People With Mental Illness Concerned About Worsening Illness, Access to Treatment During Pandemic

The journals of APA Publishing are receiving numerous submissions on aspects of the COVID-19 pandemic. To get information about findings to the field faster, Psychiatric News will be posting summaries of these submissions soon after acceptance.

People with mental illness reported that the COVID-19 pandemic has led them to feel greater feelings of isolation, less connected with others, and increasingly worried that their illnesses may worsen, according to a study in Psychiatric Services.

“People living with a mental illness not only have to deal with all the uncertainty related to the pandemic, but also with the possibility of disruption of the strategies each one has built to support [his or her] ongoing recovery,” wrote Mark Costa, M.D., M.P.H., of the Yale University School of Medicine and colleagues.

Costa and colleagues analyzed survey data collected by the online community ForLikeMinds, which is dedicated to promoting mental health recovery and wellness. ForLikeMinds has over 12,000 members and nearly 18,000 Facebook followers. The survey was distributed to its members and through its Facebook page. It asked participants if they self-identify as having a mental illness, what their diagnoses is, what their concerns are about the pandemic, how they are coping, and whether they feel socially connected. Participants were invited to complete the 11-question survey during the last week of March. Of the 214 people who took the survey, 193 self-identified as having a mental illness.

Almost all the respondents (98%) who identified as having a mental illness said they had at least one major concern regarding the pandemic, and 72% said they had at least three major concerns. These concerns were fears that their mental illness could worsen due to the COVID-19 pandemic (64%), they would run out of medication (38%), and/or be unable to receive mental health care (39%). Only 12% of the respondents thought they were coping well with the pandemic, and 23% said they were coping poorly.

Sixty-eight percent of respondents felt they were more isolated, and 57% felt they were less socially connected compared with before the pandemic. “Those who felt less connected were significantly more concerned about the worsening of their condition and running out of medication,” the authors wrote.

Respondents who self-identified as having an anxiety diagnosis presented more concerns: “They were the group, together with [those who have] posttraumatic stress disorder, that seems to be most affected by COVID-19,” the authors said.

Respondents who identified as having a mental illness said their preferred form of communication was text messaging, followed by the phone and social media. Those who said they were coping poorly with the pandemic were less likely to use their phones to communicate, the authors noted. “In reaching out to this population, providers should consider using text messaging and social media as preferred methods,” they wrote. “Specific measures/strategy could be developed to target this population and minimize the impact of the consequences of the COVID-19 pandemic.”

The Psychiatric Services article can be cited as follows: Costa M, Pavlo A, Reis G, et al.: COVID-19 Concerns Among Persons With Mental Illness. DOI: 10.1176/appi.ps.202000245

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Now in Psychiatric News

Psychiatric News continues to report on what the COVID-19 pandemic means for psychiatrists and the patients they serve. We will highlight these articles for you as they become available online:

C-L Psychiatrists Provide Overview of Response to COVID-19 Pandemic and Patient Management

APA’s District Branches Take Lead in Helping Psychiatrists Adjust to New Way of Working

Funding for Telehealth Available Under FCC’s COVID-19 Program

The COVID Telehealth Program, administered by the Federal Communications Commission (FCC), is offering funding to community mental health centers, teaching hospitals, medical schools, and other eligible nonprofit health systems seeking to adopt and integrate telehealth technology into their practices.

The $200 million program, funded by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, is designed to help eligible practices, hospitals, and other organizations provide and maintain telemedicine/telepsychiatry services so they can continue to provide care during the COVID-19 pandemic, while many states are still enforcing stay-at-home orders. Details about the program are posted in an FAQ on the FCC website.

Funding is limited to nonprofit and public eligible health care centers and systems that fall within the following eight categories:

• Postsecondary educational institutions offering health care instruction such as teaching hospitals and medical schools
• Community health centers or health centers providing health care to migrants
• Local health departments or agencies
• Community mental health centers
• Not-for-profit hospitals
• Rural health clinics
• Skilled nursing facilities
• Consortia of health care centers consisting of one or more entities falling into the first seven categories

Eligible entities may use the money to offset costs associated with a range of services, outlined in the FAQ, that are essential to telehealth. Eligible beneficiaries can submit applications for funding here; applications are being accepted on a rolling basis, with no current deadline.

Potential beneficiaries can determine whether they are eligible by filing an FCC Form 460 through My Portal on the webpage of the Universal Service Administration Co., an independent nonprofit designated by the FCC to administer FCC programs. Potential beneficiaries can submit applications for funding while their eligibility determinations are pending.

APA members with questions about recent telepsychiatry policy changes should contact the Practice Management Help Line at practicemanagement@psych.org.

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Now in Psychiatric News

Psychiatric News continues to report on what the COVID-19 pandemic means for psychiatrists and the patients they serve. We will highlight these articles for you as they become available online:

Patients With SMI in the Age of COVID-19: What Psychiatrists Need to Know

Risk Management Amid a Global Pandemic

Nurturing Home Environment May Protect Against Depression, AJP Study Suggests

The environment in which a child is raised may influence his or her risk of developing depression later in life, reports a study appearing today in AJP in Advance. The findings suggest that efforts to improve rearing environments for children at known risk for depression may help to reduce this risk.

“[N]umerous studies have shown that growing up with depressed parents can have a range of adverse psychiatric effects,” wrote Kenneth S. Kendler, M.D., of Virginia Commonwealth University School of Medicine and colleagues. “We sought to further clarify the role of the rearing environment in risk for major depression by utilizing a powerful natural experiment in which matched offspring of a high-risk biological parent were reared in different family environments.”

Kendler and colleagues used linked data from multiple Swedish nationwide registries and health care data to compare depression outcomes in children who shared at least one parent with major depression and were raised either by their biological parents or adoptive parents.

The full sibling database included 666 adopted individuals who had 1,254 full siblings who were raised by the biological parent(s), and the half sibling database included 2,596 adopted individuals who had 5,511 half siblings who were raised by the biological parent. The researchers tracked the full and half siblings from age 15 to the time of first registration for major depression, death, emigration, or end of follow-up (December 31, 2015).

