemic also has had an impact on our patients’ sleep hygiene, relationships with their loved ones, and consumption of alcohol or other drugs/substances.¹¹ Deteriorating mental health raises concerns about increased suicide risk as a secondary consequence.¹²

Physicians and other frontline teams who are taking care of these patients and their families continue to provide unexcelled, compassionate care in these unprecedented times. Selfless care continues despite awareness of the high probability of getting exposed to the virus and spreading it further to family members. Physicians involved in direct patient care for COVID-19 patients are at high risk for demoralization, burnout, depression, and anxiety.¹³

Struggles experienced by IMGs

On the personal front, IMGs often struggle with multiple stressors, such as lack of social support, ethnic-minority prejudice, and the need to understand financial structures such as mortgages in the new countries even after extended periods of residence.¹⁴ This virus has killed many health care professionals, including physicians around the world. There was a report of suicide by an emergency medicine physician who was treating patients with COVID-19 and ended up contracting the virus. That news was devastating and overwhelming for everyone, especially health care clinicians. It also adds to the stress and worries of IMGs who are still on nonimmigrant visas.

Bigger concerns exist if there is a demise of a nonimmigrant IMG and the implications of that loss for dependent families – who might face deportation. Even for those who were recently granted permanent residency status, worries about limited support systems and financial hardships to their families can be stressors.

Also, a large number of IMGs represent the geographical area where the pandemic began. Fortunately, the World Health Organization has taken a firm stance against possible discrimination by calling for global solidarity in these times. Furthermore, the WHO has emphasized the importance of referring to the disease caused by SARS-CoV-2 as “COVID-19” only – and not by the name of a particular country or city.¹⁵ Despite those official positions, people continue to express racially discriminatory opinions related to the virus, and those comments are not only disturbing to IMGs, they also are demoralizing.
 

Travel restrictions

In addition to the worries that IMGs might have about their own health and that of their families residing with them, the well-being of their extended families, including their aging parents back in their countries of origin, is unsettling as well. It is even more unnerving during the pandemic because the Centers for Disease Control and Prevention and the State Department advised avoiding all international travel at this time. Under these circumstances, IMGs are concerned about travel to their countries of origin in the event of a family emergency and the quarantine protocols in place, at both the country of origin and at residences.

Immigration issues

The U.S. administration temporarily suspended all immigration for 60 days, starting from April 2020. Recently, an executive order was signed suspending entry in the country on several visas, including the J-1 and the H1-B. Those are two categories that allow physicians to train and work in the United States.

IMGs in the United States reside and practice here under different types of immigrant and nonimmigrant visas (J-1, H1-B). This year, the Match results coincided with the timeline of those new immigration restrictions. Many IMGs are currently in the process of renewing their H1-B visas. They are worried because their visas will expire in the coming months. During the pandemic, U.S. Citizenship and Immigration Services suspended routine visa services and premium processing for visa renewals. This halt led to a delay in visa processing for graduating residents in June and practicing physicians seeking visa renewal. Those delays add to personal stress, and furthermore, distract these immigrant physicians from fighting this pandemic.

Another complication is that rules for J-1 visa holders have changed so that trainees must return to their countries of origin for at least 2 years after completing their training. If they decide to continue practicing medicine in the United States, they need a specific type of J-1 waiver and must gain a pathway to be a lawful permanent resident (Green Card). Many IMGs who are on waiver positions might not be able to treat patients ailing from COVID-19 to the full extent because waivers restrict them to practicing only in certain identified health systems.

IMGs who are coming from a country such India have to wait for more than 11 years after completing their accredited training to get permanent residency because of backlog for the permanent residency process.¹⁶ While waiting for a Green Card, they must continue to work on an H1-B visa, which requires periodic renewal.
 

Potential impact on training

Non-U.S. citizen IMGs accounted for 13% of the total of first-year positions in the 2020 Match. They will start medical training in residency programs in the United States in the coming months. The numbers for psychiatry residency matches are higher; about 16% of total first-year positions are filled by non-U.S. IMGs.¹⁷ At this time, when they should be celebrating their successful Match after many years of hard work and persistence, there is increased anxiety. They wonder whether they will be able to enter the United States to begin their training program on time. Their concerns are multifold, but the main concern is related to uncertainties around getting visas on time. With the recent executive order in place, physicians only working actively with COVID-19 patients will be able to enter the country on visas. As mental health concerns continue to rise during these times, incoming residents might not be able to start training if they are out of the country.

Furthermore, because of travel/air restrictions, there are worries about whether physicians will be able to get flights to the United States, given the lockdown in many countries around the world. Conversely, IMGs who will be graduating from residency and fellowship programs this summer and have accepted new positions also are dealing with similar uncertainty. Their new jobs will require visa processing, and the current scenario provides limited insight, so far, about whether they will be able to start their respective jobs or whether they will have to return to their home countries until their visa processing is completed.

The American Medical Association has advised the Secretary of State and acting Secretary of Homeland Security to expedite physician workforce expansion in an effort to meet the growing need for health care services during this pandemic.¹⁸ It is encouraging that, recently, the State Department declared that visa processing will continue for medical professionals and that cases would be expedited for those who meet the criteria. However, the requirement for in-person interviews remains for individuals who are seeking a U.S. visa outside the country. In the current lockdown situation in various countries, temporarily suspending the need for in-person interviews, such as those required for H-2 temporary work visas, would be helpful.

As residency programs are trying their best to continue to provide educational experiences to trainees during this phase, if psychiatry residents are placed on quarantine because of either getting exposed or contracting the illness, there is a possibility that they might need to extend their training. This would bring another challenge for IMGs, requiring them to extend their visas to complete their training. Future J-1 waiver jobs could be compromised.
 

Investment in physician wellness critical

Psychiatrists, along with other health care workers, are front-line soldiers in the fight against COVID-19. All physicians are at high risk for demoralization, burnout, depression, anxiety, and suicide. It is of utmost importance that we invest immediately in physicians’ wellness. As noted, significant numbers of psychiatrists are IMGs who are dealing with additional challenges while responding to the pandemic. There are certain challenges for IMGs, such as the well-being of their extended families in other countries, and travel bans put in place because of the pandemic. Those issues are not easy to resolve. However, addressing visa issues and providing support to their families in the event that something happens to physicians during the pandemic would be reassuring and would help alleviate additional stress. Those kinds of actions also would allow immigrant physicians to focus on clinical work and to improve their overall well-being. Given the health risks and numerous other insecurities that go along with living amid a pandemic, IMGs should not have the additional pressure of visa uncertainty.

Public health crises such as COVID-19 are associated with increased rates of anxiety,¹⁹ depression,²⁰ illicit substance use,²¹ and an increased rate of suicide.²² Patients with serious mental illness might be among the hardest hit both physically and mentally during the pandemic.²³ Even in the absence of a pandemic, there is already a shortage of psychiatrists at the national level, and it is expected that this shortage will grow in the future. Rural and underserved areas are expected to experience the physician deficit more acutely.²⁴

The pandemic is likely to resolve gradually and unpredictably – and might recur along the way over the next 1-2 years. However, the psychiatrist shortage will escalate more, as the mental health needs in the United States increase further in coming months. We need psychiatrists now more than ever, and it will be crucial that prospective residents, graduating residents, and fellows are able to come on board to join the American health care system promptly. In addition to national-level interventions, residency programs, potential employers, and communities must be aware of and do whatever they can to address the challenges faced by IMGs during these times.
 

Dr. Raman Baweja is affiliated with the department of psychiatry and behavioral health at Penn State University, Hershey. He has no conflicts of interest. Dr. Verma is affiliated with Rogers Behavioral Health in Kenosha County, Wis., and the department of psychiatry and behavioral health at Rosalind Franklin University of Medicine and Science in North Chicago. She has no conflicts of interest. Dr. Ritika Baweja is affiliated with the department of psychiatry and behavioral health at Penn State. Dr. Ritika Baweja is the spouse of Dr. Raman Baweja. Dr. Adam is affiliated with the department of psychiatry at the University of Missouri, Columbia.

References

1. American Psychiatric Association. Navigating psychiatry residency in the United States. A Guide for IMG Physicians.

2. Berg S. 5 IMG physicians who speak up for patients and fellow doctors. American Medical Association. 2019 Oct 22.

3. Tsugawa Y et al. BMJ. 2017 Feb 3;256. doi: 10.1136/bmj.j273.

4. Gogineni RR et al. Child Adolesc Psychiatr Clin N Am. 2010 Oct 1;19(4):833-53.

5. Majeed MH et al. Academic Psychiatry. 2017 Dec 1;41(6):849-51.

6. Brotherton SE and Etzel SI. JAMA. 2018 Sep 11;320(10):1051-70.

7. Sockalingam S et al. Acad Psychiatry. 2012 Jul 1;36(4):277-81.

8. Singareddy R et al. Acad Psychiatry. 2008 Jul-Aug;32(4):343-4.

9. Kramer MN. Acad Psychiatry. 2005 Jul-Aug;29(3):322-4.

10. Rao NR and Kotapati VP. Pathways for success in academic medicine for an international medical graduate: Challenges and opportunities. In “Roberts Academic Medicine Handbook” 2020. Springer:163-70.

