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COVID-19: Addressing the mental health needs of clinicians
SARS-CoV-2 and the disease it causes, COVID-19, continues to spread around the world with a devastating social and economic impact. Undoubtedly, health care workers are essential to overcoming this crisis. If these issues are left unaddressed, low morale, burnout, or absenteeism could lead to the collapse of health care systems.
Historically, the health care industry has been one of the most hazardous environments in which to work. Employees in this industry are constantly exposed to a complex variety of health and safety hazards.
Particularly, risks from biological exposure to diseases such as tuberculosis, HIV, and currently COVID-19 are taking a considerable toll on health care workers’ health and well-being. Health care workers are leaving their families to work extra shifts, dealing with limited resources, and navigating the chaos. On top of all that, they are sacrificing their lives through these uncertain times.
Despite their resilience, health care workers – like the general population – can have strong psychological reactions of anxiety and fear during a pandemic. Still, they are required to continue their work amid uncertainty and danger.
Current research studies on COVID-19
Several studies have identified the impact of working in this type of environment during previous pandemics and disasters. In a study of hospital employees in China during the SARS epidemic (2002-2003), Ping Wu, PhD, and colleagues found that 10% of the participants experienced high levels of posttraumatic stress.1 In a similar study in Taiwan, researchers found that 17.3% of employees had developed significant mental health symptoms during the SARS outbreak.2
The impact of COVID-19 on health care workers seems to be much worse. A recent study from China indicates that 50.4% of hospital employees showed signs of depression, 44.6% had anxiety, and 34% had insomnia.3
Another recent cross-sectional study conducted by Lijun Kang, PhD, and associates evaluated the impact on mental health among health care workers in Wuhan, China, during the COVID-19 outbreak. This was the first study on the mental health of health care workers. This study recruited health care workers in Wuhan to participate in the survey from Jan. 29 to Feb. 4, 2020. The data were collected online with an anonymous, self-rated questionnaire that was distributed to all workstations. All subjects provided informed consent electronically prior to participating in the survey.
The survey questionnaire was made up of six components: primary demographic data, mental health assessment, risks of direct and indirect exposure to COVID-19, mental health care services accessed, psychological needs, and self-perceived health status, compared with that before the COVID-19 outbreak. A total of 994 health care workers responded to this survey, and the results are fascinating: 36.9% had subthreshold mental health distress (mean Patient Health Questionnaire–9 score, 2.4), 34.4% reported mild disturbances (mean PHQ-9, 5.4), 22.4% had moderate (mean PHQ-9, 9.0), and 6.2% reported severe disturbance (mean PHQ-9, 15.1). In this study, young women experienced more significant psychological distress. Regarding access to mental health services, 36.3% reported access to psychological materials, such as books on mental health; 50.4% used psychological resources available through media, such as online self-help coping methods; and 17.5% participated in counseling or psychotherapy.4
These findings emphasize the importance of being equipped to ensure the health and safety of health care workers through mental health interventions, both at work and in the community during this time of anxiety and uncertainty.
Future studies will become more critical in addressing this issue.
Risks to clinicians, families prevail
According to a recent report released by the Centers for Disease Control and Prevention, more than 9,000 health care workers across the United States had contracted COVID-19 as of mid-April, and 27 had died since the start of the pandemic.5
Health care workers are at risk around the globe, not only by the nature of their jobs but also by the shortage of personal protective equipment (PPE). In addition, the scarcity of N95 masks, respirators, and COVID-19 testing programs is causing the virus to spread among health care workers all over the world.
A study published recently by Celso Arango, MD, PhD, reported that 18% of staff at a hospital in Madrid had been infected with COVID-19. Dr. Arango speculated that transmission might be attributable to interactions with colleagues rather than with patients.6 We know, for example, that large proportions of people in China reportedly carried the virus while being asymptomatic.7 Those findings might not be generalizable, but they do suggest that an asymptomatic person could be a cause of contagion among professionals. Therefore, early screening and testing are critical – and should be priorities in health care settings.
Another problem clinicians can encounter is that, when they are called on to deal with very agitated patients, they might not get enough time to put on PPE. In addition, PPE can easily break and tear during the physical restraint process.
Working long hours is also putting a significant strain on health care workers and exposes them to the risk of infection. Also, health care workers not only worry about their safety but also fear bringing the virus to their families. They can also feel guilty about their conflicting feelings about exposing themselves and their families to risk. It is quite possible that, during this COVID-19 pandemic, health care workers will face a “care paradox,” in which they must choose between patients’ safety and their own. This care paradox can significantly contribute to a feeling of burnout, stress, and anxiety. Ultimately, this pandemic could lead to attrition from the field at a time when we most need all hands on deck.8
Further, according to a World Health Organization report on mental health and psychosocial consideration during the COVID-19 outbreak, some health care workers, unfortunately, experience avoidance by their family members or communities because of stigma, fear, and anxiety. This avoidance threatens to make an already challenging situation far worse for health care workers by increasing isolation.
Even after acute outbreak are over, the effects on health care workers can persist for years. In a follow-up study 13-26 months after the SARS outbreak, Robert G. Maunder, MD, and associates found that Toronto-area health care workers reported significantly higher levels of burnout, psychological distress, and posttraumatic stress. They were more likely to have reduced patient contact and work hours, and to have avoided behavioral consequences of stress.9 Exposure to stressful work conditions during a pandemic also might put hospital employees at a much higher risk of alcohol and substance use disorders.10
Potential solutions for improving care
COVID-19 has had a massive impact on the mental health of health care workers around the globe. Fortunately, there are evidence-based strategies aimed at mitigating the effects of this pandemic on health care workers. Fostering self-efficacy and optimism has been shown to improve coping and efficiency during disasters.9 Higher perceived workplace safety is associated with a lower risk of anxiety, depression, and posttraumatic stress among health care workers, while a lack of social support has been linked to adverse behavioral outcomes.10
A recent study found that, among Chinese physicians who cared for COVID-19 victims, more significant social support was associated with better sleep quality, greater self-effectiveness, and less psychological distress.11 Positive leadership and a professional culture of trust, and openness with unambiguous communication have been shown to improve the engagement of the medical workforce.12,13 Psychiatrists must advocate for the adoption of these practices in the workplace. Assessing and addressing mental health needs, in addition to the physical health of the health care workforce, is of utmost importance.
We can accomplish this in many ways, but we have to access our health care workers. Similar to our patient population, health care workers also experience stigma and anxiety tied to the disclosure of mental health challenges. This was reported in a study conducted in China, in which a specific psychological intervention using a hotline program was used for the medical team.14 This program provided psychological interventions/group activities aimed at releasing stress and anxiety. However, initially, the implementation of psychological interventions encountered obstacles.
For example, some members of the medical staff declined to participate in group or individual psychological interventions. Moreover, nurses showed irritability, unwillingness to join, and some staff refused, stating that “they did not have any problems.” Finally, psychological counselors regularly visited the facility to listen to difficulties or stories encountered by staff at work and provide support accordingly. More than 100 frontline medical staff participated and reported feeling better.15
Currently, several U.S. universities/institutes have implemented programs aimed at protecting the health and well-being of their staff during the COVID-19 pandemic. For instance, the department of psychiatry and behavioral health at Hackensack Meridian Health has put comprehensive system programs in place for at 16 affiliated medical centers and other patient care facilities to provide support during the COVID-19 crisis. A 24/7 team member support hotline connecting team members with a behavioral health specialist has become available when needed. This hotline is backed up by social workers, who provide mental health resources. In addition, another service called “Coping with COVID Talks” is available. This service is a virtual psychoeducational group facilitated by psychologists focusing on building coping skills and resilience.