The researchers found that compared with home-reared full and half siblings, children who had been adopted had a 23% and 19% decreased risk of major depression. “This protective rearing effect was not influenced by the relative educational status of the biological and adoptive parents. However, in both full and half sibships, the protective effect of adoption disappeared when an adoptive parent or stepsibling had major depression or the adoptive home was disrupted by parental death or divorce,” Kendler and colleagues wrote.

“The results demonstrate the strong impact of the rearing environment on risk for major depression and support the importance of intervention efforts to improve the rearing environment in high-risk families,” Myrna M. Weissman, Ph.D., of Vagelos College of Physicians and Surgeons and Mailman School of Public Health at Columbia University and the New York State Psychiatric Institute, wrote in an accompanying editorial. Still, she noted, a limitation of the study acknowledged by Kendler and colleagues was that the study relied on indirect measures of the quality of the rearing environment in the home-reared or adoptive families.

Weissman wrote, “I would be curious about Sweden’s criteria and approach to determining that the adoptive home is able to provide a ‘high-quality and stable rearing environment.’ High education and economic security, while measurable, are only part of the story. Information on a stable nurturing rearing environment and how to measure it would be useful for several domains.”

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Now in Psychiatric News

Psychiatric News continues to report on what the COVID-19 pandemic means for psychiatrists and the patients they serve. We will highlight these articles for you as they become available online:

How to Prevent Psychiatric Crises During a Pandemic

Contingency Planning for a Pandemic: Be Prepared

Isolation Puts Seniors With Substance Use Disorders at Heightened Risk During COVID-19

The social distancing and stay-at-home orders of the COVID-19 pandemic may present a challenge for people with substance use disorders by triggering anxiety, depression, or the urge to take drugs or drink alcohol. For people ages 65 or older, a population already vulnerable to the mental health effects of isolation, sequestering may be disproportionately burdensome.

“As long as social distancing guidelines remain in place, older adults in recovery from substance use disorders may find themselves cut off from support if they are unable to effectively use online treatment and self-help resources,” wrote Derek D. Satre, Ph.D., of the University of California, San Francisco, and Kaiser Permanente and colleagues in an article in the American Journal of Geriatric Psychiatry.

In the article, Satre and colleagues outlined key areas of concern for mental health professionals who work with seniors and offer guidance on how to help older patients.

Alcohol. Alcohol use can impair the immune system and increase susceptibility to pneumonia and other infectious diseases. Minimizing alcohol consumption may be critical for seniors during the pandemic, the authors wrote. They encourage mental health professionals to ask about their senior patients’ drinking habits and any recent increases in drinking that may stem from causes such as social isolation, financial stressors, anxiety, depression, or thoughts of suicide. The authors noted that pharmacologic treatments for alcohol use disorders such as naltrexone and brief behavioral interventions such as motivational interviewing can be incorporated into care, including care provided through telemedicine.

Tobacco and cannabis. Satre and colleagues noted evidence that smoking tobacco raises the risk of more severe COVID-19–related symptoms and that vaping nicotine “may damage lungs in ways that make users especially vulnerable to COVID-19–related symptoms.” They wrote that patients should be encouraged to use nicotine replacement products such as patches or gum or take anti-craving medications such as bupropion. They added that patients who use cannabis should use edible forms rather than smoke or vape.

Prescription opioids and benzodiazepines. Social distancing and quarantine may interrupt care for people with opioid use disorder and decrease their access to medication treatment, they wrote. “Lack of treatment access, in combination with social isolation, increases vulnerability to relapse and overdose for older adults during the pandemic.”

Satre and colleagues noted that although there are no published data regarding changes in benzodiazepine prescription rates associated with the pandemic, previous research has shown increased use associated with “disaster situations.” They added that the American Geriatrics Society Beers Criteria strongly recommends avoiding benzodiazepine use in seniors except in specific circumstances such as alcohol withdrawal because of the risk of cognitive impairment, falls, fractures, delirium, and other serious adverse events.

“Risks to older adults can be addressed by helping to expand access to interventions and by incorporating the assistance of partners, family, and caregivers in helping older patients use healthier coping techniques to manage stress as the pandemic continues,” they concluded.

For related information, see the Psychiatric News article “SAMHSA Issues Guidance on OUD Treatment During COVID-19.”

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Join Us for APA’s Spring Highlights Meeting This Weekend

APA’s free, live virtual Spring Highlights Meeting is just days away. Join psychiatry’s foremost experts and leaders this Saturday and Sunday, April 25 and 26, for discussions about physician leadership in a time of crisis, challenges and opportunities in research, and more. Participants in the free Spring Highlights Meeting can claim up to 10 AMA PRA Category 1 Credits and 8 hours of MOC Part 2 Credit but must register to claim credit.

Intimate Partner Violence, Child Abuse May Rise During Pandemic

The COVID-19 pandemic and the associated public health response could be causing the number of people who are the victims of intimate partner violence and child abuse to rise dramatically, according to a resource document published this week by the Substance Abuse and Mental Health Services Administration (SAMHSA).

“COVID-19 has caused major economic devastation, disconnected many from community resources and support systems, and created widespread uncertainty and panic,” the document states. “Such conditions may stimulate violence in families where it didn’t exist before and worsen situations in homes where mistreatment and violence have been a problem.”

Approximately 25% of women and nearly 10% of men have experienced intimate partner violence, sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime, according to the Centers for Disease Control and Prevention (CDC). “It is important to acknowledge that IPV [intimate partner violence] can extend beyond physical injury and result in death,” the SAMHSA document states. About 16% of homicide victims are killed by an intimate partner.

“Before the pandemic, a survivor or victim could flee a violent situation or file a protective order with the police,” the document states. “For many, such options aren’t easily available right now. A stay-at-home order can force victims to stay in a dangerous situation.”

Children are also especially vulnerable to abuse during the pandemic. According to the CDC, at least 14% of children have experienced child abuse or neglect in the past year. In 2018 nearly 1,770 children died due to abuse or neglect.