11. American Psychiatric Association. New poll: COVID-19 impacting mental well-being: Americans feeling anxious, especially for loved ones; older adults are less anxious. 2020 Mar 25.

12. Reger MA et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

13. Lai J et al. JAMA Netw Open. 2020 Mar 23;3(3):e203976-e203976. doi: 10.1001/jamanetworkopen.2020.3976.

14. Kalra G et al. Acad Psychiatry. 2012 Jul;36(4):323-9.

15. WHO best practices for the naming of new human infectious diseases. World Health Organization. 2015.

16. U.S. Department of State. Bureau of Consular Affairs. Visa Bulletin for March 2020.

17. National Resident Matching Program® (NRMP®). Thousands of medical students and graduates celebrate NRMP Match results.

18. American Medical Association. AMA: U.S. should open visas to international physicians amid COVID-19. AMA press release. 2020 Mar 25.

19. McKay D et al. J Anxiety Disord. 2020 Jun;73:02233. doi: 10.1016/j.janxdis.2020.102233.

20. Tang W et al. J Affect Disord. 2020 May 13;274:1-7.

21. Collins F et al. NIH Director’s Blog. NIH.gov. 2020 Apr 21.

22. Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

23. Druss BG. JAMA Psychiatry. 2020 Apr 3. doi: 10.1001/jamapsychiatry.2020.0894.

24. American Association of Medical Colleges. “The complexities of physician supply and demand: Projections from 2018-2033.” 2020 Jun.

International medical graduates (IMGs) constitute more than 24% of the total percentage of active physicians, 30% of active psychiatrists, and 33% of psychiatry residents in the United States.¹ IMGs serve in various medical specialties and provide medical care to socioeconomically disadvantaged patients in underserved communities.² Evidence suggests that patient outcomes among elderly patients admitted in U.S. hospitals for those treated by IMGs were on par with outcomes of U.S. graduates. Moreover, patients who were treated by IMGs had a lower mortality rates.³

IMGs trained in the United States make considerable contributions to psychiatry and have been very successful as educators, researchers, and leaders. Over the last 3 decades, for example, three American Psychiatric Association (APA) presidents and one past president of the American Academy of Child and Adolescent Psychiatry were IMGs. Many of them also hold department chair positions at many academic institutions.^4,5

In short, IMGs are an important part of the U.S. health care system – particularly in psychiatry.

In addition to participating in psychiatry residency programs, IMG physicians are heavily represented in subspecialties, including geriatric psychiatry (45%), addiction psychiatry (42%), child and adolescent psychiatry (36%), psychosomatic medicine (32%), and forensic psychiatry (25%).⁶ IMG trainees face multiple challenges that begin as they transition to psychiatry residency in the United States, including understanding the American health care system, electronic medical records and documentation, and evidence-based medicine. In addition, they need to adapt to cultural changes, and work on language barriers, communication skills, and social isolation.^7,8 Training programs account for these challenges and proactively take essential steps to facilitate the transition of IMGs into the U.S. system.^9,10

As training programs prepare for the new academic year starting from July 2020 and continue to provide educational experiences to current trainees, the COVID-19 pandemic has brought additional challenges for the training programs. The gravity of the novel coronavirus pandemic continues to deepen, causing immense fear and uncertainty globally. An APA poll of more than 1,000 adults conducted early in the pandemic showed that about 40% of Americans were anxious about becoming seriously ill or dying with COVID-19. Nearly half of the respondents (48%) were anxious about the possibility of getting COVID-19, and even more (62%) were anxious about the possibility of their loved ones getting infected by this virus. Also, one-third of Americans reported a serious impact on their mental health.

Furthermore, the ailing economy and increasing unemployment are raising financial concerns for individuals and families. This pandemic also has had an impact on our patients’ sleep hygiene, relationships with their loved ones, and consumption of alcohol or other drugs/substances.¹¹ Deteriorating mental health raises concerns about increased suicide risk as a secondary consequence.¹²

Physicians and other frontline teams who are taking care of these patients and their families continue to provide unexcelled, compassionate care in these unprecedented times. Selfless care continues despite awareness of the high probability of getting exposed to the virus and spreading it further to family members. Physicians involved in direct patient care for COVID-19 patients are at high risk for demoralization, burnout, depression, and anxiety.¹³

Struggles experienced by IMGs

On the personal front, IMGs often struggle with multiple stressors, such as lack of social support, ethnic-minority prejudice, and the need to understand financial structures such as mortgages in the new countries even after extended periods of residence.¹⁴ This virus has killed many health care professionals, including physicians around the world. There was a report of suicide by an emergency medicine physician who was treating patients with COVID-19 and ended up contracting the virus. That news was devastating and overwhelming for everyone, especially health care clinicians. It also adds to the stress and worries of IMGs who are still on nonimmigrant visas.

Bigger concerns exist if there is a demise of a nonimmigrant IMG and the implications of that loss for dependent families – who might face deportation. Even for those who were recently granted permanent residency status, worries about limited support systems and financial hardships to their families can be stressors.

Also, a large number of IMGs represent the geographical area where the pandemic began. Fortunately, the World Health Organization has taken a firm stance against possible discrimination by calling for global solidarity in these times. Furthermore, the WHO has emphasized the importance of referring to the disease caused by SARS-CoV-2 as “COVID-19” only – and not by the name of a particular country or city.¹⁵ Despite those official positions, people continue to express racially discriminatory opinions related to the virus, and those comments are not only disturbing to IMGs, they also are demoralizing.
 

Travel restrictions

In addition to the worries that IMGs might have about their own health and that of their families residing with them, the well-being of their extended families, including their aging parents back in their countries of origin, is unsettling as well. It is even more unnerving during the pandemic because the Centers for Disease Control and Prevention and the State Department advised avoiding all international travel at this time. Under these circumstances, IMGs are concerned about travel to their countries of origin in the event of a family emergency and the quarantine protocols in place, at both the country of origin and at residences.

Immigration issues

The U.S. administration temporarily suspended all immigration for 60 days, starting from April 2020. Recently, an executive order was signed suspending entry in the country on several visas, including the J-1 and the H1-B. Those are two categories that allow physicians to train and work in the United States.

IMGs in the United States reside and practice here under different types of immigrant and nonimmigrant visas (J-1, H1-B). This year, the Match results coincided with the timeline of those new immigration restrictions. Many IMGs are currently in the process of renewing their H1-B visas. They are worried because their visas will expire in the coming months. During the pandemic, U.S. Citizenship and Immigration Services suspended routine visa services and premium processing for visa renewals. This halt led to a delay in visa processing for graduating residents in June and practicing physicians seeking visa renewal. Those delays add to personal stress, and furthermore, distract these immigrant physicians from fighting this pandemic.

Another complication is that rules for J-1 visa holders have changed so that trainees must return to their countries of origin for at least 2 years after completing their training. If they decide to continue practicing medicine in the United States, they need a specific type of J-1 waiver and must gain a pathway to be a lawful permanent resident (Green Card). Many IMGs who are on waiver positions might not be able to treat patients ailing from COVID-19 to the full extent because waivers restrict them to practicing only in certain identified health systems.

IMGs who are coming from a country such India have to wait for more than 11 years after completing their accredited training to get permanent residency because of backlog for the permanent residency process.¹⁶ While waiting for a Green Card, they must continue to work on an H1-B visa, which requires periodic renewal.
 

Potential impact on training

Non-U.S. citizen IMGs accounted for 13% of the total of first-year positions in the 2020 Match. They will start medical training in residency programs in the United States in the coming months. The numbers for psychiatry residency matches are higher; about 16% of total first-year positions are filled by non-U.S. IMGs.¹⁷ At this time, when they should be celebrating their successful Match after many years of hard work and persistence, there is increased anxiety. They wonder whether they will be able to enter the United States to begin their training program on time. Their concerns are multifold, but the main concern is related to uncertainties around getting visas on time. With the recent executive order in place, physicians only working actively with COVID-19 patients will be able to enter the country on visas. As mental health concerns continue to rise during these times, incoming residents might not be able to start training if they are out of the country.

Furthermore, because of travel/air restrictions, there are worries about whether physicians will be able to get flights to the United States, given the lockdown in many countries around the world. Conversely, IMGs who will be graduating from residency and fellowship programs this summer and have accepted new positions also are dealing with similar uncertainty. Their new jobs will require visa processing, and the current scenario provides limited insight, so far, about whether they will be able to start their respective jobs or whether they will have to return to their home countries until their visa processing is completed.