Also, the consultation-liaison psychiatrists in the medical centers provide daily support to clinicians working in ICUs. These efforts have led to paradoxical benefits for employers, further leading to less commuting, more safety, and enhanced productivity for the clinician, according to Ramon Solhkhah, MD, MBA, chairman of the psychiatry department.16
Some universities, such as the University of North Carolina at Chapel Hill, have created mental health/telehealth support for health care workers, where they are conducting webinars on coping with uncertainty tied to COVID-19.17 The University of California, San Francisco, also has been a leader in this effort. That institution has employed its psychiatric workforce as volunteers – encouraging health care workers to use digital health apps and referral resources. Also, these volunteers provide peer counseling, phone support, and spiritual counseling to their health care workers.18
These approaches are crucial in this uncertain, challenging time. Our mental health system is deeply flawed, understaffed, and not well prepared to manage the mental health issues among health care workers. Psychiatric institutes/facilities should follow comprehensive and multifaceted approaches to combat the COVID-19 crisis. Several preventive measures can be considered in coping with this pandemic, such as stress reduction, mindfulness, and disseminating educational materials. Also, increased use of technology, such as in-the-moment measures, development of hotlines, crisis support, and treatment telepsychiatry for therapy and medication, should play a pivotal role in addressing the mental health needs of health care workers.
In addition, it is expected that, as a nation, we will see a surge of mental health needs for illnesses such as depression and PTSD, just as we do after “natural disasters” caused by a variety of reasons, including economic downturns. After the SARS outbreak in 2003, for example, health care workers showed symptoms of PTSD. The COVID-19 pandemic could have a similar impact.
The severity of mental health challenges among clinicians cannot be predicted at this time, but we can speculate that the traumatic impact of COVID-19 will prove long lasting, particularly among clinicians who served vulnerable populations and witnessed suffering, misery, and deaths. The long-term consequences might range from stress and anxiety to fear, depression, and PTSD. Implementation of mental health programs/psychological interventions/support will reduce the impact of mental health issues among these clinicians.
We must think about the best ways to optimize mental health among health care workers while also come up with innovative ways to target this at-risk group. The mental health of people who are saving lives – our frontline heroes – should be taken into consideration seriously around the globe. We also must prioritize the mental health of these workers during this unprecedented, challenging, and anxiety-provoking time.
Dr. Malik and Mr. Van Wert are affiliated with Johns Hopkins University, Baltimore. Dr. Kumari, Dr. Afzal, Dr. Doumas, and Dr. Solhkhah are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. All six authors disclosed having no conflicts of interest. The authors would like to thank Vinay Kumar for his assistance with the literature review and for proofreading and editing this article.
References
1. Wu P et al. Can J Psychiatry. 2009;54(5):302-11.
2. Lu YC et al. Psychother Psychosom. 2006;75(6):370-5.
3. Lai J et al. JAMA Netw Open. 2020;3(3):e203976.
4. Kang L et al. Brain Behav Immun. 2020 Mar 30. doi: 10.1016/j.bbi.2020.03.028.
5. Centers for Disease Control and Prevention COVID-19 Response Team. MMWR. 2020 Apr 17;69(15):477-81.
6. Arango C. Biol Psychiatry. 2020 Apr 8. doi: 10.1016/j.biopsych.2020.04.003.
7. Day M. BMJ. 2020 Apr 2. doi: 10.1136/bmj.m1375.
8. Kirsch T. “Coronavirus, COVID-19: What happens if health care workers stop showing up?” The Atlantic. 2020 Mar 24.
9. Maunder RG et al. Emerg Infect Dis. 2006;12(12):1924-32.
10. Wu P et al. Alcohol Alcohol. 2008;43(6):706-12.
11. Brooks SK et al. BMC Psychol. 2016 Apr 26;4:18.
12. Smith BW et al. Am J Infect Control. 2009; 37:371-80.
13. Chen Q et al. Lancet Psychiatry. 2020 Apr 1;7(14):PE15-6.
14. Xiao H et al. Med Sci Monit. 2020;26:e923549.
15. Bergus GR et al. Acad Med. 2001;76:1148-52.
16. Bergeron T. “Working from home will be stressful. Here’s how employees (and employers) can handle it.” roi-nj.com. 2020 Mar 23.
17. UNChealthcare.org. “Mental Health/Emotional Support Resources for Coworkers and Providers Coping with COVID-19.”
18. Psych.ucsf.edu/coronoavirus. “Resources to Support Your Mental Health During the COVID-19 Outbreak.”
SARS-CoV-2 and the disease it causes, COVID-19, continues to spread around the world with a devastating social and economic impact. Undoubtedly, health care workers are essential to overcoming this crisis. If these issues are left unaddressed, low morale, burnout, or absenteeism could lead to the collapse of health care systems.
Historically, the health care industry has been one of the most hazardous environments in which to work. Employees in this industry are constantly exposed to a complex variety of health and safety hazards.
Particularly, risks from biological exposure to diseases such as tuberculosis, HIV, and currently COVID-19 are taking a considerable toll on health care workers’ health and well-being. Health care workers are leaving their families to work extra shifts, dealing with limited resources, and navigating the chaos. On top of all that, they are sacrificing their lives through these uncertain times.
Despite their resilience, health care workers – like the general population – can have strong psychological reactions of anxiety and fear during a pandemic. Still, they are required to continue their work amid uncertainty and danger.
Current research studies on COVID-19
Several studies have identified the impact of working in this type of environment during previous pandemics and disasters. In a study of hospital employees in China during the SARS epidemic (2002-2003), Ping Wu, PhD, and colleagues found that 10% of the participants experienced high levels of posttraumatic stress.1 In a similar study in Taiwan, researchers found that 17.3% of employees had developed significant mental health symptoms during the SARS outbreak.2
The impact of COVID-19 on health care workers seems to be much worse. A recent study from China indicates that 50.4% of hospital employees showed signs of depression, 44.6% had anxiety, and 34% had insomnia.3
Another recent cross-sectional study conducted by Lijun Kang, PhD, and associates evaluated the impact on mental health among health care workers in Wuhan, China, during the COVID-19 outbreak. This was the first study on the mental health of health care workers. This study recruited health care workers in Wuhan to participate in the survey from Jan. 29 to Feb. 4, 2020. The data were collected online with an anonymous, self-rated questionnaire that was distributed to all workstations. All subjects provided informed consent electronically prior to participating in the survey.
The survey questionnaire was made up of six components: primary demographic data, mental health assessment, risks of direct and indirect exposure to COVID-19, mental health care services accessed, psychological needs, and self-perceived health status, compared with that before the COVID-19 outbreak. A total of 994 health care workers responded to this survey, and the results are fascinating: 36.9% had subthreshold mental health distress (mean Patient Health Questionnaire–9 score, 2.4), 34.4% reported mild disturbances (mean PHQ-9, 5.4), 22.4% had moderate (mean PHQ-9, 9.0), and 6.2% reported severe disturbance (mean PHQ-9, 15.1). In this study, young women experienced more significant psychological distress. Regarding access to mental health services, 36.3% reported access to psychological materials, such as books on mental health; 50.4% used psychological resources available through media, such as online self-help coping methods; and 17.5% participated in counseling or psychotherapy.4
These findings emphasize the importance of being equipped to ensure the health and safety of health care workers through mental health interventions, both at work and in the community during this time of anxiety and uncertainty.
Future studies will become more critical in addressing this issue.
Risks to clinicians, families prevail
According to a recent report released by the Centers for Disease Control and Prevention, more than 9,000 health care workers across the United States had contracted COVID-19 as of mid-April, and 27 had died since the start of the pandemic.5
Health care workers are at risk around the globe, not only by the nature of their jobs but also by the shortage of personal protective equipment (PPE). In addition, the scarcity of N95 masks, respirators, and COVID-19 testing programs is causing the virus to spread among health care workers all over the world.
A study published recently by Celso Arango, MD, PhD, reported that 18% of staff at a hospital in Madrid had been infected with COVID-19. Dr. Arango speculated that transmission might be attributable to interactions with colleagues rather than with patients.6 We know, for example, that large proportions of people in China reportedly carried the virus while being asymptomatic.7 Those findings might not be generalizable, but they do suggest that an asymptomatic person could be a cause of contagion among professionals. Therefore, early screening and testing are critical – and should be priorities in health care settings.