Stress levels among parents are often “a major predictor of physical abuse and neglect of children,” the document states. Due to the pandemic, parents may not have access to the support systems on which they typically rely. “Stressed parents may be more likely to respond to their children’s anxious behaviors or demands in aggressive or abusive ways,” the document states. Additionally, because schools are closed, teachers and counselors are unable to identify children who show signs of abuse or neglect and notify authorities.

The document outlines various ways to support people who are experiencing abuse, including the following:

• Work with law enforcement and other state and local officials so they understand that stay-at-home orders need to be relaxed when the home is unsafe.
• Offer virtual counseling and telephone check-ins through schools whenever possible.
• Just as hotels have helped to house the homeless or health care practitioners during the pandemic, so too should businesses and localities remember that those affected by domestic violence may also need to turn to the hospitality industry for help.
• Health care practitioners should screen all patients for intimate partner violence and child abuse.

SAMHSA also includes a list of resources for communities and clinicians to help address intimate partner violence and child abuse concerns. “We must take action to alert victims of abuse that there is help available,” the document states.

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Join Us for APA’s Spring Highlights Meeting This Weekend

APA’s free, live virtual Spring Highlights Meeting is just days away. Join psychiatry’s foremost experts and leaders this Saturday and Sunday, April 25 and 26, for discussions about physician leadership in a time of crisis, challenges and opportunities in research, and more. Participants in the free Spring Highlights Meeting can claim up to 10 AMA PRA Category 1 Credits and 8 hours of MOC Part 2 Credit but must register to claim credit.

Ethics Expert Offers Guidance on Adapting to New Boundaries in Psychiatric Care

As COVID-19 continues to upend many aspects of “normal” life, psychiatrists in all settings are forced to adapt to new and evolving boundaries in research, administration, and patient care. In an article in Psychiatric News, Claire Zilber, M.D., explores how psychiatrists can continue to establish a therapeutic connection in this new normal. Zilber is a psychiatrist in private practice in Denver, chair of the Colorado Psychiatric Society’s Ethics Committee, and a senior faculty member of the PROBE (Professional Problem Based Ethics) Program.

As many psychiatrists have shifted from seeing patients in the office to seeing them over the computer or phone, Zilber recommended psychiatrists consider integrating familiar elements from the office into the video background to help “foster a sense of continuity” for patients.

Other patients may prefer audio-only communications. “Perhaps to see me in a new environment would feel disruptive, and they prefer to imagine my voice coming from my office, although there are many other possible reasons to avoid videoconference, including fear of technology or weariness from too many video meetings in their own workdays,” she wrote.

COVID-19 didn’t just change the workspace, Zilber noted. The therapeutic process is also shifting, as patients express more requests for grounding and reassurance and ask questions about how she’s coping with the pandemic.

“In the old way of the world, I would have moved asymptotically around questions that shifted the focus onto me. In a mere couple of weeks, the frame has bent; delicately avoiding these questions would feel unkind, almost inhumane,” Zilber continued. “We are two human beings doing our best to manage a crisis together. I strive to be a role model for coping and resilience, and that includes being honest and authentic in new ways.”

Zilber noted that as the COVID-19 pandemic continues to evolve, further shifts are likely. And when the pandemic recedes, there will likely be questions on how or even whether psychiatrists can restore their former routines. “Will interpersonal boundaries fall back into their old places, or will they be fundamentally altered by this shared experience?”

To read the full article, see the Psychiatric News article “Surreal Boundary Shifts During a Pandemic.”

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Join Us for APA’s Spring Highlights Meeting This Weekend

APA’s free, live virtual Spring Highlights Meeting is just days away. Join psychiatry’s foremost experts and leaders this Saturday and Sunday, April 25 and 26, for discussions about physician leadership in a time of crisis, challenges and opportunities in research, and more. Participants in the free Spring Highlights Meeting can claim up to 10 AMA PRA Category 1 Credits and 8 hours of MOC Part 2 Credit but must register to claim credit.

APA Calls for Emergency Funding as COVID-19 Overwhelms Behavioral Health System

The behavioral health system is “collapsing,” despite an increase in anxiety, fear, grief, and substance use related to the global COVID-19 pandemic, according to a statement signed by APA and 11 other organizations and sent to Congressional leadership yesterday as Congress prepares to approve another round of COVID-related federal funding.

The funding under consideration is primarily focused on shoring up existing programs—especially the Small Business Administration (SBA) Paycheck Protection Program, which ran out of money last week. Congressional Democrats are hoping to add funding for hospitals, state governments, and a nationwide testing program for COVID-19. The bill is expected to be approved by Congress this week.

APA and the other groups are hoping to alert Congress to the dire need for funding for mental and substance use treatment programs. “Before the pandemic broke out, there was bipartisan consensus that addressing mental health, substance use, and suicide were urgent national priorities. Congress took preliminary steps to increase funding for mental health and addiction services, but these investments may soon be lost because of the financial strain COVID-19 has taken on our mental health and addiction system,” the coalition stated.

Citing a survey conducted by the National Council for Behavioral Health, the coalition noted that many behavioral health organizations “don’t have the funds they need to ride out this crisis.” The survey of 880 behavioral health organizations across the country revealed that 62% believe they can survive financially for only three months or less under current conditions. “Organizations have cancelled, rescheduled, or turned away 31% of patients, and 92% have reduced their operations,” they wrote.

The statement noted that the CARES Act included funding to health care professionals, with a priority on paying hospitals through Medicare. However, community behavioral health organizations rely primarily on Medicaid and have largely been left out of critical emergency funding. “We urge Congress to dedicate significant resources specifically to supporting community behavioral health programs during the crisis,” the coalition stated. The coalition also called for $1 billion each to the SAMHSA Community Mental Health Services block grant and the Substance Abuse Prevention and Treatment block grant programs.

“Our nation’s behavioral health system is crumbling because of COVID-19 at a time when we should be strengthening it to help those in need when the pandemic ends,” said APA President Bruce Schwartz, M.D.

APA CEO and Medical Director Saul Levin, M.D., M.P.A., agreed. “It is hoped that Congress and the Trump administration will support what is expected to be an increased need for services for those with mental and substance use disorders as well as the general population in the wake of COVID-19.”