The American Medical Association has advised the Secretary of State and acting Secretary of Homeland Security to expedite physician workforce expansion in an effort to meet the growing need for health care services during this pandemic.¹⁸ It is encouraging that, recently, the State Department declared that visa processing will continue for medical professionals and that cases would be expedited for those who meet the criteria. However, the requirement for in-person interviews remains for individuals who are seeking a U.S. visa outside the country. In the current lockdown situation in various countries, temporarily suspending the need for in-person interviews, such as those required for H-2 temporary work visas, would be helpful.

As residency programs are trying their best to continue to provide educational experiences to trainees during this phase, if psychiatry residents are placed on quarantine because of either getting exposed or contracting the illness, there is a possibility that they might need to extend their training. This would bring another challenge for IMGs, requiring them to extend their visas to complete their training. Future J-1 waiver jobs could be compromised.
 

Investment in physician wellness critical

Psychiatrists, along with other health care workers, are front-line soldiers in the fight against COVID-19. All physicians are at high risk for demoralization, burnout, depression, anxiety, and suicide. It is of utmost importance that we invest immediately in physicians’ wellness. As noted, significant numbers of psychiatrists are IMGs who are dealing with additional challenges while responding to the pandemic. There are certain challenges for IMGs, such as the well-being of their extended families in other countries, and travel bans put in place because of the pandemic. Those issues are not easy to resolve. However, addressing visa issues and providing support to their families in the event that something happens to physicians during the pandemic would be reassuring and would help alleviate additional stress. Those kinds of actions also would allow immigrant physicians to focus on clinical work and to improve their overall well-being. Given the health risks and numerous other insecurities that go along with living amid a pandemic, IMGs should not have the additional pressure of visa uncertainty.

Public health crises such as COVID-19 are associated with increased rates of anxiety,¹⁹ depression,²⁰ illicit substance use,²¹ and an increased rate of suicide.²² Patients with serious mental illness might be among the hardest hit both physically and mentally during the pandemic.²³ Even in the absence of a pandemic, there is already a shortage of psychiatrists at the national level, and it is expected that this shortage will grow in the future. Rural and underserved areas are expected to experience the physician deficit more acutely.²⁴

The pandemic is likely to resolve gradually and unpredictably – and might recur along the way over the next 1-2 years. However, the psychiatrist shortage will escalate more, as the mental health needs in the United States increase further in coming months. We need psychiatrists now more than ever, and it will be crucial that prospective residents, graduating residents, and fellows are able to come on board to join the American health care system promptly. In addition to national-level interventions, residency programs, potential employers, and communities must be aware of and do whatever they can to address the challenges faced by IMGs during these times.
 

Dr. Raman Baweja is affiliated with the department of psychiatry and behavioral health at Penn State University, Hershey. He has no conflicts of interest. Dr. Verma is affiliated with Rogers Behavioral Health in Kenosha County, Wis., and the department of psychiatry and behavioral health at Rosalind Franklin University of Medicine and Science in North Chicago. She has no conflicts of interest. Dr. Ritika Baweja is affiliated with the department of psychiatry and behavioral health at Penn State. Dr. Ritika Baweja is the spouse of Dr. Raman Baweja. Dr. Adam is affiliated with the department of psychiatry at the University of Missouri, Columbia.

References

1. American Psychiatric Association. Navigating psychiatry residency in the United States. A Guide for IMG Physicians.

2. Berg S. 5 IMG physicians who speak up for patients and fellow doctors. American Medical Association. 2019 Oct 22.

3. Tsugawa Y et al. BMJ. 2017 Feb 3;256. doi: 10.1136/bmj.j273.

4. Gogineni RR et al. Child Adolesc Psychiatr Clin N Am. 2010 Oct 1;19(4):833-53.

5. Majeed MH et al. Academic Psychiatry. 2017 Dec 1;41(6):849-51.

6. Brotherton SE and Etzel SI. JAMA. 2018 Sep 11;320(10):1051-70.

7. Sockalingam S et al. Acad Psychiatry. 2012 Jul 1;36(4):277-81.

8. Singareddy R et al. Acad Psychiatry. 2008 Jul-Aug;32(4):343-4.

9. Kramer MN. Acad Psychiatry. 2005 Jul-Aug;29(3):322-4.

10. Rao NR and Kotapati VP. Pathways for success in academic medicine for an international medical graduate: Challenges and opportunities. In “Roberts Academic Medicine Handbook” 2020. Springer:163-70.

11. American Psychiatric Association. New poll: COVID-19 impacting mental well-being: Americans feeling anxious, especially for loved ones; older adults are less anxious. 2020 Mar 25.

12. Reger MA et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

13. Lai J et al. JAMA Netw Open. 2020 Mar 23;3(3):e203976-e203976. doi: 10.1001/jamanetworkopen.2020.3976.

14. Kalra G et al. Acad Psychiatry. 2012 Jul;36(4):323-9.

15. WHO best practices for the naming of new human infectious diseases. World Health Organization. 2015.

16. U.S. Department of State. Bureau of Consular Affairs. Visa Bulletin for March 2020.

17. National Resident Matching Program® (NRMP®). Thousands of medical students and graduates celebrate NRMP Match results.

18. American Medical Association. AMA: U.S. should open visas to international physicians amid COVID-19. AMA press release. 2020 Mar 25.

19. McKay D et al. J Anxiety Disord. 2020 Jun;73:02233. doi: 10.1016/j.janxdis.2020.102233.

20. Tang W et al. J Affect Disord. 2020 May 13;274:1-7.

21. Collins F et al. NIH Director’s Blog. NIH.gov. 2020 Apr 21.

22. Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

23. Druss BG. JAMA Psychiatry. 2020 Apr 3. doi: 10.1001/jamapsychiatry.2020.0894.

24. American Association of Medical Colleges. “The complexities of physician supply and demand: Projections from 2018-2033.” 2020 Jun.

International medical graduates (IMGs) constitute more than 24% of the total percentage of active physicians, 30% of active psychiatrists, and 33% of psychiatry residents in the United States.¹ IMGs serve in various medical specialties and provide medical care to socioeconomically disadvantaged patients in underserved communities.² Evidence suggests that patient outcomes among elderly patients admitted in U.S. hospitals for those treated by IMGs were on par with outcomes of U.S. graduates. Moreover, patients who were treated by IMGs had a lower mortality rates.³

IMGs trained in the United States make considerable contributions to psychiatry and have been very successful as educators, researchers, and leaders. Over the last 3 decades, for example, three American Psychiatric Association (APA) presidents and one past president of the American Academy of Child and Adolescent Psychiatry were IMGs. Many of them also hold department chair positions at many academic institutions.^4,5

In short, IMGs are an important part of the U.S. health care system – particularly in psychiatry.

In addition to participating in psychiatry residency programs, IMG physicians are heavily represented in subspecialties, including geriatric psychiatry (45%), addiction psychiatry (42%), child and adolescent psychiatry (36%), psychosomatic medicine (32%), and forensic psychiatry (25%).⁶ IMG trainees face multiple challenges that begin as they transition to psychiatry residency in the United States, including understanding the American health care system, electronic medical records and documentation, and evidence-based medicine. In addition, they need to adapt to cultural changes, and work on language barriers, communication skills, and social isolation.^7,8 Training programs account for these challenges and proactively take essential steps to facilitate the transition of IMGs into the U.S. system.^9,10

As training programs prepare for the new academic year starting from July 2020 and continue to provide educational experiences to current trainees, the COVID-19 pandemic has brought additional challenges for the training programs. The gravity of the novel coronavirus pandemic continues to deepen, causing immense fear and uncertainty globally. An APA poll of more than 1,000 adults conducted early in the pandemic showed that about 40% of Americans were anxious about becoming seriously ill or dying with COVID-19. Nearly half of the respondents (48%) were anxious about the possibility of getting COVID-19, and even more (62%) were anxious about the possibility of their loved ones getting infected by this virus. Also, one-third of Americans reported a serious impact on their mental health.

Furthermore, the ailing economy and increasing unemployment are raising financial concerns for individuals and families. This pandemic also has had an impact on our patients’ sleep hygiene, relationships with their loved ones, and consumption of alcohol or other drugs/substances.¹¹ Deteriorating mental health raises concerns about increased suicide risk as a secondary consequence.¹²

Physicians and other frontline teams who are taking care of these patients and their families continue to provide unexcelled, compassionate care in these unprecedented times. Selfless care continues despite awareness of the high probability of getting exposed to the virus and spreading it further to family members. Physicians involved in direct patient care for COVID-19 patients are at high risk for demoralization, burnout, depression, and anxiety.¹³

Struggles experienced by IMGs

On the personal front, IMGs often struggle with multiple stressors, such as lack of social support, ethnic-minority prejudice, and the need to understand financial structures such as mortgages in the new countries even after extended periods of residence.¹⁴ This virus has killed many health care professionals, including physicians around the world. There was a report of suicide by an emergency medicine physician who was treating patients with COVID-19 and ended up contracting the virus. That news was devastating and overwhelming for everyone, especially health care clinicians. It also adds to the stress and worries of IMGs who are still on nonimmigrant visas.