Another problem clinicians can encounter is that, when they are called on to deal with very agitated patients, they might not get enough time to put on PPE. In addition, PPE can easily break and tear during the physical restraint process.
Working long hours is also putting a significant strain on health care workers and exposes them to the risk of infection. Also, health care workers not only worry about their safety but also fear bringing the virus to their families. They can also feel guilty about their conflicting feelings about exposing themselves and their families to risk. It is quite possible that, during this COVID-19 pandemic, health care workers will face a “care paradox,” in which they must choose between patients’ safety and their own. This care paradox can significantly contribute to a feeling of burnout, stress, and anxiety. Ultimately, this pandemic could lead to attrition from the field at a time when we most need all hands on deck.8
Further, according to a World Health Organization report on mental health and psychosocial consideration during the COVID-19 outbreak, some health care workers, unfortunately, experience avoidance by their family members or communities because of stigma, fear, and anxiety. This avoidance threatens to make an already challenging situation far worse for health care workers by increasing isolation.
Even after acute outbreak are over, the effects on health care workers can persist for years. In a follow-up study 13-26 months after the SARS outbreak, Robert G. Maunder, MD, and associates found that Toronto-area health care workers reported significantly higher levels of burnout, psychological distress, and posttraumatic stress. They were more likely to have reduced patient contact and work hours, and to have avoided behavioral consequences of stress.9 Exposure to stressful work conditions during a pandemic also might put hospital employees at a much higher risk of alcohol and substance use disorders.10
Potential solutions for improving care
COVID-19 has had a massive impact on the mental health of health care workers around the globe. Fortunately, there are evidence-based strategies aimed at mitigating the effects of this pandemic on health care workers. Fostering self-efficacy and optimism has been shown to improve coping and efficiency during disasters.9 Higher perceived workplace safety is associated with a lower risk of anxiety, depression, and posttraumatic stress among health care workers, while a lack of social support has been linked to adverse behavioral outcomes.10
A recent study found that, among Chinese physicians who cared for COVID-19 victims, more significant social support was associated with better sleep quality, greater self-effectiveness, and less psychological distress.11 Positive leadership and a professional culture of trust, and openness with unambiguous communication have been shown to improve the engagement of the medical workforce.12,13 Psychiatrists must advocate for the adoption of these practices in the workplace. Assessing and addressing mental health needs, in addition to the physical health of the health care workforce, is of utmost importance.
We can accomplish this in many ways, but we have to access our health care workers. Similar to our patient population, health care workers also experience stigma and anxiety tied to the disclosure of mental health challenges. This was reported in a study conducted in China, in which a specific psychological intervention using a hotline program was used for the medical team.14 This program provided psychological interventions/group activities aimed at releasing stress and anxiety. However, initially, the implementation of psychological interventions encountered obstacles.
For example, some members of the medical staff declined to participate in group or individual psychological interventions. Moreover, nurses showed irritability, unwillingness to join, and some staff refused, stating that “they did not have any problems.” Finally, psychological counselors regularly visited the facility to listen to difficulties or stories encountered by staff at work and provide support accordingly. More than 100 frontline medical staff participated and reported feeling better.15
Currently, several U.S. universities/institutes have implemented programs aimed at protecting the health and well-being of their staff during the COVID-19 pandemic. For instance, the department of psychiatry and behavioral health at Hackensack Meridian Health has put comprehensive system programs in place for at 16 affiliated medical centers and other patient care facilities to provide support during the COVID-19 crisis. A 24/7 team member support hotline connecting team members with a behavioral health specialist has become available when needed. This hotline is backed up by social workers, who provide mental health resources. In addition, another service called “Coping with COVID Talks” is available. This service is a virtual psychoeducational group facilitated by psychologists focusing on building coping skills and resilience.
Also, the consultation-liaison psychiatrists in the medical centers provide daily support to clinicians working in ICUs. These efforts have led to paradoxical benefits for employers, further leading to less commuting, more safety, and enhanced productivity for the clinician, according to Ramon Solhkhah, MD, MBA, chairman of the psychiatry department.16
Some universities, such as the University of North Carolina at Chapel Hill, have created mental health/telehealth support for health care workers, where they are conducting webinars on coping with uncertainty tied to COVID-19.17 The University of California, San Francisco, also has been a leader in this effort. That institution has employed its psychiatric workforce as volunteers – encouraging health care workers to use digital health apps and referral resources. Also, these volunteers provide peer counseling, phone support, and spiritual counseling to their health care workers.18
These approaches are crucial in this uncertain, challenging time. Our mental health system is deeply flawed, understaffed, and not well prepared to manage the mental health issues among health care workers. Psychiatric institutes/facilities should follow comprehensive and multifaceted approaches to combat the COVID-19 crisis. Several preventive measures can be considered in coping with this pandemic, such as stress reduction, mindfulness, and disseminating educational materials. Also, increased use of technology, such as in-the-moment measures, development of hotlines, crisis support, and treatment telepsychiatry for therapy and medication, should play a pivotal role in addressing the mental health needs of health care workers.
In addition, it is expected that, as a nation, we will see a surge of mental health needs for illnesses such as depression and PTSD, just as we do after “natural disasters” caused by a variety of reasons, including economic downturns. After the SARS outbreak in 2003, for example, health care workers showed symptoms of PTSD. The COVID-19 pandemic could have a similar impact.
The severity of mental health challenges among clinicians cannot be predicted at this time, but we can speculate that the traumatic impact of COVID-19 will prove long lasting, particularly among clinicians who served vulnerable populations and witnessed suffering, misery, and deaths. The long-term consequences might range from stress and anxiety to fear, depression, and PTSD. Implementation of mental health programs/psychological interventions/support will reduce the impact of mental health issues among these clinicians.
We must think about the best ways to optimize mental health among health care workers while also come up with innovative ways to target this at-risk group. The mental health of people who are saving lives – our frontline heroes – should be taken into consideration seriously around the globe. We also must prioritize the mental health of these workers during this unprecedented, challenging, and anxiety-provoking time.
Dr. Malik and Mr. Van Wert are affiliated with Johns Hopkins University, Baltimore. Dr. Kumari, Dr. Afzal, Dr. Doumas, and Dr. Solhkhah are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. All six authors disclosed having no conflicts of interest. The authors would like to thank Vinay Kumar for his assistance with the literature review and for proofreading and editing this article.
References
1. Wu P et al. Can J Psychiatry. 2009;54(5):302-11.
2. Lu YC et al. Psychother Psychosom. 2006;75(6):370-5.
3. Lai J et al. JAMA Netw Open. 2020;3(3):e203976.
4. Kang L et al. Brain Behav Immun. 2020 Mar 30. doi: 10.1016/j.bbi.2020.03.028.
5. Centers for Disease Control and Prevention COVID-19 Response Team. MMWR. 2020 Apr 17;69(15):477-81.
6. Arango C. Biol Psychiatry. 2020 Apr 8. doi: 10.1016/j.biopsych.2020.04.003.
7. Day M. BMJ. 2020 Apr 2. doi: 10.1136/bmj.m1375.
8. Kirsch T. “Coronavirus, COVID-19: What happens if health care workers stop showing up?” The Atlantic. 2020 Mar 24.
9. Maunder RG et al. Emerg Infect Dis. 2006;12(12):1924-32.
10. Wu P et al. Alcohol Alcohol. 2008;43(6):706-12.
11. Brooks SK et al. BMC Psychol. 2016 Apr 26;4:18.
12. Smith BW et al. Am J Infect Control. 2009; 37:371-80.
13. Chen Q et al. Lancet Psychiatry. 2020 Apr 1;7(14):PE15-6.
14. Xiao H et al. Med Sci Monit. 2020;26:e923549.
15. Bergus GR et al. Acad Med. 2001;76:1148-52.
16. Bergeron T. “Working from home will be stressful. Here’s how employees (and employers) can handle it.” roi-nj.com. 2020 Mar 23.
