For most physicians, the needs of the individual patient in their office or clinic is the focus of their attention. But outside the setting of that single patient encounter is a larger community of patients in need, their families, and individuals who may later need care.
Even in the best of times there may be a tension between a physician’s ethical obligations to the individual patient and to the broader public. During a global pandemic such as COVID-19, that tension has been heightened and may come into play in many clinical scenarios, according to Rebecca Brendel, M.D., J.D., chair of the APA Committee on Ethics. She is director of the master’s degree program at the Harvard Medical School Center for Bioethics and a member of the AMA Council on Ethical and Judicial Affairs.
“For most of us, in our practices, what we are most commonly thinking about is the single patient before us. Now we are in the midst of an enormous public health crisis, and as physicians we have an ethical obligation to think as well about the greater good.”
She outlined two specific clinical scenarios that are liable to be common and in which competing ethical obligations to patient or public health will be at play:
Prescriptions and hoarding of medicines: Patients are bound to be anxious about having an adequate supply of their medications during a period when pharmacies are being deluged and may be experiencing shortages. These patients may be inclined to request an extra supply of medications. Psychiatrists should be certain their patients have an adequate supply of their medications (taking into account whether the risk of suicide exists), but Brendel advised that psychiatrists avoid prescribing refills that could lead a patient to hoard medications. “One way we can be absolutely sure there will be shortages of medications is by not thinking cautiously about how we prescribe.”
(Reimbursement for multiple months of prescriptions varies with health plans; many plans cover a maximum of a 60- or 90-day supply, but physicians could theoretically write scripts for even longer, and mail-order pharmacies could auto-fill them; moreover, some patients might be willing to pay out of pocket for extra supplies.)
Brendel said psychiatrists can help allay patients’ fears and should talk to them about planning ahead and not waiting until they are about to run out of a medication to request a refill.
Social distancing and scheduling appointments: Psychiatrists and mental health professionals are likely to have patients who prefer, expect, and may even insist upon face-to-face visits. “In normal times, psychiatrists have an obligation to put their patients’ needs and wants first and to accommodate them within established clinical boundaries to the best of their ability,” Brendel said. “We are not in normal times. Data very clearly show that the best way to contain the spread of COVID-19 is social distancing and that person-to-person contact is the major source of spread of the virus. Telephone and video teleconferencing may not be ideal in the course of routine care, but in the current circumstances are essential.”
Brendel emphasized that psychiatrists and health care professionals must also be mindful of their own health, for their own sake and the sake of their families, but also for the greater good. “Psychiatrists have a personal but also a professional responsibility to be healthy and available in this extraordinary new circumstance,” she said.
(Image: iStock/izusek)
Join APA-NABH Webinar on Caring for Patients Through COVID-19 Crisis: April 1
APA and the National Association for Behavioral Healthcare (NABH) will host a joint webinar on Wednesday, April 1, from 2 p.m. to 3 p.m. EDT with experts working in inpatient, residential, and other nonambulatory care settings about how they are assessing the current environment and developing new protocols to care for their patients during the COVID-19 crisis. Hear from experts about the management of different types of services, key messages to give your team leaders, unique challenges for people with serious mental illness (SMI), how to handle group therapy, and more. Questions can also be submitted via chat during the live session. A recording will be posted after the event. More information about the webinar, including how to register, is posted here.
Register Now to Participate in 2020 Minority and Underrepresented Group Caucus Election
The Caucus of Asian-American Psychiatrists is holding an election for three leadership positions: president, Assembly representative, and Assembly deputy representative. To be eligible to vote in the election, APA members must join the caucus by Wednesday, April 1. Find more information on how to join the caucus here.
The U.S. Supreme Court ruled last week that states can prevent criminal defendants from pleading insanity without violating their constitutional rights.
In the case Kahler v. Kansas, the justices ruled 6-3 in favor of the state. The defendant, James Kraig Kahler, had been sentenced to death for the murder of his family. His lawyers wanted to mount an insanity defense, but Kansas is one of four states that eliminated a defendant’s ability to plead not guilty by reason of insanity. (Idaho, Montana, and Utah are the others; Alaska substantially limits the insanity defense.)
Justice Elena Kagan wrote the majority opinion for the court, saying that Kansas takes into account a defendant’s mental health at both trial and sentencing, but the option of an insanity defense and the scope of its application are “for Kansas to make—and, if it wishes, to remake and remake again as the future unfolds.”
Experts in psychiatry and the law said that the decision could have significant consequences. “The most immediate impact of the case is on Kansas and the four other states that have elected to effectively get rid of their insanity defenses. Their laws will remain valid,” said Paul Appelbaum, M.D., a member of APA’s Committee on Judicial Action.