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APA Members Invited to Join AHA Webinar to Focus on Lessons Learned Regarding Behavioral Health Services During COVID-19 Pandemic

Wednesday, April 22, 2-3 p.m. ET

Senior leaders from Baltimore’s Sheppard Pratt Health System, including President and CEO and AHA Trustee Harsh Trivedi, M.D., will discuss how they re-engineered care processes, developed new care protocols for agitated patients, and created a virtual emergency department assessment to decrease the number of psychiatric patients in the ED during the COVID-19 surge. Sheppard Pratt also will discuss its efforts to support staff and build resilience during the crisis. Register for the webinar here.

State Reforms Can Bolster Support for SMI Patients, Providers Through COVID-19

The journals of APA Publishing are receiving numerous submissions on aspects of the COVID-19 pandemic. To get information about findings to the field faster, Psychiatric News is posting summaries of these submissions soon after journal submissions are accepted.

People with serious mental illness (SMI) are particularly vulnerable to COVID-19. The authors of an article in press at Psychiatric Services describe policy, regulatory, and payment reforms in Massachusetts to ensure that patients with SMI have access to the care they need during this critical time.

“Rapidly implementing measures at state and local levels may not only contribute to mitigating the disproportionate morbidity, mortality, and spread of COVID-19 for people with serious mental illness, but may have substantial implications for reducing the impact of this pandemic for the broader population of vulnerable adults with complex physical, social, and psychological needs and disabilities,” wrote Stephen J. Bartels, M.D., M.S., of Harvard Medical School and colleagues.

Among the emergency policy and financing initiatives rolled out by the state in response to COVID-19 were the following:

• State Medicaid, third-party, and federal Medicare and HIPAA waivers allowing extensive use of provider-to-person home and community-based telehealth assessments and treatments.
• Guaranteed coverage for all individuals with MassHealth as of March 18, and for all individuals approved for coverage during the COVID-19 national emergency and one month after the emergency period ends.
• Over $100 million in stabilization funding to support the salaries of essential residential, outpatient, and institution-based behavioral health professionals.
• Approval of temporary three-month medical licenses for graduating medical students and recently retired physicians.

“These and other adopted measures could subsequently translate to downstream reforms in how we care for these populations during more ordinary times,” the authors wrote. “Once we make it through this crisis and reflect on the lessons learned in implementing these innovations and reforms, we should not waste this potentially transformative opportunity by returning to business as usual.”

For related news, see the Psychiatric News article “Patients With SMI in the Age of COVID-19: What Psychiatrists Need to Know.”

The article is in press at Psychiatric Services and can be cited as follows: Bartels SJ, Baggett TP, Freudenreich O, Bird BL: Case Study of Massachusetts COVID-19 Emergency Policy Reforms to Support Community-based Behavioral Health and Reduce Mortality of People With Serious Mental Illness.

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APA Members Invited to Join AHA Webinar to Focus on Lessons Learned Regarding Behavioral Health Services During COVID-19 Pandemic

Wednesday, April 22, 2-3 p.m. ET

Senior leaders from Baltimore’s Sheppard Pratt Health System, including President and CEO and AHA Trustee Harsh Trivedi, M.D., will discuss how they re-engineered care processes, developed new care protocols for agitated patients, and created a virtual emergency department assessment to decrease the number of psychiatric patients in the ED during the COVID-19 surge. Sheppard Pratt also will discuss its efforts to support staff and build resilience during the crisis. Register for the webinar here.

Federal Agencies Offer Financial Assistance for Health Care Professionals and Practices

Psychiatrists and other health care professionals who need financial support to continue to provide services during the COVID-19 pandemic may be eligible for assistance from the federal government. There are several options to choose from depending on practice setting and services provided. The options include the following:

• The COVID-19 Telehealth Program, a $200 million program administered by the Federal Communications Commission, is now accepting applications to help health professionals who provide telehealth services to patients in their homes or in mobile locations during the pandemic. This program is part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act passed by Congress in March. It will enable eligible nonprofit and public health care professionals to purchase telecommunications equipment, broadband connectivity, and devices necessary to engage in telehealth. This program is not a grant program. Eligible health care professionals who are approved for funding will be required to submit an invoicing form and supporting documentation to receive reimbursement for eligible expenses and services.
• The Public Health and Social Services Emergency Fund is also part of the CARES Act. The Department of Health and Human Services (HHS) is beginning to disburse the first part of the $100 billion dollar fund. As part of the CARES Act Provider Relief Fund, these payments are not loans and will not need to be repaid, although recipients must accept the terms and conditions of the payments. Eligible recipients will receive a portion of the initial $30 billion based on their share of total Medicare fee-for-service reimbursements in 2019.
• The Centers for Medicare & Medicaid (CMS) has expanded its Accelerated and Advanced Payment Program to a broader group of those who provide care through Medicare Part A or Part B. CMS is authorized to provide accelerated or advance payments during the period of the public health emergency to those who submit a request to the appropriate Medicare Administrative Contractor and meet the required qualifications. CMS has extended the repayment of the accelerated and advance payments to begin 120 days after the date the payment was issued.

(Image: iStock/flySnow)

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APA Members Invited to Join AHA Webinar to Focus on Lessons Learned Regarding Behavioral Health Services During COVID-19 Pandemic

Wednesday, April 22, 2-3 p.m. ET

Senior leaders from Baltimore’s Sheppard Pratt Health System, including President and CEO and AHA Trustee Harsh Trivedi, M.D., will discuss how they re-engineered care processes, developed new care protocols for agitated patients, and created a virtual emergency department assessment to decrease the number of psychiatric patients in the ED during the COVID-19 surge. Sheppard Pratt also will discuss its efforts to support staff and build resilience during the crisis. Register for the webinar here.

Harnessing Resiliency Said to Be Key Path Forward From COVID-19

During the era of COVID-19, health care workers and organizations must be deliberate about promoting resilience, wrote Abby R. Rosenberg, M.D., M.S., M.A., of the University of Washington School of Medicine in Seattle in an article published in JAMA Pediatrics.

“The potential for resilience is not a unique trait that one has or does not have; the capacity for resilience is inherent in all people,” she wrote. “Resilience is neither lucky nor passive. It takes deliberate effort. Indeed, while resilience researchers have quibbled over nuanced definitions and requirements for resilience, they agree that it can be strengthened with practice.”