17. UNChealthcare.org. “Mental Health/Emotional Support Resources for Coworkers and Providers Coping with COVID-19.”
18. Psych.ucsf.edu/coronoavirus. “Resources to Support Your Mental Health During the COVID-19 Outbreak.”
SARS-CoV-2 and the disease it causes, COVID-19, continues to spread around the world with a devastating social and economic impact. Undoubtedly, health care workers are essential to overcoming this crisis. If these issues are left unaddressed, low morale, burnout, or absenteeism could lead to the collapse of health care systems.
Historically, the health care industry has been one of the most hazardous environments in which to work. Employees in this industry are constantly exposed to a complex variety of health and safety hazards.
Particularly, risks from biological exposure to diseases such as tuberculosis, HIV, and currently COVID-19 are taking a considerable toll on health care workers’ health and well-being. Health care workers are leaving their families to work extra shifts, dealing with limited resources, and navigating the chaos. On top of all that, they are sacrificing their lives through these uncertain times.
Despite their resilience, health care workers – like the general population – can have strong psychological reactions of anxiety and fear during a pandemic. Still, they are required to continue their work amid uncertainty and danger.
Current research studies on COVID-19
Several studies have identified the impact of working in this type of environment during previous pandemics and disasters. In a study of hospital employees in China during the SARS epidemic (2002-2003), Ping Wu, PhD, and colleagues found that 10% of the participants experienced high levels of posttraumatic stress.1 In a similar study in Taiwan, researchers found that 17.3% of employees had developed significant mental health symptoms during the SARS outbreak.2
The impact of COVID-19 on health care workers seems to be much worse. A recent study from China indicates that 50.4% of hospital employees showed signs of depression, 44.6% had anxiety, and 34% had insomnia.3
Another recent cross-sectional study conducted by Lijun Kang, PhD, and associates evaluated the impact on mental health among health care workers in Wuhan, China, during the COVID-19 outbreak. This was the first study on the mental health of health care workers. This study recruited health care workers in Wuhan to participate in the survey from Jan. 29 to Feb. 4, 2020. The data were collected online with an anonymous, self-rated questionnaire that was distributed to all workstations. All subjects provided informed consent electronically prior to participating in the survey.
The survey questionnaire was made up of six components: primary demographic data, mental health assessment, risks of direct and indirect exposure to COVID-19, mental health care services accessed, psychological needs, and self-perceived health status, compared with that before the COVID-19 outbreak. A total of 994 health care workers responded to this survey, and the results are fascinating: 36.9% had subthreshold mental health distress (mean Patient Health Questionnaire–9 score, 2.4), 34.4% reported mild disturbances (mean PHQ-9, 5.4), 22.4% had moderate (mean PHQ-9, 9.0), and 6.2% reported severe disturbance (mean PHQ-9, 15.1). In this study, young women experienced more significant psychological distress. Regarding access to mental health services, 36.3% reported access to psychological materials, such as books on mental health; 50.4% used psychological resources available through media, such as online self-help coping methods; and 17.5% participated in counseling or psychotherapy.4
These findings emphasize the importance of being equipped to ensure the health and safety of health care workers through mental health interventions, both at work and in the community during this time of anxiety and uncertainty.
Future studies will become more critical in addressing this issue.
Risks to clinicians, families prevail
According to a recent report released by the Centers for Disease Control and Prevention, more than 9,000 health care workers across the United States had contracted COVID-19 as of mid-April, and 27 had died since the start of the pandemic.5
Health care workers are at risk around the globe, not only by the nature of their jobs but also by the shortage of personal protective equipment (PPE). In addition, the scarcity of N95 masks, respirators, and COVID-19 testing programs is causing the virus to spread among health care workers all over the world.
A study published recently by Celso Arango, MD, PhD, reported that 18% of staff at a hospital in Madrid had been infected with COVID-19. Dr. Arango speculated that transmission might be attributable to interactions with colleagues rather than with patients.6 We know, for example, that large proportions of people in China reportedly carried the virus while being asymptomatic.7 Those findings might not be generalizable, but they do suggest that an asymptomatic person could be a cause of contagion among professionals. Therefore, early screening and testing are critical – and should be priorities in health care settings.
Another problem clinicians can encounter is that, when they are called on to deal with very agitated patients, they might not get enough time to put on PPE. In addition, PPE can easily break and tear during the physical restraint process.
Working long hours is also putting a significant strain on health care workers and exposes them to the risk of infection. Also, health care workers not only worry about their safety but also fear bringing the virus to their families. They can also feel guilty about their conflicting feelings about exposing themselves and their families to risk. It is quite possible that, during this COVID-19 pandemic, health care workers will face a “care paradox,” in which they must choose between patients’ safety and their own. This care paradox can significantly contribute to a feeling of burnout, stress, and anxiety. Ultimately, this pandemic could lead to attrition from the field at a time when we most need all hands on deck.8
Further, according to a World Health Organization report on mental health and psychosocial consideration during the COVID-19 outbreak, some health care workers, unfortunately, experience avoidance by their family members or communities because of stigma, fear, and anxiety. This avoidance threatens to make an already challenging situation far worse for health care workers by increasing isolation.
Even after acute outbreak are over, the effects on health care workers can persist for years. In a follow-up study 13-26 months after the SARS outbreak, Robert G. Maunder, MD, and associates found that Toronto-area health care workers reported significantly higher levels of burnout, psychological distress, and posttraumatic stress. They were more likely to have reduced patient contact and work hours, and to have avoided behavioral consequences of stress.9 Exposure to stressful work conditions during a pandemic also might put hospital employees at a much higher risk of alcohol and substance use disorders.10
Potential solutions for improving care
COVID-19 has had a massive impact on the mental health of health care workers around the globe. Fortunately, there are evidence-based strategies aimed at mitigating the effects of this pandemic on health care workers. Fostering self-efficacy and optimism has been shown to improve coping and efficiency during disasters.9 Higher perceived workplace safety is associated with a lower risk of anxiety, depression, and posttraumatic stress among health care workers, while a lack of social support has been linked to adverse behavioral outcomes.10
A recent study found that, among Chinese physicians who cared for COVID-19 victims, more significant social support was associated with better sleep quality, greater self-effectiveness, and less psychological distress.11 Positive leadership and a professional culture of trust, and openness with unambiguous communication have been shown to improve the engagement of the medical workforce.12,13 Psychiatrists must advocate for the adoption of these practices in the workplace. Assessing and addressing mental health needs, in addition to the physical health of the health care workforce, is of utmost importance.
We can accomplish this in many ways, but we have to access our health care workers. Similar to our patient population, health care workers also experience stigma and anxiety tied to the disclosure of mental health challenges. This was reported in a study conducted in China, in which a specific psychological intervention using a hotline program was used for the medical team.14 This program provided psychological interventions/group activities aimed at releasing stress and anxiety. However, initially, the implementation of psychological interventions encountered obstacles.
For example, some members of the medical staff declined to participate in group or individual psychological interventions. Moreover, nurses showed irritability, unwillingness to join, and some staff refused, stating that “they did not have any problems.” Finally, psychological counselors regularly visited the facility to listen to difficulties or stories encountered by staff at work and provide support accordingly. More than 100 frontline medical staff participated and reported feeling better.15
Currently, several U.S. universities/institutes have implemented programs aimed at protecting the health and well-being of their staff during the COVID-19 pandemic. For instance, the department of psychiatry and behavioral health at Hackensack Meridian Health has put comprehensive system programs in place for at 16 affiliated medical centers and other patient care facilities to provide support during the COVID-19 crisis. A 24/7 team member support hotline connecting team members with a behavioral health specialist has become available when needed. This hotline is backed up by social workers, who provide mental health resources. In addition, another service called “Coping with COVID Talks” is available. This service is a virtual psychoeducational group facilitated by psychologists focusing on building coping skills and resilience.