Bigger concerns exist if there is a demise of a nonimmigrant IMG and the implications of that loss for dependent families – who might face deportation. Even for those who were recently granted permanent residency status, worries about limited support systems and financial hardships to their families can be stressors.

Also, a large number of IMGs represent the geographical area where the pandemic began. Fortunately, the World Health Organization has taken a firm stance against possible discrimination by calling for global solidarity in these times. Furthermore, the WHO has emphasized the importance of referring to the disease caused by SARS-CoV-2 as “COVID-19” only – and not by the name of a particular country or city.¹⁵ Despite those official positions, people continue to express racially discriminatory opinions related to the virus, and those comments are not only disturbing to IMGs, they also are demoralizing.
 

Travel restrictions

In addition to the worries that IMGs might have about their own health and that of their families residing with them, the well-being of their extended families, including their aging parents back in their countries of origin, is unsettling as well. It is even more unnerving during the pandemic because the Centers for Disease Control and Prevention and the State Department advised avoiding all international travel at this time. Under these circumstances, IMGs are concerned about travel to their countries of origin in the event of a family emergency and the quarantine protocols in place, at both the country of origin and at residences.

Immigration issues

The U.S. administration temporarily suspended all immigration for 60 days, starting from April 2020. Recently, an executive order was signed suspending entry in the country on several visas, including the J-1 and the H1-B. Those are two categories that allow physicians to train and work in the United States.

IMGs in the United States reside and practice here under different types of immigrant and nonimmigrant visas (J-1, H1-B). This year, the Match results coincided with the timeline of those new immigration restrictions. Many IMGs are currently in the process of renewing their H1-B visas. They are worried because their visas will expire in the coming months. During the pandemic, U.S. Citizenship and Immigration Services suspended routine visa services and premium processing for visa renewals. This halt led to a delay in visa processing for graduating residents in June and practicing physicians seeking visa renewal. Those delays add to personal stress, and furthermore, distract these immigrant physicians from fighting this pandemic.

Another complication is that rules for J-1 visa holders have changed so that trainees must return to their countries of origin for at least 2 years after completing their training. If they decide to continue practicing medicine in the United States, they need a specific type of J-1 waiver and must gain a pathway to be a lawful permanent resident (Green Card). Many IMGs who are on waiver positions might not be able to treat patients ailing from COVID-19 to the full extent because waivers restrict them to practicing only in certain identified health systems.

IMGs who are coming from a country such India have to wait for more than 11 years after completing their accredited training to get permanent residency because of backlog for the permanent residency process.¹⁶ While waiting for a Green Card, they must continue to work on an H1-B visa, which requires periodic renewal.
 

Potential impact on training

Non-U.S. citizen IMGs accounted for 13% of the total of first-year positions in the 2020 Match. They will start medical training in residency programs in the United States in the coming months. The numbers for psychiatry residency matches are higher; about 16% of total first-year positions are filled by non-U.S. IMGs.¹⁷ At this time, when they should be celebrating their successful Match after many years of hard work and persistence, there is increased anxiety. They wonder whether they will be able to enter the United States to begin their training program on time. Their concerns are multifold, but the main concern is related to uncertainties around getting visas on time. With the recent executive order in place, physicians only working actively with COVID-19 patients will be able to enter the country on visas. As mental health concerns continue to rise during these times, incoming residents might not be able to start training if they are out of the country.

Furthermore, because of travel/air restrictions, there are worries about whether physicians will be able to get flights to the United States, given the lockdown in many countries around the world. Conversely, IMGs who will be graduating from residency and fellowship programs this summer and have accepted new positions also are dealing with similar uncertainty. Their new jobs will require visa processing, and the current scenario provides limited insight, so far, about whether they will be able to start their respective jobs or whether they will have to return to their home countries until their visa processing is completed.

The American Medical Association has advised the Secretary of State and acting Secretary of Homeland Security to expedite physician workforce expansion in an effort to meet the growing need for health care services during this pandemic.¹⁸ It is encouraging that, recently, the State Department declared that visa processing will continue for medical professionals and that cases would be expedited for those who meet the criteria. However, the requirement for in-person interviews remains for individuals who are seeking a U.S. visa outside the country. In the current lockdown situation in various countries, temporarily suspending the need for in-person interviews, such as those required for H-2 temporary work visas, would be helpful.

As residency programs are trying their best to continue to provide educational experiences to trainees during this phase, if psychiatry residents are placed on quarantine because of either getting exposed or contracting the illness, there is a possibility that they might need to extend their training. This would bring another challenge for IMGs, requiring them to extend their visas to complete their training. Future J-1 waiver jobs could be compromised.
 

Investment in physician wellness critical

Psychiatrists, along with other health care workers, are front-line soldiers in the fight against COVID-19. All physicians are at high risk for demoralization, burnout, depression, anxiety, and suicide. It is of utmost importance that we invest immediately in physicians’ wellness. As noted, significant numbers of psychiatrists are IMGs who are dealing with additional challenges while responding to the pandemic. There are certain challenges for IMGs, such as the well-being of their extended families in other countries, and travel bans put in place because of the pandemic. Those issues are not easy to resolve. However, addressing visa issues and providing support to their families in the event that something happens to physicians during the pandemic would be reassuring and would help alleviate additional stress. Those kinds of actions also would allow immigrant physicians to focus on clinical work and to improve their overall well-being. Given the health risks and numerous other insecurities that go along with living amid a pandemic, IMGs should not have the additional pressure of visa uncertainty.

Public health crises such as COVID-19 are associated with increased rates of anxiety,¹⁹ depression,²⁰ illicit substance use,²¹ and an increased rate of suicide.²² Patients with serious mental illness might be among the hardest hit both physically and mentally during the pandemic.²³ Even in the absence of a pandemic, there is already a shortage of psychiatrists at the national level, and it is expected that this shortage will grow in the future. Rural and underserved areas are expected to experience the physician deficit more acutely.²⁴

The pandemic is likely to resolve gradually and unpredictably – and might recur along the way over the next 1-2 years. However, the psychiatrist shortage will escalate more, as the mental health needs in the United States increase further in coming months. We need psychiatrists now more than ever, and it will be crucial that prospective residents, graduating residents, and fellows are able to come on board to join the American health care system promptly. In addition to national-level interventions, residency programs, potential employers, and communities must be aware of and do whatever they can to address the challenges faced by IMGs during these times.
 

Dr. Raman Baweja is affiliated with the department of psychiatry and behavioral health at Penn State University, Hershey. He has no conflicts of interest. Dr. Verma is affiliated with Rogers Behavioral Health in Kenosha County, Wis., and the department of psychiatry and behavioral health at Rosalind Franklin University of Medicine and Science in North Chicago. She has no conflicts of interest. Dr. Ritika Baweja is affiliated with the department of psychiatry and behavioral health at Penn State. Dr. Ritika Baweja is the spouse of Dr. Raman Baweja. Dr. Adam is affiliated with the department of psychiatry at the University of Missouri, Columbia.

References

1. American Psychiatric Association. Navigating psychiatry residency in the United States. A Guide for IMG Physicians.

2. Berg S. 5 IMG physicians who speak up for patients and fellow doctors. American Medical Association. 2019 Oct 22.

3. Tsugawa Y et al. BMJ. 2017 Feb 3;256. doi: 10.1136/bmj.j273.

4. Gogineni RR et al. Child Adolesc Psychiatr Clin N Am. 2010 Oct 1;19(4):833-53.

5. Majeed MH et al. Academic Psychiatry. 2017 Dec 1;41(6):849-51.

6. Brotherton SE and Etzel SI. JAMA. 2018 Sep 11;320(10):1051-70.

7. Sockalingam S et al. Acad Psychiatry. 2012 Jul 1;36(4):277-81.

8. Singareddy R et al. Acad Psychiatry. 2008 Jul-Aug;32(4):343-4.

9. Kramer MN. Acad Psychiatry. 2005 Jul-Aug;29(3):322-4.

10. Rao NR and Kotapati VP. Pathways for success in academic medicine for an international medical graduate: Challenges and opportunities. In “Roberts Academic Medicine Handbook” 2020. Springer:163-70.

11. American Psychiatric Association. New poll: COVID-19 impacting mental well-being: Americans feeling anxious, especially for loved ones; older adults are less anxious. 2020 Mar 25.

12. Reger MA et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

13. Lai J et al. JAMA Netw Open. 2020 Mar 23;3(3):e203976-e203976. doi: 10.1001/jamanetworkopen.2020.3976.

14. Kalra G et al. Acad Psychiatry. 2012 Jul;36(4):323-9.

15. WHO best practices for the naming of new human infectious diseases. World Health Organization. 2015.

16. U.S. Department of State. Bureau of Consular Affairs. Visa Bulletin for March 2020.

17. National Resident Matching Program® (NRMP®). Thousands of medical students and graduates celebrate NRMP Match results.

18. American Medical Association. AMA: U.S. should open visas to international physicians amid COVID-19. AMA press release. 2020 Mar 25.