Health care workers and organizations should harness what Rosenberg refers to as “resilience resources”: individual (personal characteristics and skills), community (social supports and sense of connection), and existential (sense of meaning and purpose).

Rosenberg described ways individual health care workers might bolster resiliency by setting short-term goals for working from home or self-care after a stressful day on the hospital ward. For organizations, it may involve “deliberately celebrating systems-level steps toward shared community goals, such as evidence that local social distancing practices are beginning to flatten the curve,” she wrote.

To bolster community resiliency, professionals and organizations could work to develop connections via frequent video conferences and communication of COVID-19 policies.

To strengthen existential resiliency requires finding ways to continue to develop a sense of meaning and purpose. “[P]rofessionals and organizations might deliberately consider the value of their contributions; appreciate experiences, people, and things for which they are grateful; or ground themselves by recalling their missions to help vulnerable populations,” Rosenberg wrote.

“So, let us now be proactive,” she concluded. “Let us imagine our future narrative and direct ourselves toward its end. Let us harness our individual, community, and existential resources so that we not only navigate this experience but also continue to thrive.”

(Image: iStock/Juanmonino)

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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.

Survey Reveals Challenges Faced by Psychiatric Patients in China Amid COVID-19 Outbreak

The journals of APA Publishing are receiving numerous submissions on aspects of the COVID-19 pandemic. To get information about findings to the field faster, Psychiatric News is posting summaries of these submissions soon after journal submissions are accepted.

More than 20% of patients diagnosed with depression, bipolar disorder, or schizophrenia who receive care at a large Chinese medical center reported they were not able to receive their routine care due to suspended hospital visits during the COVID-19 pandemic. This was one of the findings of a survey reported in an article in press in the American Journal of Psychiatry.

Moreover, nearly all of those patients with existing diagnoses who couldn’t get care experienced a deterioration in their condition. Almost a quarter of new patients experiencing anxiety, depression, or insomnia could not get timely care, the survey found.

“[O]ur data reiterated the importance of implementing appropriate mental health measures in the face of the COVID-19 pandemic,” wrote Junying Zhou, M.D., Ph.D., of West China Hospital of Sichuan University in Chengdu, China, and colleagues.

Using the “Questionnaire Starr” survey program on WeChat, a popular Chinese smartphone application, Zhou and colleagues surveyed 2,065 outpatients seeking care in the departments of Psychiatry, Neurology, or Sleep Medicine in West China Hospital from February 25 to March 9. There were 589 new patients and 1,476 patients with existing psychiatric diagnoses. Here are the major findings:

• 25.5% of the respondents in the combined groups experienced anxiety (defined as a score of 5 or more on the Generalized Anxiety Disorder-7 scale), and 26.2% experienced insomnia (defined as a score of 8 or more on the Insomnia Severity Index). Just under 17% experienced depression (defined as a score of 5 or more the Patient Health Questionnaire-9).
• Among existing patients, 22.2% could not get their routine care, and 20.9% experienced a deterioration in symptoms. Just over 17% stopped taking their medications because of problems related to filling their prescriptions during the outbreak.
• Among new patients, 24.5% could not get “timely diagnosis and treatment” at the hospital. These included 46 patients with anxiety, 37 patients with depression, 79 patients with insomnia, and 21 patients with schizophrenia.

The researchers wrote that “transport restriction, isolation at home, and fear of cross-infection in the hospital have inevitably become the major concerns and barriers to treatment for these patients during the outbreak.”

The researchers noted that a number of hospitals in China have initiated telemedicine services for patients in need, and in January, West China Hospital opened a free online outpatient service to provide prescriptions to existing patients and consultations to new patients. Although thousands of patients have received health care through this service, only 7.4% of those with mental disorders in the survey did so. “Thus, there is a need for promoting online mental health services across China to manage mental problems during the pandemic,” they wrote.

(Image: PeopleImage/shutterstock.com)

The commentary describing the results of the survey is in press at the American Journal of Psychiatry and can be cited as follows: Zhou J: Mental health response to COVID-19 outbreak in China. Am J Psychiatry [doi: 10.1176/appi.ajp.2020.20030304]

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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.

Take Steps Now to Mitigate Mental Health Effects of COVID-19

In the aftermath of disaster, there is often an uptick in the number of people with mental and behavioral disorders. Experts predict the same is likely to emerge in the wake of COVID-19.

“In the context of the COVID-19 pandemic, it appears likely that there will be substantial increases in anxiety and depression, substance use, loneliness, and domestic violence; and with schools closed, there is a very real possibility of an epidemic of child abuse,” wrote Sandro Galea, M.D., of Boston University School of Medicine; Raina M. Merchant, M.D., of Perelman School of Medicine; and Nicole Lurie, M.D., of the Coalition for Epidemic Preparedness Innovations in Norway, in an article in JAMA Internal Medicine. “This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care and to emerge from this pandemic with new ways of doing so.”

Galea, Merchant, and Lurie recommended three steps they believe can help to address the likely rise of mental disorders and related challenges from the pandemic:

Make plans to address loneliness and its aftereffects as populations physically isolate and to develop ways to intervene. Even while physically separated, digital technologies can be used to create spaces for connection and structure through shared online activities and gatherings, the authors wrote. They emphasized the importance of “developing and implementing routines, particularly for children who are out of school, ensuring that they have access to regular programmed work,” but noted that not all children have access to technologies that allow them to connect remotely. They also described the importance of reaching out to groups often marginalized (including elderly people and those with mental illness) and the ways that social media can be used to connect individuals to reputable resources for mental health support.

Have mechanisms in place for surveillance, reporting, and intervention, particularly when it comes to domestic violence and child abuse. “Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home. Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they wrote.

Bolster the mental health system. Innovative approaches will also need to be developed to meet the need for mental health services, Galea, Merchant, and Lurie wrote. They described the value of stepped care to identify patients with the greatest mental health needs early on and refer for additional treatment as needed. “Telemedicine mental health visits, group visits, and delivery of care via technology platforms will be important components of stepped care for both acute crisis management and more routine communication and support.”