Also, the consultation-liaison psychiatrists in the medical centers provide daily support to clinicians working in ICUs. These efforts have led to paradoxical benefits for employers, further leading to less commuting, more safety, and enhanced productivity for the clinician, according to Ramon Solhkhah, MD, MBA, chairman of the psychiatry department.16
Some universities, such as the University of North Carolina at Chapel Hill, have created mental health/telehealth support for health care workers, where they are conducting webinars on coping with uncertainty tied to COVID-19.17 The University of California, San Francisco, also has been a leader in this effort. That institution has employed its psychiatric workforce as volunteers – encouraging health care workers to use digital health apps and referral resources. Also, these volunteers provide peer counseling, phone support, and spiritual counseling to their health care workers.18
These approaches are crucial in this uncertain, challenging time. Our mental health system is deeply flawed, understaffed, and not well prepared to manage the mental health issues among health care workers. Psychiatric institutes/facilities should follow comprehensive and multifaceted approaches to combat the COVID-19 crisis. Several preventive measures can be considered in coping with this pandemic, such as stress reduction, mindfulness, and disseminating educational materials. Also, increased use of technology, such as in-the-moment measures, development of hotlines, crisis support, and treatment telepsychiatry for therapy and medication, should play a pivotal role in addressing the mental health needs of health care workers.
In addition, it is expected that, as a nation, we will see a surge of mental health needs for illnesses such as depression and PTSD, just as we do after “natural disasters” caused by a variety of reasons, including economic downturns. After the SARS outbreak in 2003, for example, health care workers showed symptoms of PTSD. The COVID-19 pandemic could have a similar impact.
The severity of mental health challenges among clinicians cannot be predicted at this time, but we can speculate that the traumatic impact of COVID-19 will prove long lasting, particularly among clinicians who served vulnerable populations and witnessed suffering, misery, and deaths. The long-term consequences might range from stress and anxiety to fear, depression, and PTSD. Implementation of mental health programs/psychological interventions/support will reduce the impact of mental health issues among these clinicians.
We must think about the best ways to optimize mental health among health care workers while also come up with innovative ways to target this at-risk group. The mental health of people who are saving lives – our frontline heroes – should be taken into consideration seriously around the globe. We also must prioritize the mental health of these workers during this unprecedented, challenging, and anxiety-provoking time.
Dr. Malik and Mr. Van Wert are affiliated with Johns Hopkins University, Baltimore. Dr. Kumari, Dr. Afzal, Dr. Doumas, and Dr. Solhkhah are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. All six authors disclosed having no conflicts of interest. The authors would like to thank Vinay Kumar for his assistance with the literature review and for proofreading and editing this article.
References
1. Wu P et al. Can J Psychiatry. 2009;54(5):302-11.
2. Lu YC et al. Psychother Psychosom. 2006;75(6):370-5.
3. Lai J et al. JAMA Netw Open. 2020;3(3):e203976.
4. Kang L et al. Brain Behav Immun. 2020 Mar 30. doi: 10.1016/j.bbi.2020.03.028.
5. Centers for Disease Control and Prevention COVID-19 Response Team. MMWR. 2020 Apr 17;69(15):477-81.
6. Arango C. Biol Psychiatry. 2020 Apr 8. doi: 10.1016/j.biopsych.2020.04.003.
7. Day M. BMJ. 2020 Apr 2. doi: 10.1136/bmj.m1375.
8. Kirsch T. “Coronavirus, COVID-19: What happens if health care workers stop showing up?” The Atlantic. 2020 Mar 24.
9. Maunder RG et al. Emerg Infect Dis. 2006;12(12):1924-32.
10. Wu P et al. Alcohol Alcohol. 2008;43(6):706-12.
11. Brooks SK et al. BMC Psychol. 2016 Apr 26;4:18.
12. Smith BW et al. Am J Infect Control. 2009; 37:371-80.
13. Chen Q et al. Lancet Psychiatry. 2020 Apr 1;7(14):PE15-6.
14. Xiao H et al. Med Sci Monit. 2020;26:e923549.
15. Bergus GR et al. Acad Med. 2001;76:1148-52.
16. Bergeron T. “Working from home will be stressful. Here’s how employees (and employers) can handle it.” roi-nj.com. 2020 Mar 23.
17. UNChealthcare.org. “Mental Health/Emotional Support Resources for Coworkers and Providers Coping with COVID-19.”
18. Psych.ucsf.edu/coronoavirus. “Resources to Support Your Mental Health During the COVID-19 Outbreak.”
COVID-19: A ‘marathon, not a sprint’ for psychiatry
The tragic death by suicide of an emergency department physician who had been caring for COVID-19 patients in New York City underscores the huge psychological impact of the pandemic – which will linger long after the virus is gone, experts say.
“For frontline responders, the trauma of witnessing so much illness and death will have lasting effects for many,” Bruce Schwartz, MD, president of the American Psychiatric Association (APA), said during the opening session of the annual meeting of the American Psychiatric Association, which was held as a virtual live event, replacing the organization’s canceled annual meeting.
“We will need the full workforce to cope with the psychiatric effects” of the pandemic, added Dr. Schwartz, deputy chairman and professor, department of psychiatry and behavioral sciences, Montefiore Medical Center and Albert Einstein College of Medicine, New York.
Joshua Morganstein, MD, chair of the APA’s Committee on the Psychiatric Dimensions of Disaster, led an afternoon session at the virtual meeting on “healthcare worker and organizational sustainment during COVID-19.”
The crisis is shaping up to be “a marathon, not a sprint; and self-care will remain a critical and ongoing issue. We are in this together,” he said.
Once the pandemic passes, Dr. Morganstein added.
Psychological first aid
It is important to realize that the psychological and behavioral effects of disasters are experienced by “more people, over a greater geography, across a much longer period of time than all other medical effects combined. This is important for disaster resource planning,” Dr. Morganstein told meeting attendees.
At times of crisis, many people will experience distress reactions and engage in behaviors that put their health at risk. Insomnia, increased alcohol and substance use, and family conflict are common and have a negative impact on functioning, he said.
In addition, pandemics result in unique responses. Protracted fear and uncertainty, elements of isolation, anger, misinformation, and faltering confidence in government/institutions may alter perceptions of risk.
“It’s the perception of risk, not the actual risk, that will ultimately determine how people behave,” Dr. Morganstein said.
“The ability to influence risk perception will alter the degree to which any group, community, or population ultimately chooses to engage in or reject recommended health behaviors,” he added.
In times of crisis, it’s also helpful to keep in mind and act upon the five essential elements of “psychological first aid,” he noted. These are safety, calming, self/community efficacy, social connectedness, and hope/optimism.
Psychological first aid is an evidence-based framework of supporting resilience in individuals, communities, and organizations, Dr. Morganstein said.
Individuals have a wide range of needs during times of crisis, and support should be tailored accordingly, he noted. As with many crises, instrumental support needs are significant and may be the primary need for many people. These include the need for food, clothing, rent/mortgage, financial relief, and child care.
Providing emotional support – empathy, validation, self-actualization, encouragement, and insight – will help individuals engage with instrumental supports.
“The reality is that it’s often difficult to talk about being sad when you feel hungry or worried you can’t pay the rent,” said Dr. Morganstein.
He also emphasized the importance of appropriate messaging and language during a crisis. These can have a profound impact on community well-being and the willingness of the public to engage in recommended health behaviors.
“As psychiatrists, we understand [that] the words we choose when we discuss this pandemic will have power. Communication is not only a means by which we deliver interventions, but it is, in and of itself, a behavioral health intervention. Good communication can serve to normalize experiences and function as an antidote to distress during times of uncertainty,” Dr. Morganstein said.
Importantly, “we need to remind people that eventually this will end and the vast majority of people, including those who have difficulties along the way, will ultimately be okay.”
The APA has provided a COVID-19 resource page on its website.
Dr. Morganstein and Dr. Schwartz have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
The tragic death by suicide of an emergency department physician who had been caring for COVID-19 patients in New York City underscores the huge psychological impact of the pandemic – which will linger long after the virus is gone, experts say.
“For frontline responders, the trauma of witnessing so much illness and death will have lasting effects for many,” Bruce Schwartz, MD, president of the American Psychiatric Association (APA), said during the opening session of the annual meeting of the American Psychiatric Association, which was held as a virtual live event, replacing the organization’s canceled annual meeting.