He said the longer-term impact of the case is more difficult to predict because states can make their own choices; 45 states and the federal government retain meaningful insanity defense laws. “Given the long-standing acceptance of insanity as a defense to criminal charges—dating back in the Anglo-American tradition to medieval times—most states will probably choose to retain that option [for defendants who want to plead insanity],” Appelbaum said. “Defendants in the states without an effective insanity defense will be most adversely impacted by the decision. More people with severe mental illness will spend decades in prison.”
Debra Pinals, M.D., chair of the APA Council on Psychiatry and Law, agreed. “Persons with serious mental illness who engage in criminal behavior living in states with narrower criteria for insanity, or in states with no insanity defense, will likely be found guilty and sentenced.”
For related information, see the Psychiatric News article “States Move to Exempt People With SMI From Death Penalty.”
(Image: iStock/Amy Sparwasser)
Join APA-NABH Webinar on Caring for Patients Through COVID-19 Crisis: April 1
APA and the National Association for Behavioral Healthcare (NABH) will host a joint webinar on Wednesday, April 1, from 2 p.m. to 3 p.m. EDT with experts working in inpatient, residential, and other nonambulatory care settings about how they are assessing the current environment and developing new protocols to care for their patients during the COVID-19 crisis. Hear from experts about the management of different types of services, key messages to give your team leaders, unique challenges for people with serious mental illness (SMI), how to handle group therapy, and more. Questions can also be submitted via chat during the live session. A recording will be posted after the event. More information about the webinar, including how to register, is posted here.
APA today praised Congress for approving a $2 trillion stimulus aid package to provide fiscal relief for Americans and businesses in the face of the COVID-19 pandemic. The legislation, known as the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), includes many provisions supported by APA that will enable psychiatrists and mental health care professionals to better respond to the pandemic. The relief package will now go to President Donald Trump, where he is expected to sign.
“You can’t have a healthy economy without healthy people—and that includes mental health,” said APA President Bruce Schwartz, M.D. “This stimulus bill will strengthen our ability to help the millions of Americans with existing mental illnesses or substance use disorders, and more with emerging mental health issues as the pandemic unfolds. This is a promising development in the nation’s efforts to fight the impact of COVID-19.”
Among the provisions of the CARES Act that APA supports are $425 million for Substance Abuse and Mental Health Services Administration programs (including $250 for Certified Community Behavioral Health Clinics and $50 million for suicide prevention programs) and $4 billion for community health centers. The bill further loosens restrictions governing telehealth services by repealing the Medicare requirement that allows only health care professionals to see a patient remotely if they have previously seen that patient within the past three years. The legislation also aligns 42 CFR Part II with the Health Insurance Portability and Accountability Act (HIPAA) to allow sharing of substance use disorder records between health care professionals. Additionally, the legislation suspends the 2% Medicare sequester cut through December 2020.
“As we respond to one of the largest public health threats facing our country in decades, funding for behavioral health initiatives and expanding telemedicine is critical,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We strongly believe that federal and state government will need to continue to support physicians, who will be working long hours and in many cases risking their own health, as we continue to address this pandemic.”
APA’s COVID-19 Resource Center Keeps You Updated
APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.
As health care workers at hospitals and emergency departments (EDs) focus greater attention on diagnosing and treating patients with coronavirus (COVID-19), psychiatrists across the country are bracing for the inevitable impact on their patients. Psychiatric News asked experts in the field what psychiatrists can do to help identify and address the needs of patients experiencing a worsening of psychiatric symptoms before they seek care in the ED.
It’s not whether EDs have the capacity to conduct assessments and crisis evaluations for patients with psychiatric conditions that worries Scott Simpson, M.D., medical director of psychiatric emergency services at Denver Health and an associate professor of psychiatry at the University of Colorado Anschutz Medical Campus. It’s what will happen to patients after such assessments are made that worries him. “I think there are going to be [many] challenges coming up related to transitions of care,” he said.
To help reduce the need for crisis services, psychiatrists and mental health professionals working in outpatient services should be connecting with patients, particularly those most vulnerable, explained Kim Nordstrom, M.D., J.D., an associate clinical professor of psychiatry at the University of Colorado School of Medicine. “This is paramount. Outpatient psychiatrists may be able to prevent crisis stabilization unit and ED visits, which in turn may reduce secondary exposure to the virus.”
Physicians should anticipate which of their patients are at risk for acute exacerbations of their symptoms during the pandemic and reach out to them, said Jon Levenson, M.D., an associate professor of psychiatry at Columbia University and chair of APA’s Council on Consultation-Liaison Psychiatry. Physicians may want to consider scheduling more frequent visits with these patients or arranging for other clinical staff to reach out via telemedicine or phone, as well.