Additionally, the authors recommended that communities and organizations consider training nontraditional groups to provide psychological first aid and educate the public on ways to check in with one another and provide support. “Even small signs that someone cares could make a difference,” they wrote.

“The worldwide COVID-19 pandemic, and efforts to contain it, represent a unique threat, and we must recognize the pandemic that will quickly follow it—that of mental and behavioral illness—and implement the steps needed to mitigate it,” they concluded.

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Experts Warn of Potential of COVID-19 to Increase Suicide Risk

The rapid spread of the novel coronavirus (COVID-19) has led to dramatic public health actions at a national level to reduce human contact in hopes of slowing virus transmission. In an article published in JAMA Psychiatry, mental health experts discuss the potential of this long-term isolation to increase suicide risk.

“Concerns about negative secondary outcomes of COVID-19 prevention efforts should not be taken to imply that these public health actions should not be taken,” wrote Mark Reger, Ph.D., of the University of Washington and colleagues. “However, implementation should include a comprehensive approach that considers multiple U.S. public health priorities, including suicide prevention. There are opportunities to enhance suicide prevention services during this crisis.”

Among the notable factors contributing to suicide risk during this pandemic are the economic difficulties and social isolation being experienced by so many, Reger and colleagues wrote. Beyond the reduced connections to family, friends, and community, the stay-at-home directives also create barriers to accessing mental health treatment, the authors continued. For example, at some care facilities, patients cannot be accompanied by a family member during an appointment, which creates problems for patients with young children who are out of school. 

“In addition to anxiety, many people are struggling with guilt, which is known to have toxic effects on mental health,” Maria A. Oquendo, M.D., Ph.D., the Ruth Meltzer Professor and Chair of Psychiatry at the University of Pennsylvania and past president of APA, told Psychiatric News. She noted that guilt could take the form of people thinking they exposed others to the virus, as well as other worries such as thinking they are not doing enough to help care for others.

Reger and colleagues also noted reports on a surge in firearm sales as concerning, given the strong connection between firearm access and suicide rates. And, they noted that suicides tend to peak in the late spring/early summer in the Northern hemisphere, which coincides with the predicted peak of COVID-19 prevention efforts in the United States.

To help counter these risks, psychiatrists and mental health professionals should determine ways to incorporate mental health screening into COVID-19 screening and prevention efforts. They should also consider ways to reach patients who are using tele-mental health services or receiving care in alternative treatment settings (such as a private space outside). They also noted the value of social media to help patients maintain social connections despite physical restrictions.

“There may be a silver lining to the current situation. Suicide rates have declined in the period after past national disasters (for example, the September 11, 2001, terrorist attacks),” Reger and colleagues wrote. “One hypothesis is the so-called pulling together effect, whereby individuals undergoing a shared experience might support one another, thus strengthening social connectedness. Recent advancements in technology (for example, videoconferencing) might facilitate pulling together.”

Oquendo agreed that it is not uncommon for suicide rates to recede in the context of a major crisis, “but we cannot be complacent; the entire population is going through a period of heightened stress right now. In the next few months we will see the psychiatric [after-effects] of this crisis emerge.”

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APA, Coalition Seek Emergency Funding for Mental Health Organizations During COVID-19 Pandemic

APA has joined the National Council for Behavioral Health, the American Society of Addiction Medicine, and 37 other mental health organizations to urge Congress to approve $38.5 billion in emergency funding to support the behavioral health care system during the COVID-19 public health crisis. The funding would support Community Mental Health Centers, crisis service providers, and other organizations whose primary mission is to treat people who have mental or substance use disorders. A significant portion of the money would go to behavioral health organizations that provide care to Medicaid beneficiaries.

The request comes at a time when local mental health and addiction organizations have begun to lay off staff and face hard decisions about limiting services or shutting down, yet the need for their services is on the rise. A national poll released by APA in late March found that more than 36% of Americans say that coronavirus is having a serious impact on their mental health, 19% are having trouble sleeping, and 8% have been consuming more alcohol or other drugs/substances.

“As the COVID-19 pandemic continues, the need for mental health services will only rise,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We must not only ensure that our communities have access to these services, we must also prepare for a surge in mental health and substance use disorder patients that will occur both during the pandemic and in its aftermath.”

The $38.5 billion figure is based on a survey by the National Council for Behavioral Health in which its members, community behavioral health organizations, projected how much revenue they would lose because of the pandemic. The projections include lost revenue from all sources, including Medicaid, Medicare, and private donations, among others.

Thus far Congress has approved three COVID-19 packages that have allocated hundreds of billions of dollars for health care, yet none of the funding has been dedicated specifically to mental and behavioral health organizations. APA is calling on psychiatrists to take action and reach out to their senators and representatives in support of the $38.5 billion request. Psychiatrists may contact their lawmakers using a prepared message offered through APA’s online advocacy tool. Legislators’ contact information is automatically generated once the user enters his/her zip code.

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Guidance From APA on Deployment of Psychiatrists, Trainees During COVID-19 Crisis

The following is a message to APA members from APA CEO and Medical Director Saul Levin, M.D., M.P.A.

We know there have been a number of discussions on COVID-19 and physician redeployment from a variety of APA groups. The APA Executive Committee has discussed this issue and developed the following statement below for APA members to use as needed:

As the COVID-19 pandemic continues to spread and reaches its peak at different times across the country, hospitals are turning as many beds as possible into intensive care beds to meet the demands of the rapidly growing patient population. Psychiatrists across the country are already helping support the mental and physical health of patients and their colleagues across medicine by providing stress management, support groups, urgent mental health evaluations, and other core psychiatric services, including for patients who have been affected by COVID-19.

Many hospitals and health care systems are calling on physicians, regardless of their specialty, to redeploy to areas beyond their specialty to meet the current medical needs of COVID-19 patients. As physicians, we are trained and can contribute to these teams during this ongoing pandemic.

For psychiatry residents and fellows who are currently in accredited residency training programs, APA recommends that hospitals follow the Accreditation Council for Graduate Medical Education Guidelines for Stage 3: Pandemic Emergency Status Guidance. The guidelines allow residents to redeploy to other units if requirements are met that ensure adequate supervision and resources on that unit.