“We will need the full workforce to cope with the psychiatric effects” of the pandemic, added Dr. Schwartz, deputy chairman and professor, department of psychiatry and behavioral sciences, Montefiore Medical Center and Albert Einstein College of Medicine, New York.
Joshua Morganstein, MD, chair of the APA’s Committee on the Psychiatric Dimensions of Disaster, led an afternoon session at the virtual meeting on “healthcare worker and organizational sustainment during COVID-19.”
The crisis is shaping up to be “a marathon, not a sprint; and self-care will remain a critical and ongoing issue. We are in this together,” he said.
Once the pandemic passes, Dr. Morganstein added.
Psychological first aid
It is important to realize that the psychological and behavioral effects of disasters are experienced by “more people, over a greater geography, across a much longer period of time than all other medical effects combined. This is important for disaster resource planning,” Dr. Morganstein told meeting attendees.
At times of crisis, many people will experience distress reactions and engage in behaviors that put their health at risk. Insomnia, increased alcohol and substance use, and family conflict are common and have a negative impact on functioning, he said.
In addition, pandemics result in unique responses. Protracted fear and uncertainty, elements of isolation, anger, misinformation, and faltering confidence in government/institutions may alter perceptions of risk.
“It’s the perception of risk, not the actual risk, that will ultimately determine how people behave,” Dr. Morganstein said.
“The ability to influence risk perception will alter the degree to which any group, community, or population ultimately chooses to engage in or reject recommended health behaviors,” he added.
In times of crisis, it’s also helpful to keep in mind and act upon the five essential elements of “psychological first aid,” he noted. These are safety, calming, self/community efficacy, social connectedness, and hope/optimism.
Psychological first aid is an evidence-based framework of supporting resilience in individuals, communities, and organizations, Dr. Morganstein said.
Individuals have a wide range of needs during times of crisis, and support should be tailored accordingly, he noted. As with many crises, instrumental support needs are significant and may be the primary need for many people. These include the need for food, clothing, rent/mortgage, financial relief, and child care.
Providing emotional support – empathy, validation, self-actualization, encouragement, and insight – will help individuals engage with instrumental supports.
“The reality is that it’s often difficult to talk about being sad when you feel hungry or worried you can’t pay the rent,” said Dr. Morganstein.
He also emphasized the importance of appropriate messaging and language during a crisis. These can have a profound impact on community well-being and the willingness of the public to engage in recommended health behaviors.
“As psychiatrists, we understand [that] the words we choose when we discuss this pandemic will have power. Communication is not only a means by which we deliver interventions, but it is, in and of itself, a behavioral health intervention. Good communication can serve to normalize experiences and function as an antidote to distress during times of uncertainty,” Dr. Morganstein said.
Importantly, “we need to remind people that eventually this will end and the vast majority of people, including those who have difficulties along the way, will ultimately be okay.”
The APA has provided a COVID-19 resource page on its website.
Dr. Morganstein and Dr. Schwartz have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
The tragic death by suicide of an emergency department physician who had been caring for COVID-19 patients in New York City underscores the huge psychological impact of the pandemic – which will linger long after the virus is gone, experts say.
“For frontline responders, the trauma of witnessing so much illness and death will have lasting effects for many,” Bruce Schwartz, MD, president of the American Psychiatric Association (APA), said during the opening session of the annual meeting of the American Psychiatric Association, which was held as a virtual live event, replacing the organization’s canceled annual meeting.
“We will need the full workforce to cope with the psychiatric effects” of the pandemic, added Dr. Schwartz, deputy chairman and professor, department of psychiatry and behavioral sciences, Montefiore Medical Center and Albert Einstein College of Medicine, New York.
Joshua Morganstein, MD, chair of the APA’s Committee on the Psychiatric Dimensions of Disaster, led an afternoon session at the virtual meeting on “healthcare worker and organizational sustainment during COVID-19.”
The crisis is shaping up to be “a marathon, not a sprint; and self-care will remain a critical and ongoing issue. We are in this together,” he said.
Once the pandemic passes, Dr. Morganstein added.
Psychological first aid
It is important to realize that the psychological and behavioral effects of disasters are experienced by “more people, over a greater geography, across a much longer period of time than all other medical effects combined. This is important for disaster resource planning,” Dr. Morganstein told meeting attendees.
At times of crisis, many people will experience distress reactions and engage in behaviors that put their health at risk. Insomnia, increased alcohol and substance use, and family conflict are common and have a negative impact on functioning, he said.
In addition, pandemics result in unique responses. Protracted fear and uncertainty, elements of isolation, anger, misinformation, and faltering confidence in government/institutions may alter perceptions of risk.
“It’s the perception of risk, not the actual risk, that will ultimately determine how people behave,” Dr. Morganstein said.
“The ability to influence risk perception will alter the degree to which any group, community, or population ultimately chooses to engage in or reject recommended health behaviors,” he added.
In times of crisis, it’s also helpful to keep in mind and act upon the five essential elements of “psychological first aid,” he noted. These are safety, calming, self/community efficacy, social connectedness, and hope/optimism.
Psychological first aid is an evidence-based framework of supporting resilience in individuals, communities, and organizations, Dr. Morganstein said.
Individuals have a wide range of needs during times of crisis, and support should be tailored accordingly, he noted. As with many crises, instrumental support needs are significant and may be the primary need for many people. These include the need for food, clothing, rent/mortgage, financial relief, and child care.
Providing emotional support – empathy, validation, self-actualization, encouragement, and insight – will help individuals engage with instrumental supports.
“The reality is that it’s often difficult to talk about being sad when you feel hungry or worried you can’t pay the rent,” said Dr. Morganstein.
He also emphasized the importance of appropriate messaging and language during a crisis. These can have a profound impact on community well-being and the willingness of the public to engage in recommended health behaviors.
“As psychiatrists, we understand [that] the words we choose when we discuss this pandemic will have power. Communication is not only a means by which we deliver interventions, but it is, in and of itself, a behavioral health intervention. Good communication can serve to normalize experiences and function as an antidote to distress during times of uncertainty,” Dr. Morganstein said.
Importantly, “we need to remind people that eventually this will end and the vast majority of people, including those who have difficulties along the way, will ultimately be okay.”
The APA has provided a COVID-19 resource page on its website.
Dr. Morganstein and Dr. Schwartz have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
FROM APA 2020
COVID-19: No U.S. spike expected in pandemic-related suicidal ideation
Americans are not feeling more suicidal even in the depths of the COVID-19 pandemic of spring 2020, according to analysis of real-time national data accrued through the Crisis Text Line.
But that’s not to say Americans are feeling less distressed. Quite the contrary, Nancy Lublin, CEO and cofounder of Crisis Text Line, noted at the virtual annual meeting of the American Association of Suicidology.
“We’ve seen a 40% increase in volume since early March. Seventy-eight percent of our conversations are now including words like ‘freaked out,’ ‘panicked,’ ‘scared.’ People are worried about COVID-19. They’re nervous about symptoms; they’re concerned for family on the front lines,” she said.
And yet, from mid-March through mid-April, only 22% of texters to the crisis line expressed suicidal ideation, down from a usual background rate of 28%. Moreover, just 13% of texters who mentioned ‘COVID,’ ‘quarantine,’ or ‘virus’ expressed suicidal ideation, compared with 25% of other texters.
Ms. Lublin and her data crunchers are tracking not only the impact of the disease, but they’re also monitoring the mental health effects of the quarantine and social distancing.
“People are away from their routines, and perhaps [are] quarantined with abusive people. We’ve seen a 48% increase in texts involving sexual abuse and a 74% increase in domestic violence,” she said.
Texts focused on eating disorders or body image issues have jumped by 45%. And roughly two-thirds of texters now describe feelings of depression.
One of the biggest mental health impacts she and colleagues have seen stem from the economic recession triggered by the pandemic.