19. McKay D et al. J Anxiety Disord. 2020 Jun;73:02233. doi: 10.1016/j.janxdis.2020.102233.

20. Tang W et al. J Affect Disord. 2020 May 13;274:1-7.

21. Collins F et al. NIH Director’s Blog. NIH.gov. 2020 Apr 21.

22. Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.1001/jamapsychiatry.2020.1060.

23. Druss BG. JAMA Psychiatry. 2020 Apr 3. doi: 10.1001/jamapsychiatry.2020.0894.

24. American Association of Medical Colleges. “The complexities of physician supply and demand: Projections from 2018-2033.” 2020 Jun.

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner. Today I have a special guest, Dr James Gordon, founder and executive director of the Center for Mind-Body Medicine. Welcome, Dr Gordon.

Courtesy Center for Mind-Body Medicine

James S. Gordon, MD: Thank you very much. It’s good to be with you.

Dr. Wilner: Thanks for joining us. We are recording this in late May 2020, in the midst of the coronavirus pandemic. Millions of people have been infected. Hundreds of thousands have died. Millions have lost their jobs. I think it’s fair to say that people are under a greater degree of stress than they’re normally accustomed to. Would you agree with that?

Dr. Gordon: I think it’s more than fair to say that everybody in the United States, and actually pretty much everyone in the world, is under extreme stress. And that compounds any stresses that they’ve experienced before in their lives. Everyone is affected.

Dr. Wilner: The mind-body medicine concept is one that you’ve pursued for decades. Tell us a little bit about the Center for Mind-Body Medicine and how that’s led to the program that you have to help us deal with the coronavirus.

Dr. Gordon: I started the Center for Mind-Body Medicine about 30 years ago. I’d been a researcher at the National Institute of Mental Health for a number of years, in private practice, and a professor at Georgetown Medical School. But I wanted to really focus on how to change and enrich medicine by making self-care, self-awareness, and group support central to all healthcare.

Western medicine is enormously powerful in certain situations, such as physical trauma, high levels of infection, congenital anomalies. But we’re not so good at working with chronic physical or psychological problems. Those are much more complex.

We’ve been discovering that what is going to make the long-term difference in conditions like type 2 diabetes, pain syndromes, hypertension, depression, and anxiety are those approaches that we can learn to do for ourselves. These are changes we can make in how we deal with stress, eat, exercise, relate to other people, and whether we find meaning and purpose in our lives.

For the past 25 years, the major part of our focus has been on whole populations that have been psychologically traumatized by wars, climate-related disasters, the opioid epidemic, chronic poverty, historical trauma. We do a lot of work with indigenous people here in North America. We’ve worked in a number of communities where school shootings have traumatized everyone.

What we’ve learned over these past 25 years, and what interested me professionally as well as personally over the past 50 years, is what we’re now bringing out on an even larger scale. The kind of approaches that we’ve developed, studied, and published research on are exactly what everyone needs to include and incorporate in their daily life, as well as in their medical and health care, from now on.

Dr. Wilner: Do you have a program that’s specifically for health care providers?

Dr. Gordon: Yes. The Center for Mind-Body Medicine is primarily an educational organization rather than a service organization. Since the beginning, I’ve been focused on training health professionals. My first passion was for training physicians – I’m a physician, so there’s a feeling of fellowship there – but also health care workers and mental health professionals of every kind.

We teach health professionals a whole system, a comprehensive program of techniques of self-awareness and self-care. We teach them so that they can practice on themselves and study the underlying science, so they can then teach what they’ve learned to the patients or clients they work with. They integrate it into what they’re already doing, regardless of their specialty. At times we also offer some of the same kinds of mind-body skills groups that are the fundamental part of our training as a stand-alone intervention. You can’t really teach other people how to take care of themselves unless you’re also doing it yourself. Otherwise, it’s just a theory.

Dr. Wilner: As a neurologist, I’m interested in the mind-body system. You are a psychiatrist and understand that it’s a lot more difficult to objectify certain things. What is stress? What is happiness? What is sadness? It’s very hard to measure. You can have scales, but it requires insight on the part of the individual. So I think it’s certainly an ambitious project.

Dr. Gordon: You’re absolutely right. It requires insight. And one of the shortcomings of our medical education is that it doesn’t encourage us to look inside ourselves enough. There’s so much focus on objectivity and on data, that we’ve lost some of the subjective art of medicine.

My experience with myself, as well as with the thousands of people we’ve trained here in the United States and around the world and the many hundreds of thousands with whom they’ve worked, is that all of us have a greater capacity to understand and help ourselves than we ordinarily think or than most of us learn about in our medical education.

This work is saying to people to take a little bit of time and relax a little in order to allow yourself to come into a meditative state. And I don’t mean anything fancy by that. Meditation is just being relaxed. Moment-to-moment awareness doesn’t have to do with any particular religion or spiritual practice. It’s part of all of them. If you can get into that state, then you can begin to say, “Oh, that’s what’s going on with me. That’s why my pain is worse.”

For example, you often wonder in people with peripheral neuropathy why it becomes worse or better at certain points. I would encourage neurologists and other physicians to ask your patients, “Why do you think it’s worse?” They may say, “I don’t know, doc; that’s why I’m here.” But I would ask them to take a couple of minutes to let me know. They could think it has something to do with the fact that they had a big fight with their wife that morning, they don’t want to go to work, or whatever it is. This is part of the lost art that we need to bring back into medicine for ourselves and especially for our patients.

Dr. Wilner: Can you give me an example of some of the exercises you’d do in a class?

Dr. Gordon: All of the exercises and our entire program that we teach at the Center for Mind-Body Medicine is in this new book of mine, “The Transformation: Discovering Wholeness and Healing After Trauma.” It’s really the distillation of not just the past 25 or 30 years, but really 50 years of work.

Courtesy Center for Mind-Body Medicine

The techniques are all pretty simple and, as we say, evidence based. There is evidence that shows how they work on us physiologically, as well as psychologically. And they’re all pretty easy to teach to anyone.

Myself and about 60 or 70 of our faculty at the Center for Mind-Body Medicine are currently leading online groups. Then several hundred of the other people we’ve trained are also leading these groups. We’re still counting it up, but we probably have between 700 and 1,000 groups going around the world, led by our faculty and by people we’ve trained.

We teach a different technique every week in these online groups. Last week, after getting people energized and focused, we did a written dialogue with an emotion. You put down the initial of your name – in my case, “J” for Jim – and create a dialogue with an emotion, such as sadness. I would write it as fast as I can.

I would say, “OK, Sadness. Why are you here? What are you doing? I don’t enjoy having you around.” And Sadness writes back to me, “But you need me.” And J says, “What do you mean I need you?” And Sadness says, “Well, your brother died 7 weeks ago, didn’t he?” And I say, “Yes, he did.” And Sadness says, “Aren’t you sad?” I say, “Yes. I’m terribly sad and grieving all the time. But I wasn’t thinking about him at this moment.” And Sadness says, “But he’s there with you all the time and that sadness is in you.” And I say, “You mean it’s in me even here, now, as I’m talking with Andrew in this interview?” And Sadness says, “Yes. You can talk about your work. But in between the words, as you take a breath, don’t you feel it in your chest?” That’s the way the dialogue goes.

Dr. Wilner: What about specifically with the coronavirus? Fear is certainly an emotion. Nobody wants to get sick and die. Nobody wants to bring this disease home to their family. People are reluctant to even go outside and you can’t shake someone’s hand. Are there precedents for this?

Dr. Gordon: There are precedents, but only relatively small groups were affected before by, for example, severe acute respiratory syndrome or H1N1, at least in the United States. But we haven’t seen a global pandemic like this since 1918. None of us was around then – or I certainly wasn’t around. So for most everyone, not only has it not happened before, but we’ve never been so globally aware of everything that’s going on and how different groups are reacting.

I’ve been reading Daniel Defoe’s book, “A Journal of the Plague Year.” It’s really very interesting. It’s about the bubonic plague in 1665 London, although he wrote it in the 1720s. Some of the same things were going on then: the enormous fear, the isolation; rich people being able to escape, poor people having nowhere to go; conspiracy theories of one kind or another, about where the plague came from or blaming a group of people for it; magical thinking that it’s just going to go away. All of those things that happened several hundred years ago are going on now.

And we’re all simultaneously aware of all those things. There’s not only the fear, which should be universal because it’s a reasonable response to this situation, but also the terrible confusion about what to do. The President is saying one thing, governors something else; Anthony Fauci is saying something else, and Deborah Birx is saying something a little bit different. There’s this tremendous confusion that overlays the fear, and I think everybody is more or less feeling these things.

So yes, a dialogue with fear is a good thing to do because it can be clarifying. What we need here is a sense of, what is it that makes sense for me to do? What precautions should I take? What precautions shouldn’t I take?