For practicing psychiatrists who volunteer or are called upon by their hospital to help on nonpsychiatric units, APA recommends that they be part of a care team, are provided appropriate supervision for the clinical circumstance, and are provided with personal protective equipment (PPE) to ensure they can deliver care in a safe and effective manner.

States need to expand “good Samaritan” immunity and provide immunity for physicians who are serving during this crisis, and hospitals need to ensure that their insurance coverage extends to all physicians who serve the hospitals’ patients during this crisis, even if they are serving outside of their medical specialty.

Psychiatric units must ensure that psychiatric patients continue to receive high-quality psychiatric care and medical treatment during this pandemic. APA supports and thanks psychiatrists and trainees who bring medical experience and training as well as a range of psychiatric services to patients during this crisis.

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Expert Offers Guidance on Helping Seniors Handle COVID-19 Stresses

Navigating the critical need for social distancing and the enduring human need for social contact is a challenge for nearly everyone living through the worldwide COVID-19 pandemic. For seniors—at heightened risk of serious complications from COVID-19, yet also susceptible to the adverse effects of loneliness and social isolation—it may be especially trying.

Psychiatrists and mental health professionals can assist seniors during this time by drawing on their strengths of experience and resilience as well as resources available in the community.

“This is a perfect storm,” Yeates Conwell, M.D., director of the University of Rochester Medical Center Office for Aging Research and Health Services, said of the delicate balance between the need for social distancing and the psychiatric risks of loneliness in older adults. For instance, data from Hong Kong following the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic showed that there was nearly a 30% increase in suicide among people aged 65 or older, with women at higher risk than men. Moreover, research looking at coroners’ reports suggested that what was driving the phenomenon, in addition to fear of becoming ill, was loneliness and loss of social support, according to Conwell. “We have also known for a long time that social connectedness is protective [against suicide],” he said.

But seniors have important strengths that can be leveraged, Conwell said. By virtue of age and experience, older people can often accept dramatic changes, such as are being necessitated by the pandemic, with greater equanimity than can younger people. Moreover, seniors have learned to value close relationships with a handful of really important people in their lives over large numbers of superficial acquaintances.

In addition, Conwell offered the following recommendations for mental health professionals working with older patients:

• Advise patients and family members to be creative about using telephone, Skype, Zoom, or other technologies to maintain regular contact with the most important people in patients’ lives. Social distancing can be mitigated by staying in contact—through whatever means are available—with the people who matter most.
• Empower patients by reminding them that they can be helpful to others by initiating contact with grandchildren and other family and friends. Loneliness tends to be embarrassing to talk about and stigmatizing, Conwell said, but seniors can be the ones who offer solace and companionship to those suffering from social distancing.
• Encourage patients to get regular exercise. Even taking walks outside while maintaining an appropriate distance from other individuals is mentally and physically beneficial. Moreover, maintaining a regular schedule with daily times set aside for walking or other exercise can help maintain a sense of normalcy.
• Psychiatrists can work with social service agencies in the community that will help older adults with social connectedness. In Rochester, Conwell partners with the nonprofit Lifespan, a community aging services agency helping people stay connected by delivering meals and providing in-home and telephone-based supports.

“There is only so much that health care professionals can do in the current crisis,” Conwell said. “This is a problem that requires a public health approach that includes drawing on resources in the community that are there to help in times of crisis and can be enormously beneficial to older people and their physicians.”

For related information, see the Psychiatric News article “Loneliness Persists Even When Older Adults Live in Social Environments.”

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Psychiatrists Offer Insights, Guidance Regarding SMI Patients During COVID-19 Pandemic

The information regarding the impacts of COVID-19 has come fast and furious—but most guidelines, advisories, and directives that have emerged in recent weeks have focused on the general public, with little mention of treating those with serious mental illness (SMI). In an article published online today in Psychiatric News, APA President-elect Jeffrey Geller, M.D., M.P.H., and Margarita Abi Zeid Daou, M.D., both of the University of Massachusetts Medical School, offer an overview of COVID-19 issues as they impact inpatients and outpatients with SMI. These issues include symptoms, service locations, comorbidities, and medications.

“Our aim is to heighten awareness of the interfaces between COVID-19 and SMI to facilitate informed treatment of people with SMI during this pandemic, with each hospital and outpatient setting knowingly modifying what it does to meet local needs,” Geller and Abi Zeid Daou wrote.

Working with patients with SMI through the COVID-19 pandemic requires that psychiatrists and mental health professionals pay attention to the many ways that common SMI symptoms—such as hallucinations, cognitive deficits, and anxiety—might impact the ability of patients to successfully engage in treatment, grasp the severity of the pandemic, and/or even recognize COVID-19 symptoms, the authors wrote. For instance, auditory hallucinations can interfere with a patient’s ability to communicate with a doctor over the phone, and paranoia can escalate when required to communicate through electronic devices. Similarly, cognitive deficits can make it challenging for a patient to follow new handwashing and social distancing practices. 

Geller and Abi Zeid Daou described the challenges that staff at psychiatric hospitals and residential settings for individuals with SMI now face, as they implement procedures to prevent the possible spread of COVID-19. Such procedures include restricting hospitalized patients to their own unit, which the authors noted in some cases “were never designed to have patients stay in them during the day”; and in residential settings, reducing the amount of time residents spend in common areas, staggering mealtimes, and excluding visitors.

“For many persons with mental illness, being alone is a terrible burden, far beyond that experienced by many others. … Loneliness precipitates psychiatric symptoms in those without SMI, let alone those with these disorders,” they noted, adding that the message of social distancing can be hard for some patients with SMI to grasp. “A clubhouse member living at home said, ‘For years they told me not to isolate myself and to be out with other people. Now they’re telling me to stay home and isolate myself. I’m confused.’”

Nonetheless, efforts to prevent the spread of COVID-19 among patients with SMI are critical, as these patients are likely at greater risk than the general public, due to their worse physical health and potential side effects of medications commonly used to treat their symptoms, the authors wrote.