“We’ve seen more people reach out with fears of bankruptcy, fears of homelessness, fears of financial ruin. Thirty-two percent of our texters now report household incomes under $20,000 per year. That’s up from 19% before,” according to Ms. Lublin.
The Crisis Text Line (text HOME to 741741) uses machine-learning algorithms that sift through incoming text messages from people in crisis for key words, then ranks the messages by severity. Since its launch in 2013, this service, available 24/7, has processed roughly 150 million text messages. The high-risk texters – for example, someone who’s swallowed a bottle of pills or is texting from the San Francisco’s Golden Gate Bridge, as has occurred some 500 times – are connected in an average of 24 seconds with a thoroughly trained volunteer crisis counselor. And there is a third party in these texting conversations: a paid staff supervisor with a master’s degree in a relevant discipline who follows the encounter in real time and can step in if needed.
“Active rescues are involved in less than 1% of our conversations, but still we do them on average 26 times per day. Over the years, we’ve completed more than 32,000 active rescues,” she said.
The Crisis Text Line is not exclusively a suicide prevention hotline. The top five issues people text about involve relationship concerns, depression, anxiety, self-harm, and suicidal ideation. Over time, Ms. Lublin and staff have used Big Data to tweak the screening algorithm as they’ve identified even higher red flag texting words than “suicide.”
“The word ‘military’ makes it twice as likely that we’ll have to call 9-1-1 than the word ‘suicide.’ ‘Gun,’ ‘rope’ – four times as likely. In the [United KIngdom], where we’re also operating, we see the word ‘cliff’ is a more lethal word than the word ‘suicide.’ But the most dangerous words that we see are any named pill,” she said.
The Crisis Text Line was recently awarded a 2020 TED Audacious Project grant to expand their services from English to also be offered in Spanish, French, Portuguese, and Arabic worldwide within the next two and a half years. This will provide coverage to one-third of the world’s population, including people with cell phones living in countries with very limited mental health services.
Will COVID-19 trigger a spike in deaths by suicide?
Whether the COVID-19 pandemic will result in a bump in suicide rates is unclear and will remain so for quite a while, according to David Gunnell, MD, PhD, a suicidologist and professor of epidemiology at the University of Bristol (England).
In the United Kingdom, investigation of a suspicious death typically takes more than 6 months before an official declaration of suicide is recorded by the medical examiner. The lag time is even longer in the United States: The latest national suicide rate data are for 2018 because state-by-state reporting practices vary widely, he noted at a National Press Foundation briefing on COVID-19 and mental health.
Although suicide is consistently the 10th-leading cause of death in the United States, it’s important to put it in perspective, he added. In 2018, there were an average of 4,000 deaths by suicide per month nationally, whereas in March and April of 2020, there were 28,400 deaths per month attributable to COVID-19.
A classic study of the Spanish influenza pandemic in the United States during 1918-1919 concluded that there was “a slight upturn” in the rate of suicide in the months following the pandemic’s peak. More recently, a study of the 2003 SARS (severe acute respiratory syndrome) epidemic in Hong Kong found roughly a 30% increase in the rate of suicide among the elderly during that time frame, Dr. Gunnell noted.
“What limited evidence there is provides an indication of a small rise in suicides, but the number of deaths is far outweighed by the number of deaths associated with these big pandemics,” according to the epidemiologist.
Pandemics aside, there is far more compelling evidence that periods of economic recession are associated with an increase in the suicide rate, he added.
Another speaker, Holly C. Wilcox, PhD, a psychiatric epidemiologist at Johns Hopkins University, Baltimore, commented: “It’s not surprising that, during times of disaster the suicide rates decrease a bit. It could be because of people coming toghether. It could be one silver lining of COVID-19. But if there’s prolonged stress economically and socially and we can’t work towards reducing stress for people, we could see an increase. I don’t know if we will.”
In a recent article, Dr. Gunnell and coauthors offered a series of recommendations aimed at blunting the mental health consequences of COVID-19 and the related economic fallout (Lancet Psychiatry. 2020 Apr 21. doi: 10.1016/S2215-0366[20]30171-1).
The authors highlighted the need for interventions aimed at defusing the adverse impact of self-isolation, social distancing, fear, an anticipated rise in alcohol misuse, joblessness, interrupted education, bereavement, and complicated grief. Governments can blunt the well-established effect of financial distress as a risk factor for suicide by providing safety nets in the form of supports for housing, food, and unemployment benefits. And it will be important that those mental health services that develop expertise in performing psychiatric assessments and interventions remotely via telemedicine share their insights, Dr. Gunnell said.
Americans are not feeling more suicidal even in the depths of the COVID-19 pandemic of spring 2020, according to analysis of real-time national data accrued through the Crisis Text Line.
But that’s not to say Americans are feeling less distressed. Quite the contrary, Nancy Lublin, CEO and cofounder of Crisis Text Line, noted at the virtual annual meeting of the American Association of Suicidology.
“We’ve seen a 40% increase in volume since early March. Seventy-eight percent of our conversations are now including words like ‘freaked out,’ ‘panicked,’ ‘scared.’ People are worried about COVID-19. They’re nervous about symptoms; they’re concerned for family on the front lines,” she said.
And yet, from mid-March through mid-April, only 22% of texters to the crisis line expressed suicidal ideation, down from a usual background rate of 28%. Moreover, just 13% of texters who mentioned ‘COVID,’ ‘quarantine,’ or ‘virus’ expressed suicidal ideation, compared with 25% of other texters.
Ms. Lublin and her data crunchers are tracking not only the impact of the disease, but they’re also monitoring the mental health effects of the quarantine and social distancing.
“People are away from their routines, and perhaps [are] quarantined with abusive people. We’ve seen a 48% increase in texts involving sexual abuse and a 74% increase in domestic violence,” she said.
Texts focused on eating disorders or body image issues have jumped by 45%. And roughly two-thirds of texters now describe feelings of depression.
One of the biggest mental health impacts she and colleagues have seen stem from the economic recession triggered by the pandemic.
“We’ve seen more people reach out with fears of bankruptcy, fears of homelessness, fears of financial ruin. Thirty-two percent of our texters now report household incomes under $20,000 per year. That’s up from 19% before,” according to Ms. Lublin.
The Crisis Text Line (text HOME to 741741) uses machine-learning algorithms that sift through incoming text messages from people in crisis for key words, then ranks the messages by severity. Since its launch in 2013, this service, available 24/7, has processed roughly 150 million text messages. The high-risk texters – for example, someone who’s swallowed a bottle of pills or is texting from the San Francisco’s Golden Gate Bridge, as has occurred some 500 times – are connected in an average of 24 seconds with a thoroughly trained volunteer crisis counselor. And there is a third party in these texting conversations: a paid staff supervisor with a master’s degree in a relevant discipline who follows the encounter in real time and can step in if needed.
“Active rescues are involved in less than 1% of our conversations, but still we do them on average 26 times per day. Over the years, we’ve completed more than 32,000 active rescues,” she said.
The Crisis Text Line is not exclusively a suicide prevention hotline. The top five issues people text about involve relationship concerns, depression, anxiety, self-harm, and suicidal ideation. Over time, Ms. Lublin and staff have used Big Data to tweak the screening algorithm as they’ve identified even higher red flag texting words than “suicide.”
“The word ‘military’ makes it twice as likely that we’ll have to call 9-1-1 than the word ‘suicide.’ ‘Gun,’ ‘rope’ – four times as likely. In the [United KIngdom], where we’re also operating, we see the word ‘cliff’ is a more lethal word than the word ‘suicide.’ But the most dangerous words that we see are any named pill,” she said.
The Crisis Text Line was recently awarded a 2020 TED Audacious Project grant to expand their services from English to also be offered in Spanish, French, Portuguese, and Arabic worldwide within the next two and a half years. This will provide coverage to one-third of the world’s population, including people with cell phones living in countries with very limited mental health services.
Will COVID-19 trigger a spike in deaths by suicide?
Whether the COVID-19 pandemic will result in a bump in suicide rates is unclear and will remain so for quite a while, according to David Gunnell, MD, PhD, a suicidologist and professor of epidemiology at the University of Bristol (England).