I have a 17-year-old son who lives with his mom in California. He and I were on the phone the other day. He’s a basketball player and very serious about it. He said, “I don’t want to put my life on hold.” And my response was, “If you go outside too soon, your life may be on hold for a hell of a lot longer than if you stay inside because, if you get sick, it’s serious. But you also need to start looking at the evidence and asking yourself the right questions because I can’t be there all the time and neither can your mom.”

Everybody really needs to use these kinds of tools to help themselves. The tools we teach are extremely good at bringing us back into a state of psychological and physiological balance — slow, deep breathing being a very basic one. Because it’s only in that state that we’re going to be able to make the most intelligent decisions about what to do. It’s only in that state that we’re going to be able to really look our fear in the face and find out what we should be afraid of and what we shouldn’t be afraid of.

It’s a process that’s very much integrated. We’re talking now about how to deal with the emotions. But the first part of what we do in our groups and our online trainings and webinars is teach people to just take a few deep breaths. Just take a few deep breaths in through the nose, out through the mouth, with your belly soft and relaxed. You can keep breathing this way while talking. That’s the antidote to the fight-or-flight response. We all learn about fight-or-flight in first-year physiology. We need to deal with it. We need to bring ourselves into balance. That’s the way we’re going to make the wisest decisions for ourselves and be best able to help our patients.
 

Dr. Wilner: As you mentioned, part of modern culture is that we now have access to all of this information worldwide. There’s a continual stream of newsfeeds, people flipping on their phones, receiving constant updates, 24/7. That’s a new phenomenon. Does that steal from us the time we had before for just breathing and synthesizing data as opposed to just acquiring it all the time?

Dr. Gordon: You’re absolutely right. It does and it’s a challenge. It can’t steal from us unless we’re letting our emotional, psychological, and physiological pockets be picked!

What we need to do is to make it our priority to come into balance. I don’t watch news all day long – a little tiny bit in the morning and in the evening, just to get a sense of what’s happening. That’s enough. And I think everybody needs to take a step back, ask if this is really what they want to be doing, and to come into balance.

The other thing that’s really important is physical activity, especially during this time. In addition to using slow, deep breathing to come into balance, physical exercise and movement of any kind is extremely good as an antidote to fight-or-flight and that shut-down, freeze-up response that we get into when we feel completely overwhelmed.

We’ve got to take it into our own hands. The media just want to sell us things. Let’s face it: They’re not here for our good. Our job as physicians and health care professionals is to really reinforce for people not only what we can do for them but what they can do for themselves.

Dr. Wilner: I’m certainly interested in learning more about mind-body medicine. For those who feel the same, where do you recommend they go to learn more?

Dr. Gordon: We have a website, cmbm.org, which features a number of webinars. I do a free webinar there every week. We have mind-body skills groups that meet once a week for 8 weeks. There are six physicians in my group and all kinds of health professionals in other groups. We have a training program that we’re bringing online. We’ve trained well over 6,000 people around the world and would love to train more. You can read about that on the website.

We’re starting to do more and more consulting with health care organizations. We’re working with the largest division of Veterans Affairs, which is in Florida, as well as in south Georgia and the Caribbean. We’re working with a large health system in Indiana and others elsewhere. In addition, we’re working with groups of physicians and mental health professionals, helping them to integrate what we have to offer into what they’re already doing.

That’s our job – to help you do your job.

Dr. Wilner: Dr Gordon, I feel more relaxed just speaking with you. Thank you for talking with me and sharing your experiences with Medscape. I look forward to learning more.

Dr. Gordon: Thank you. My pleasure.

A version of this article originally appeared on Medscape.com.

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner. Today I have a special guest, Dr James Gordon, founder and executive director of the Center for Mind-Body Medicine. Welcome, Dr Gordon.

Courtesy Center for Mind-Body Medicine

James S. Gordon, MD: Thank you very much. It’s good to be with you.

Dr. Wilner: Thanks for joining us. We are recording this in late May 2020, in the midst of the coronavirus pandemic. Millions of people have been infected. Hundreds of thousands have died. Millions have lost their jobs. I think it’s fair to say that people are under a greater degree of stress than they’re normally accustomed to. Would you agree with that?

Dr. Gordon: I think it’s more than fair to say that everybody in the United States, and actually pretty much everyone in the world, is under extreme stress. And that compounds any stresses that they’ve experienced before in their lives. Everyone is affected.

Dr. Wilner: The mind-body medicine concept is one that you’ve pursued for decades. Tell us a little bit about the Center for Mind-Body Medicine and how that’s led to the program that you have to help us deal with the coronavirus.

Dr. Gordon: I started the Center for Mind-Body Medicine about 30 years ago. I’d been a researcher at the National Institute of Mental Health for a number of years, in private practice, and a professor at Georgetown Medical School. But I wanted to really focus on how to change and enrich medicine by making self-care, self-awareness, and group support central to all healthcare.

Western medicine is enormously powerful in certain situations, such as physical trauma, high levels of infection, congenital anomalies. But we’re not so good at working with chronic physical or psychological problems. Those are much more complex.

We’ve been discovering that what is going to make the long-term difference in conditions like type 2 diabetes, pain syndromes, hypertension, depression, and anxiety are those approaches that we can learn to do for ourselves. These are changes we can make in how we deal with stress, eat, exercise, relate to other people, and whether we find meaning and purpose in our lives.

For the past 25 years, the major part of our focus has been on whole populations that have been psychologically traumatized by wars, climate-related disasters, the opioid epidemic, chronic poverty, historical trauma. We do a lot of work with indigenous people here in North America. We’ve worked in a number of communities where school shootings have traumatized everyone.

What we’ve learned over these past 25 years, and what interested me professionally as well as personally over the past 50 years, is what we’re now bringing out on an even larger scale. The kind of approaches that we’ve developed, studied, and published research on are exactly what everyone needs to include and incorporate in their daily life, as well as in their medical and health care, from now on.

Dr. Wilner: Do you have a program that’s specifically for health care providers?

Dr. Gordon: Yes. The Center for Mind-Body Medicine is primarily an educational organization rather than a service organization. Since the beginning, I’ve been focused on training health professionals. My first passion was for training physicians – I’m a physician, so there’s a feeling of fellowship there – but also health care workers and mental health professionals of every kind.

We teach health professionals a whole system, a comprehensive program of techniques of self-awareness and self-care. We teach them so that they can practice on themselves and study the underlying science, so they can then teach what they’ve learned to the patients or clients they work with. They integrate it into what they’re already doing, regardless of their specialty. At times we also offer some of the same kinds of mind-body skills groups that are the fundamental part of our training as a stand-alone intervention. You can’t really teach other people how to take care of themselves unless you’re also doing it yourself. Otherwise, it’s just a theory.

Dr. Wilner: As a neurologist, I’m interested in the mind-body system. You are a psychiatrist and understand that it’s a lot more difficult to objectify certain things. What is stress? What is happiness? What is sadness? It’s very hard to measure. You can have scales, but it requires insight on the part of the individual. So I think it’s certainly an ambitious project.

Dr. Gordon: You’re absolutely right. It requires insight. And one of the shortcomings of our medical education is that it doesn’t encourage us to look inside ourselves enough. There’s so much focus on objectivity and on data, that we’ve lost some of the subjective art of medicine.

My experience with myself, as well as with the thousands of people we’ve trained here in the United States and around the world and the many hundreds of thousands with whom they’ve worked, is that all of us have a greater capacity to understand and help ourselves than we ordinarily think or than most of us learn about in our medical education.

This work is saying to people to take a little bit of time and relax a little in order to allow yourself to come into a meditative state. And I don’t mean anything fancy by that. Meditation is just being relaxed. Moment-to-moment awareness doesn’t have to do with any particular religion or spiritual practice. It’s part of all of them. If you can get into that state, then you can begin to say, “Oh, that’s what’s going on with me. That’s why my pain is worse.”

For example, you often wonder in people with peripheral neuropathy why it becomes worse or better at certain points. I would encourage neurologists and other physicians to ask your patients, “Why do you think it’s worse?” They may say, “I don’t know, doc; that’s why I’m here.” But I would ask them to take a couple of minutes to let me know. They could think it has something to do with the fact that they had a big fight with their wife that morning, they don’t want to go to work, or whatever it is. This is part of the lost art that we need to bring back into medicine for ourselves and especially for our patients.

Dr. Wilner: Can you give me an example of some of the exercises you’d do in a class?

Dr. Gordon: All of the exercises and our entire program that we teach at the Center for Mind-Body Medicine is in this new book of mine, “The Transformation: Discovering Wholeness and Healing After Trauma.” It’s really the distillation of not just the past 25 or 30 years, but really 50 years of work.

Courtesy Center for Mind-Body Medicine

The techniques are all pretty simple and, as we say, evidence based. There is evidence that shows how they work on us physiologically, as well as psychologically. And they’re all pretty easy to teach to anyone.

Myself and about 60 or 70 of our faculty at the Center for Mind-Body Medicine are currently leading online groups. Then several hundred of the other people we’ve trained are also leading these groups. We’re still counting it up, but we probably have between 700 and 1,000 groups going around the world, led by our faculty and by people we’ve trained.