“People with pre-existing psychiatric disorders are even more vulnerable with the uncertainty associated with the COVID-19 pandemic,” he said. “Many patients with psychiatric disorders who are already somewhat stigmatized and marginalized will feel even further isolated with the enforced quarantine, and they may start having more active symptomatology.”
Some patients may benefit from a reassessment of their psychotropic medicines and dosage, as well, he continued. Those who are acutely symptomatic might need a dosage increase to effectively treat their symptoms, he said.
Despite these efforts, some patients will continue to experience psychiatric crises requiring hospitalization during the COVID-19 pandemic.
“[Physicians on] inpatient psychiatric units are going to have to make hard decisions about what kinds of patients they’re going to accept and how they’re going to handle patients with even suspected coronavirus,” Simpson said.
Physicians also need to be flexible about the types of patients they treat, Simpson said, and inpatient units must be prepared to accept patients they may not otherwise, as capacity throughout the health care system shifts to care for COVID-19 patients.
It’s better to figure out how to safely treat a patient experiencing manic episodes who is COVID-19 positive in an inpatient psychiatric unit, rather than in a medical bed where they may be under continuous restraints, Simpson pointed out.
“There are hard times ahead,” said Jack Rozel, M.D., M.S.L., president of the American Association for Emergency Psychiatry, medical director for resolve Crisis Services, and an associate professor psychiatry at the University of Pittsburgh. “But psychiatrists got into this work because we care about people, and we want to help people. Now, more than ever, we’re needed. If not us, then who?”
(Image: iStock/MJFelt)
DEA, FTC Issue Warning: Beware of Scammers
Be aware: Scammers posing as representatives from the Drug Enforcement Administration (DEA) and officials from other agencies are targeting physicians.
It was recently brought to the attention of the Massachusetts Board of Medicine that Massachusetts licensees have been receiving scam calls from individuals posing as investigators of the Massachusetts Board of Medicine of the DEA. In these cases, the impersonator falsely stated that the licensee is under investigation and that their medical license is in jeopardy or has been suspended. Impersonators may demand money and/or seek additional information about the licensee’s DEA registration number and financial information. Physicians from other states received similar scam calls from individuals purporting to be FBI and DEA. The DEA webpage includes information for reporting the threat online.
Additionally, the Federal Trade Commission is warning the public on how best to avoid coronavirus scams, including recorded scam calls on “fake tests for Medicare recipients” and “free test kit scam.”
Many Americans are feeling anxious over the risk that the novel coronavirus (COVID-19) poses to their health, the health of their family and friends, their finances, and the long-term impact the virus will have on the economy, according to a national poll released today by APA.
“The stress and anxiety caused by the pandemic can and is having an effect on people’s physical and mental health,” APA President Bruce Schwartz, M.D., said in a press statement. “During this time, it is important to do what we can to maintain self-care and manage the stress. I would suggest this for everyone coping at home as well as those who are still in their workplaces by necessity, especially the health care professionals on the front lines of this pandemic.”
The findings were based on an online survey of a nationally representative sample of 1,004 U.S. adults aged 18 and older conducted on March 18 and 19.
Several takeaways from the poll include the following:
- Nearly half of respondents (48%) are anxious about getting coronavirus, and even more (62%) worry their family members and loved ones will catch coronavirus.
- More than half of respondents (57%) are concerned that the coronavirus will have a serious negative impact on their finances, and 68% fear that the coronavirus will have a long-lasting impact on the economy.
- More than a third of respondents (36%) reported that coronavirus is having a serious impact on their mental health, and more than half (59%) feel that coronavirus is having a serious impact on their day-to-day lives.
- Despite these concerns, only 19% of respondents reported that they are having trouble sleeping, and 12% reported they have been fighting more with a partner or loved ones.
- Nearly 40% of respondents said that they believe people are overreacting/being overly cautious about coronavirus, while nearly 40% said that they disagree with this statement.
“The poll highlights both the anxiety caused by the pandemic and the need for clear, consistent communications on how to prevent the spread of COVID-19,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “In the disruption COVID-19 is causing, everyone needs to make sure they are taking the time to take care of their own physical and mental health, alongside with their families, friends, and work colleagues. Social isolation can be prevented by taking the time to use social media, letters, or simply the phone to communicate with loved ones and friends, particularly those we haven’t been in touch with over the years as we would have liked. Together, we will get through this.”
(Image: iStock/Highwaystarz-Photography)
APA’s COVID-19 Resource Center Keeps You Updated
APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.