“Like so many others in health care, we now find ourselves in rough waters with one broken oar in a craft that requires two paddles. In this health care crisis, psychiatry, like every other medical discipline, finds itself venturing forth in practice patterns with which we have no experience,” they concluded. “We might do well to heed the words of Mahatma Gandhi: ‘You may never know what results come of your actions, but if you do nothing, there will be no results.’”

To read the full article, see the Psychiatric News article “Patients With SMI in the Age of COVID-19: What Psychiatrists Need to Know.”

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Five Strategies to Protect Patients, Staff in Psychiatric Inpatient Units From COVID-19

The journals of APA Publishing are receiving numerous submissions on aspects of the COVID-19 pandemic. To get information about findings to the field faster, Psychiatric News is posting summaries of these submissions soon after journal submissions are accepted.

For psychiatric inpatient facilities, the coronavirus (COVID-19) pandemic presents unique challenges related to space constraints, close contact between staff and patients, and structural barriers in care delivery, according to an article in press in Psychiatric Services.

“Beyond the direct challenges in physical space and exposure risks to staff and patients, there are additional indirect challenges that can impact services delivery in inpatient psychiatric settings during a pandemic,” wrote Luming Li, M.D., of the Yale School of Medicine.

Li outlined five strategies for responding to COVID-19 in inpatient psychiatric facilities:

Manage COVID-19 precautions: Inpatient psychiatric facilities should consider screening patients for respiratory symptoms and fever prior to admission, as well as throughout the patient’s hospitalization. Staff should use personal protective equipment (PPE) when patients develop fever and respiratory symptoms, and surfaces should be cleaned and disinfected often, especially those that are frequently used.

Restrict visitors and minimize nonessential contacts: To protect essential staff and patients from potential COVID-19 exposure, inpatient psychiatric facilities should restrict visitations by family members, nonessential employees, and trainees. Preventing visitors, however, may impact patients’ treatment course, affect how patients reconnect with family members, and cause significant anxiety for family members.

Develop contingency staff plan: Li noted that a national shortage of psychiatrists will likely worsen during the COVID-19 pandemic, as they are exposed and become ill. Li encouraged administrators and clinical leaders to consider back-up plans for staffing. These plans might include reducing team sizes so that an alternate team is available should frontline workers be unable to continue to provide care and incorporating telepsychiatry to deliver services to minimize staff exposure.

Plan for patients suspected of COVID-19: Patients who develop symptoms of COVID-19 should immediately be given a mask and gown and isolated to minimize spread. Due to the difficulty of isolating patients on psychiatric units, which often have open layouts, steps should be taken to transfer patients to inpatient medicine for COVID-19 testing. Patients who develop COVID-19 symptoms should be monitored closely for worsening of psychiatric symptoms and the emergence of new psychiatric symptoms.

Modify group therapy: Though group therapy can be an important aspect of treatment, facilities may need to change the way group meetings take place, including limiting the number of individuals who can participate at one time and enhancing social distancing.

“With increasing volumes of individuals seeking care, it is important to strategically plan and advocate for services and resources to support high-quality, safe psychiatric care delivery,” she advised. “Otherwise, psychiatric patients will be vulnerable … not only from their mental illness but also from the repercussions of COVID-19.”

This Open Forum article is in press at Psychiatric Services and can be cited as follows: Li L: Challenges and priorities in responding to COVID-19 in inpatient psychiatry. Psychiatric Services.

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Speakers Share Insights on Inpatient Psychiatric Care During COVID-19 Pandemic

Inpatient psychiatric units all over the country are grappling with the need to continue treating patients in the midst of the coronavirus (COVID-19) pandemic. On Wednesday, APA and the National Association for Behavioral Healthcare hosted a webinar with the leaders of three inpatient facilities so they could share their experiences so far.

The leaders were Harsh Trivedi, M.D., M.B.A., president and CEO of Sheppard Pratt Health Systems in Maryland; Ryan Kimmel, M.D., chief of psychiatry at the University of Washington Medical Center; and Frank A. Ghinassi, Ph.D., A.B.P.P., president and CEO of Rutgers University Behavioral Health Care. APA Education Director Tristan Gorrindo, M.D., moderated the webinar.

The speakers stressed the importance of addressing COVID-19 in health systems in a way that does not limit people’s access to behavioral health care. “We’re trying not to reduce our inpatient psychiatry footprint,” Kimmel said. “If anything, we’re trying to increase it.”

The participants outlined strategies they’ve adopted to deliver psychiatric care during the COVID-19 crisis, including the following:

Setting up remote services wherever possible: The participants explained that their systems have worked to rapidly provide outpatient services through telemedicine.

Trivedi said Sheppard Pratt is working to launch a virtual assessment service for patients in crisis. When patients on inpatient wards test positive for COVID-19, Ghinassi said his staff use video technology to allow patients to participate in educational and group activities from their rooms.

Restricting outside visitor access: Ghinassi said his system’s inpatient units and screening facilities have stopped allowing visitors. The only exception to this protocol is pediatric patients, some of whom are as young as 6 or 7. The policy allows visitors on a case-by-case basis, but “as difficult as it is, we have not allowed more than one or two of those visits to actually happen,” he said. “We are making ample access to video technology … to allow the parents to visit virtually, but visiting has, for all practical purposes, ceased on any of our units.”

The system has also started doing temperature scans of everybody who comes in and out of the buildings on a daily basis, Ghinassi said.

Using personal protective equipment (PPE) carefully: Typically, on inpatient psychiatric units, plastic biohazard bags or PPE supplies that could be used as ligatures must be stored where patients cannot access them, Kimmel explained.

“On our inpatient unit we’ve had to develop systems where inside the patient’s room is a locking closet, to which the staff has a key but the patient doesn’t, where we store some of the supplies and the biohazard bags,” he said.

Supporting staff: Communication has been essential for each of the participants and their staffs, they said. Information from the Centers for Disease Control and Prevention and local departments of health changes rapidly, they said, and strong lines of communication with staff are vital. Kimmel said the University of Washington Medical Center has set up a peer-to-peer program to support staff.

“We are all human beings, and we are all relationship-based,” Trivedi said. “Within our messages we ask: How do we take the time to support one another?”

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