We teach a different technique every week in these online groups. Last week, after getting people energized and focused, we did a written dialogue with an emotion. You put down the initial of your name – in my case, “J” for Jim – and create a dialogue with an emotion, such as sadness. I would write it as fast as I can.

I would say, “OK, Sadness. Why are you here? What are you doing? I don’t enjoy having you around.” And Sadness writes back to me, “But you need me.” And J says, “What do you mean I need you?” And Sadness says, “Well, your brother died 7 weeks ago, didn’t he?” And I say, “Yes, he did.” And Sadness says, “Aren’t you sad?” I say, “Yes. I’m terribly sad and grieving all the time. But I wasn’t thinking about him at this moment.” And Sadness says, “But he’s there with you all the time and that sadness is in you.” And I say, “You mean it’s in me even here, now, as I’m talking with Andrew in this interview?” And Sadness says, “Yes. You can talk about your work. But in between the words, as you take a breath, don’t you feel it in your chest?” That’s the way the dialogue goes.

Dr. Wilner: What about specifically with the coronavirus? Fear is certainly an emotion. Nobody wants to get sick and die. Nobody wants to bring this disease home to their family. People are reluctant to even go outside and you can’t shake someone’s hand. Are there precedents for this?

Dr. Gordon: There are precedents, but only relatively small groups were affected before by, for example, severe acute respiratory syndrome or H1N1, at least in the United States. But we haven’t seen a global pandemic like this since 1918. None of us was around then – or I certainly wasn’t around. So for most everyone, not only has it not happened before, but we’ve never been so globally aware of everything that’s going on and how different groups are reacting.

I’ve been reading Daniel Defoe’s book, “A Journal of the Plague Year.” It’s really very interesting. It’s about the bubonic plague in 1665 London, although he wrote it in the 1720s. Some of the same things were going on then: the enormous fear, the isolation; rich people being able to escape, poor people having nowhere to go; conspiracy theories of one kind or another, about where the plague came from or blaming a group of people for it; magical thinking that it’s just going to go away. All of those things that happened several hundred years ago are going on now.

And we’re all simultaneously aware of all those things. There’s not only the fear, which should be universal because it’s a reasonable response to this situation, but also the terrible confusion about what to do. The President is saying one thing, governors something else; Anthony Fauci is saying something else, and Deborah Birx is saying something a little bit different. There’s this tremendous confusion that overlays the fear, and I think everybody is more or less feeling these things.

So yes, a dialogue with fear is a good thing to do because it can be clarifying. What we need here is a sense of, what is it that makes sense for me to do? What precautions should I take? What precautions shouldn’t I take?

I have a 17-year-old son who lives with his mom in California. He and I were on the phone the other day. He’s a basketball player and very serious about it. He said, “I don’t want to put my life on hold.” And my response was, “If you go outside too soon, your life may be on hold for a hell of a lot longer than if you stay inside because, if you get sick, it’s serious. But you also need to start looking at the evidence and asking yourself the right questions because I can’t be there all the time and neither can your mom.”

Everybody really needs to use these kinds of tools to help themselves. The tools we teach are extremely good at bringing us back into a state of psychological and physiological balance — slow, deep breathing being a very basic one. Because it’s only in that state that we’re going to be able to make the most intelligent decisions about what to do. It’s only in that state that we’re going to be able to really look our fear in the face and find out what we should be afraid of and what we shouldn’t be afraid of.

It’s a process that’s very much integrated. We’re talking now about how to deal with the emotions. But the first part of what we do in our groups and our online trainings and webinars is teach people to just take a few deep breaths. Just take a few deep breaths in through the nose, out through the mouth, with your belly soft and relaxed. You can keep breathing this way while talking. That’s the antidote to the fight-or-flight response. We all learn about fight-or-flight in first-year physiology. We need to deal with it. We need to bring ourselves into balance. That’s the way we’re going to make the wisest decisions for ourselves and be best able to help our patients.
 

Dr. Wilner: As you mentioned, part of modern culture is that we now have access to all of this information worldwide. There’s a continual stream of newsfeeds, people flipping on their phones, receiving constant updates, 24/7. That’s a new phenomenon. Does that steal from us the time we had before for just breathing and synthesizing data as opposed to just acquiring it all the time?

Dr. Gordon: You’re absolutely right. It does and it’s a challenge. It can’t steal from us unless we’re letting our emotional, psychological, and physiological pockets be picked!

What we need to do is to make it our priority to come into balance. I don’t watch news all day long – a little tiny bit in the morning and in the evening, just to get a sense of what’s happening. That’s enough. And I think everybody needs to take a step back, ask if this is really what they want to be doing, and to come into balance.

The other thing that’s really important is physical activity, especially during this time. In addition to using slow, deep breathing to come into balance, physical exercise and movement of any kind is extremely good as an antidote to fight-or-flight and that shut-down, freeze-up response that we get into when we feel completely overwhelmed.

We’ve got to take it into our own hands. The media just want to sell us things. Let’s face it: They’re not here for our good. Our job as physicians and health care professionals is to really reinforce for people not only what we can do for them but what they can do for themselves.

Dr. Wilner: I’m certainly interested in learning more about mind-body medicine. For those who feel the same, where do you recommend they go to learn more?

Dr. Gordon: We have a website, cmbm.org, which features a number of webinars. I do a free webinar there every week. We have mind-body skills groups that meet once a week for 8 weeks. There are six physicians in my group and all kinds of health professionals in other groups. We have a training program that we’re bringing online. We’ve trained well over 6,000 people around the world and would love to train more. You can read about that on the website.

We’re starting to do more and more consulting with health care organizations. We’re working with the largest division of Veterans Affairs, which is in Florida, as well as in south Georgia and the Caribbean. We’re working with a large health system in Indiana and others elsewhere. In addition, we’re working with groups of physicians and mental health professionals, helping them to integrate what we have to offer into what they’re already doing.

That’s our job – to help you do your job.

Dr. Wilner: Dr Gordon, I feel more relaxed just speaking with you. Thank you for talking with me and sharing your experiences with Medscape. I look forward to learning more.

Dr. Gordon: Thank you. My pleasure.

A version of this article originally appeared on Medscape.com.

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner. Today I have a special guest, Dr James Gordon, founder and executive director of the Center for Mind-Body Medicine. Welcome, Dr Gordon.

Courtesy Center for Mind-Body Medicine

James S. Gordon, MD: Thank you very much. It’s good to be with you.

Dr. Wilner: Thanks for joining us. We are recording this in late May 2020, in the midst of the coronavirus pandemic. Millions of people have been infected. Hundreds of thousands have died. Millions have lost their jobs. I think it’s fair to say that people are under a greater degree of stress than they’re normally accustomed to. Would you agree with that?

Dr. Gordon: I think it’s more than fair to say that everybody in the United States, and actually pretty much everyone in the world, is under extreme stress. And that compounds any stresses that they’ve experienced before in their lives. Everyone is affected.

Dr. Wilner: The mind-body medicine concept is one that you’ve pursued for decades. Tell us a little bit about the Center for Mind-Body Medicine and how that’s led to the program that you have to help us deal with the coronavirus.

Dr. Gordon: I started the Center for Mind-Body Medicine about 30 years ago. I’d been a researcher at the National Institute of Mental Health for a number of years, in private practice, and a professor at Georgetown Medical School. But I wanted to really focus on how to change and enrich medicine by making self-care, self-awareness, and group support central to all healthcare.

Western medicine is enormously powerful in certain situations, such as physical trauma, high levels of infection, congenital anomalies. But we’re not so good at working with chronic physical or psychological problems. Those are much more complex.

We’ve been discovering that what is going to make the long-term difference in conditions like type 2 diabetes, pain syndromes, hypertension, depression, and anxiety are those approaches that we can learn to do for ourselves. These are changes we can make in how we deal with stress, eat, exercise, relate to other people, and whether we find meaning and purpose in our lives.

For the past 25 years, the major part of our focus has been on whole populations that have been psychologically traumatized by wars, climate-related disasters, the opioid epidemic, chronic poverty, historical trauma. We do a lot of work with indigenous people here in North America. We’ve worked in a number of communities where school shootings have traumatized everyone.

What we’ve learned over these past 25 years, and what interested me professionally as well as personally over the past 50 years, is what we’re now bringing out on an even larger scale. The kind of approaches that we’ve developed, studied, and published research on are exactly what everyone needs to include and incorporate in their daily life, as well as in their medical and health care, from now on.

Dr. Wilner: Do you have a program that’s specifically for health care providers?

Dr. Gordon: Yes. The Center for Mind-Body Medicine is primarily an educational organization rather than a service organization. Since the beginning, I’ve been focused on training health professionals. My first passion was for training physicians – I’m a physician, so there’s a feeling of fellowship there – but also health care workers and mental health professionals of every kind.