In response to the unfolding COVID-19 public health crisis, federal agencies have announced new changes intended to lighten the burden on health care systems and professionals working to respond to the crisis. These include separate announcements by the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS).
The FDA has released new guidance regarding Risk Evaluation and Mitigation Strategy (REMS) requirements for certain medications, including clozapine. According to the notice, the FDA does not intend to take action against health care professionals for failing to adhere to certain REMS requirements for these medications for the duration of the COVID-19 public health emergency. Clozapine is considered one of the most effective antipsychotics for serious mental illness, especially treatment of refractory schizophrenia.
The FDA guidance is posted along with other COVID-related items on the APA website.
According to the guidance, health care professionals prescribing and/or dispensing medications subject to REMS with laboratory testing (or imaging) requirements should consider whether there are compelling reasons not to complete or delay lab tests during this public health emergency. Health care professionals should discuss the benefits and risks of continuing treatment in the absence of laboratory testing with their patients.
The FDA guidance followed a separate and distinct announcement by CMS on granting exceptions for health care professionals enrolled in Medicare quality reporting programs. For those programs with data submission deadlines in April and May, submission of those data will be optional. In addition, no data reflecting services provided from January 1, 2020, through June 30, 2020, will be used in CMS’s calculations for the Medicare quality reporting and value-based purchasing programs.
(Image: iStock/Wavebreakmedia)
APA’s COVID-19 Resource Center Keeps You Updated
APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.
As communities across the world continue to grapple with containing the spread of the novel coronavirus (COVID-19) and deal with the quickly proliferating number of cases, a study out of China reports troubling information on the psychological ramifications of COVID-19 on health care workers: A survey of more than 1,200 nurses and physicians working in hospitals in the Wuhan region (where the outbreak originated) and across mainland China revealed that more than 50% reported symptoms of depression, and more than 70% reported symptoms of psychological distress. The findings were published today in JAMA Network Open.
“Protecting health care workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women, nurses, and frontline workers requiring particular attention,” wrote Jianbo Lai, M.Sc., of Renmin Hospital of Wuhan University in China and colleagues.
The researchers surveyed health care workers from 34 hospitals in China with fever clinics or wards for COVID-19 between January 29, 2020, and February 3, 2020. (During this period, the total confirmed cases of COVID-19 exceeded 10,000 in China, according to the authors.) The researchers assessed the survey respondents’ depression, anxiety, insomnia, and distress using the Chinese versions of the Patient Health Questionnaire, the Generalized Anxiety Disorder scale, the Insomnia Severity Index, and the Impact of Event Scale–Revised.
Of the 1,257 surveyed (493 physicians and 764 nurses), 634 (50.4%) reported depression symptoms, 560 (44.6%) reported anxiety, 427 (34.0%) reported insomnia, and 899 (71.5%) reported distress. Health care workers engaged in the direct diagnosis, treatment, and care of patients with COVID-19 were more likely to report symptoms of depression (odds ratio, 1.52), anxiety (odds ratio, 1.57), insomnia (odds ratio, 2.97), and distress (odds ratio, 1.60) compared with those not involved in the diagnosis, treatment, and care of patients with COVID-19.
“These findings, consistent with those observed in the 2003 severe acute respiratory system (SARS) epidemic, may help to guide strategies for responding to mental health sequelae of this and future epidemics,” wrote Roy Perlis, M.D., a professor of psychiatry at Harvard Medical School, in an accompanying commentary.
“While the peak of the COVID-19 epidemic remains to be seen, it will ultimately subside. The work of Lai et al. provides a reminder of the toll that will likely linger: the consequences of chronic stress, including major depression and anxiety disorders. … [J]ust as the world has joined efforts to manage COVID-19 infection, it will be critical not to neglect the mental health consequences of the fight against the epidemic.”
For related information, see “Coronavirus and Mental Health: Taking Care of Ourselves During Infectious Disease Outbreaks,” by Joshua Morganstein, M.D., chair of the APA Committee on Psychiatric Dimensions of Disasters.
(Image: iStock/Hispanolistic)
APA’s COVID-19 Resource Center Keeps You Updated
APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19 crisis.
How to Participate in 2020 Minority and Underrepresented Group Caucus Election
The Caucus of Asian-American Psychiatrists is holding an election for three leadership positions: president, Assembly representative, and Assembly deputy representative. To be eligible to vote in the election, APA members must join the caucus by Wednesday, April 1. Find more information on how to join the caucus here.
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The content of Psychiatric News does not necessarily reflect the views of APA or the editors. Unless so stated, neither Psychiatric News nor APA guarantees, warrants, or endorses information or advertising in this newspaper. Clinical opinions are not peer reviewed and thus should be independently verified.