We teach health professionals a whole system, a comprehensive program of techniques of self-awareness and self-care. We teach them so that they can practice on themselves and study the underlying science, so they can then teach what they’ve learned to the patients or clients they work with. They integrate it into what they’re already doing, regardless of their specialty. At times we also offer some of the same kinds of mind-body skills groups that are the fundamental part of our training as a stand-alone intervention. You can’t really teach other people how to take care of themselves unless you’re also doing it yourself. Otherwise, it’s just a theory.

Dr. Wilner: As a neurologist, I’m interested in the mind-body system. You are a psychiatrist and understand that it’s a lot more difficult to objectify certain things. What is stress? What is happiness? What is sadness? It’s very hard to measure. You can have scales, but it requires insight on the part of the individual. So I think it’s certainly an ambitious project.

Dr. Gordon: You’re absolutely right. It requires insight. And one of the shortcomings of our medical education is that it doesn’t encourage us to look inside ourselves enough. There’s so much focus on objectivity and on data, that we’ve lost some of the subjective art of medicine.

My experience with myself, as well as with the thousands of people we’ve trained here in the United States and around the world and the many hundreds of thousands with whom they’ve worked, is that all of us have a greater capacity to understand and help ourselves than we ordinarily think or than most of us learn about in our medical education.

This work is saying to people to take a little bit of time and relax a little in order to allow yourself to come into a meditative state. And I don’t mean anything fancy by that. Meditation is just being relaxed. Moment-to-moment awareness doesn’t have to do with any particular religion or spiritual practice. It’s part of all of them. If you can get into that state, then you can begin to say, “Oh, that’s what’s going on with me. That’s why my pain is worse.”

For example, you often wonder in people with peripheral neuropathy why it becomes worse or better at certain points. I would encourage neurologists and other physicians to ask your patients, “Why do you think it’s worse?” They may say, “I don’t know, doc; that’s why I’m here.” But I would ask them to take a couple of minutes to let me know. They could think it has something to do with the fact that they had a big fight with their wife that morning, they don’t want to go to work, or whatever it is. This is part of the lost art that we need to bring back into medicine for ourselves and especially for our patients.

Dr. Wilner: Can you give me an example of some of the exercises you’d do in a class?

Dr. Gordon: All of the exercises and our entire program that we teach at the Center for Mind-Body Medicine is in this new book of mine, “The Transformation: Discovering Wholeness and Healing After Trauma.” It’s really the distillation of not just the past 25 or 30 years, but really 50 years of work.

Courtesy Center for Mind-Body Medicine

The techniques are all pretty simple and, as we say, evidence based. There is evidence that shows how they work on us physiologically, as well as psychologically. And they’re all pretty easy to teach to anyone.

Myself and about 60 or 70 of our faculty at the Center for Mind-Body Medicine are currently leading online groups. Then several hundred of the other people we’ve trained are also leading these groups. We’re still counting it up, but we probably have between 700 and 1,000 groups going around the world, led by our faculty and by people we’ve trained.

We teach a different technique every week in these online groups. Last week, after getting people energized and focused, we did a written dialogue with an emotion. You put down the initial of your name – in my case, “J” for Jim – and create a dialogue with an emotion, such as sadness. I would write it as fast as I can.

I would say, “OK, Sadness. Why are you here? What are you doing? I don’t enjoy having you around.” And Sadness writes back to me, “But you need me.” And J says, “What do you mean I need you?” And Sadness says, “Well, your brother died 7 weeks ago, didn’t he?” And I say, “Yes, he did.” And Sadness says, “Aren’t you sad?” I say, “Yes. I’m terribly sad and grieving all the time. But I wasn’t thinking about him at this moment.” And Sadness says, “But he’s there with you all the time and that sadness is in you.” And I say, “You mean it’s in me even here, now, as I’m talking with Andrew in this interview?” And Sadness says, “Yes. You can talk about your work. But in between the words, as you take a breath, don’t you feel it in your chest?” That’s the way the dialogue goes.

Dr. Wilner: What about specifically with the coronavirus? Fear is certainly an emotion. Nobody wants to get sick and die. Nobody wants to bring this disease home to their family. People are reluctant to even go outside and you can’t shake someone’s hand. Are there precedents for this?

Dr. Gordon: There are precedents, but only relatively small groups were affected before by, for example, severe acute respiratory syndrome or H1N1, at least in the United States. But we haven’t seen a global pandemic like this since 1918. None of us was around then – or I certainly wasn’t around. So for most everyone, not only has it not happened before, but we’ve never been so globally aware of everything that’s going on and how different groups are reacting.

I’ve been reading Daniel Defoe’s book, “A Journal of the Plague Year.” It’s really very interesting. It’s about the bubonic plague in 1665 London, although he wrote it in the 1720s. Some of the same things were going on then: the enormous fear, the isolation; rich people being able to escape, poor people having nowhere to go; conspiracy theories of one kind or another, about where the plague came from or blaming a group of people for it; magical thinking that it’s just going to go away. All of those things that happened several hundred years ago are going on now.

And we’re all simultaneously aware of all those things. There’s not only the fear, which should be universal because it’s a reasonable response to this situation, but also the terrible confusion about what to do. The President is saying one thing, governors something else; Anthony Fauci is saying something else, and Deborah Birx is saying something a little bit different. There’s this tremendous confusion that overlays the fear, and I think everybody is more or less feeling these things.

So yes, a dialogue with fear is a good thing to do because it can be clarifying. What we need here is a sense of, what is it that makes sense for me to do? What precautions should I take? What precautions shouldn’t I take?

I have a 17-year-old son who lives with his mom in California. He and I were on the phone the other day. He’s a basketball player and very serious about it. He said, “I don’t want to put my life on hold.” And my response was, “If you go outside too soon, your life may be on hold for a hell of a lot longer than if you stay inside because, if you get sick, it’s serious. But you also need to start looking at the evidence and asking yourself the right questions because I can’t be there all the time and neither can your mom.”

Everybody really needs to use these kinds of tools to help themselves. The tools we teach are extremely good at bringing us back into a state of psychological and physiological balance — slow, deep breathing being a very basic one. Because it’s only in that state that we’re going to be able to make the most intelligent decisions about what to do. It’s only in that state that we’re going to be able to really look our fear in the face and find out what we should be afraid of and what we shouldn’t be afraid of.

It’s a process that’s very much integrated. We’re talking now about how to deal with the emotions. But the first part of what we do in our groups and our online trainings and webinars is teach people to just take a few deep breaths. Just take a few deep breaths in through the nose, out through the mouth, with your belly soft and relaxed. You can keep breathing this way while talking. That’s the antidote to the fight-or-flight response. We all learn about fight-or-flight in first-year physiology. We need to deal with it. We need to bring ourselves into balance. That’s the way we’re going to make the wisest decisions for ourselves and be best able to help our patients.
 

Dr. Wilner: As you mentioned, part of modern culture is that we now have access to all of this information worldwide. There’s a continual stream of newsfeeds, people flipping on their phones, receiving constant updates, 24/7. That’s a new phenomenon. Does that steal from us the time we had before for just breathing and synthesizing data as opposed to just acquiring it all the time?

Dr. Gordon: You’re absolutely right. It does and it’s a challenge. It can’t steal from us unless we’re letting our emotional, psychological, and physiological pockets be picked!

What we need to do is to make it our priority to come into balance. I don’t watch news all day long – a little tiny bit in the morning and in the evening, just to get a sense of what’s happening. That’s enough. And I think everybody needs to take a step back, ask if this is really what they want to be doing, and to come into balance.

The other thing that’s really important is physical activity, especially during this time. In addition to using slow, deep breathing to come into balance, physical exercise and movement of any kind is extremely good as an antidote to fight-or-flight and that shut-down, freeze-up response that we get into when we feel completely overwhelmed.

We’ve got to take it into our own hands. The media just want to sell us things. Let’s face it: They’re not here for our good. Our job as physicians and health care professionals is to really reinforce for people not only what we can do for them but what they can do for themselves.

Dr. Wilner: I’m certainly interested in learning more about mind-body medicine. For those who feel the same, where do you recommend they go to learn more?

Dr. Gordon: We have a website, cmbm.org, which features a number of webinars. I do a free webinar there every week. We have mind-body skills groups that meet once a week for 8 weeks. There are six physicians in my group and all kinds of health professionals in other groups. We have a training program that we’re bringing online. We’ve trained well over 6,000 people around the world and would love to train more. You can read about that on the website.

We’re starting to do more and more consulting with health care organizations. We’re working with the largest division of Veterans Affairs, which is in Florida, as well as in south Georgia and the Caribbean. We’re working with a large health system in Indiana and others elsewhere. In addition, we’re working with groups of physicians and mental health professionals, helping them to integrate what we have to offer into what they’re already doing.

That’s our job – to help you do your job.

Dr. Wilner: Dr Gordon, I feel more relaxed just speaking with you. Thank you for talking with me and sharing your experiences with Medscape. I look forward to learning more.

Dr. Gordon: Thank you. My pleasure.

A version of this article originally appeared on Medscape.com.