In the United Kingdom, investigation of a suspicious death typically takes more than 6 months before an official declaration of suicide is recorded by the medical examiner. The lag time is even longer in the United States: The latest national suicide rate data are for 2018 because state-by-state reporting practices vary widely, he noted at a National Press Foundation briefing on COVID-19 and mental health.
Although suicide is consistently the 10th-leading cause of death in the United States, it’s important to put it in perspective, he added. In 2018, there were an average of 4,000 deaths by suicide per month nationally, whereas in March and April of 2020, there were 28,400 deaths per month attributable to COVID-19.
A classic study of the Spanish influenza pandemic in the United States during 1918-1919 concluded that there was “a slight upturn” in the rate of suicide in the months following the pandemic’s peak. More recently, a study of the 2003 SARS (severe acute respiratory syndrome) epidemic in Hong Kong found roughly a 30% increase in the rate of suicide among the elderly during that time frame, Dr. Gunnell noted.
“What limited evidence there is provides an indication of a small rise in suicides, but the number of deaths is far outweighed by the number of deaths associated with these big pandemics,” according to the epidemiologist.
Pandemics aside, there is far more compelling evidence that periods of economic recession are associated with an increase in the suicide rate, he added.
Another speaker, Holly C. Wilcox, PhD, a psychiatric epidemiologist at Johns Hopkins University, Baltimore, commented: “It’s not surprising that, during times of disaster the suicide rates decrease a bit. It could be because of people coming toghether. It could be one silver lining of COVID-19. But if there’s prolonged stress economically and socially and we can’t work towards reducing stress for people, we could see an increase. I don’t know if we will.”
In a recent article, Dr. Gunnell and coauthors offered a series of recommendations aimed at blunting the mental health consequences of COVID-19 and the related economic fallout (Lancet Psychiatry. 2020 Apr 21. doi: 10.1016/S2215-0366[20]30171-1).
The authors highlighted the need for interventions aimed at defusing the adverse impact of self-isolation, social distancing, fear, an anticipated rise in alcohol misuse, joblessness, interrupted education, bereavement, and complicated grief. Governments can blunt the well-established effect of financial distress as a risk factor for suicide by providing safety nets in the form of supports for housing, food, and unemployment benefits. And it will be important that those mental health services that develop expertise in performing psychiatric assessments and interventions remotely via telemedicine share their insights, Dr. Gunnell said.
Americans are not feeling more suicidal even in the depths of the COVID-19 pandemic of spring 2020, according to analysis of real-time national data accrued through the Crisis Text Line.
But that’s not to say Americans are feeling less distressed. Quite the contrary, Nancy Lublin, CEO and cofounder of Crisis Text Line, noted at the virtual annual meeting of the American Association of Suicidology.
“We’ve seen a 40% increase in volume since early March. Seventy-eight percent of our conversations are now including words like ‘freaked out,’ ‘panicked,’ ‘scared.’ People are worried about COVID-19. They’re nervous about symptoms; they’re concerned for family on the front lines,” she said.
And yet, from mid-March through mid-April, only 22% of texters to the crisis line expressed suicidal ideation, down from a usual background rate of 28%. Moreover, just 13% of texters who mentioned ‘COVID,’ ‘quarantine,’ or ‘virus’ expressed suicidal ideation, compared with 25% of other texters.
Ms. Lublin and her data crunchers are tracking not only the impact of the disease, but they’re also monitoring the mental health effects of the quarantine and social distancing.
“People are away from their routines, and perhaps [are] quarantined with abusive people. We’ve seen a 48% increase in texts involving sexual abuse and a 74% increase in domestic violence,” she said.
Texts focused on eating disorders or body image issues have jumped by 45%. And roughly two-thirds of texters now describe feelings of depression.
One of the biggest mental health impacts she and colleagues have seen stem from the economic recession triggered by the pandemic.
“We’ve seen more people reach out with fears of bankruptcy, fears of homelessness, fears of financial ruin. Thirty-two percent of our texters now report household incomes under $20,000 per year. That’s up from 19% before,” according to Ms. Lublin.
The Crisis Text Line (text HOME to 741741) uses machine-learning algorithms that sift through incoming text messages from people in crisis for key words, then ranks the messages by severity. Since its launch in 2013, this service, available 24/7, has processed roughly 150 million text messages. The high-risk texters – for example, someone who’s swallowed a bottle of pills or is texting from the San Francisco’s Golden Gate Bridge, as has occurred some 500 times – are connected in an average of 24 seconds with a thoroughly trained volunteer crisis counselor. And there is a third party in these texting conversations: a paid staff supervisor with a master’s degree in a relevant discipline who follows the encounter in real time and can step in if needed.
“Active rescues are involved in less than 1% of our conversations, but still we do them on average 26 times per day. Over the years, we’ve completed more than 32,000 active rescues,” she said.
The Crisis Text Line is not exclusively a suicide prevention hotline. The top five issues people text about involve relationship concerns, depression, anxiety, self-harm, and suicidal ideation. Over time, Ms. Lublin and staff have used Big Data to tweak the screening algorithm as they’ve identified even higher red flag texting words than “suicide.”
“The word ‘military’ makes it twice as likely that we’ll have to call 9-1-1 than the word ‘suicide.’ ‘Gun,’ ‘rope’ – four times as likely. In the [United KIngdom], where we’re also operating, we see the word ‘cliff’ is a more lethal word than the word ‘suicide.’ But the most dangerous words that we see are any named pill,” she said.
The Crisis Text Line was recently awarded a 2020 TED Audacious Project grant to expand their services from English to also be offered in Spanish, French, Portuguese, and Arabic worldwide within the next two and a half years. This will provide coverage to one-third of the world’s population, including people with cell phones living in countries with very limited mental health services.
Will COVID-19 trigger a spike in deaths by suicide?
Whether the COVID-19 pandemic will result in a bump in suicide rates is unclear and will remain so for quite a while, according to David Gunnell, MD, PhD, a suicidologist and professor of epidemiology at the University of Bristol (England).
In the United Kingdom, investigation of a suspicious death typically takes more than 6 months before an official declaration of suicide is recorded by the medical examiner. The lag time is even longer in the United States: The latest national suicide rate data are for 2018 because state-by-state reporting practices vary widely, he noted at a National Press Foundation briefing on COVID-19 and mental health.
Although suicide is consistently the 10th-leading cause of death in the United States, it’s important to put it in perspective, he added. In 2018, there were an average of 4,000 deaths by suicide per month nationally, whereas in March and April of 2020, there were 28,400 deaths per month attributable to COVID-19.
A classic study of the Spanish influenza pandemic in the United States during 1918-1919 concluded that there was “a slight upturn” in the rate of suicide in the months following the pandemic’s peak. More recently, a study of the 2003 SARS (severe acute respiratory syndrome) epidemic in Hong Kong found roughly a 30% increase in the rate of suicide among the elderly during that time frame, Dr. Gunnell noted.
“What limited evidence there is provides an indication of a small rise in suicides, but the number of deaths is far outweighed by the number of deaths associated with these big pandemics,” according to the epidemiologist.
Pandemics aside, there is far more compelling evidence that periods of economic recession are associated with an increase in the suicide rate, he added.
Another speaker, Holly C. Wilcox, PhD, a psychiatric epidemiologist at Johns Hopkins University, Baltimore, commented: “It’s not surprising that, during times of disaster the suicide rates decrease a bit. It could be because of people coming toghether. It could be one silver lining of COVID-19. But if there’s prolonged stress economically and socially and we can’t work towards reducing stress for people, we could see an increase. I don’t know if we will.”
In a recent article, Dr. Gunnell and coauthors offered a series of recommendations aimed at blunting the mental health consequences of COVID-19 and the related economic fallout (Lancet Psychiatry. 2020 Apr 21. doi: 10.1016/S2215-0366[20]30171-1).
The authors highlighted the need for interventions aimed at defusing the adverse impact of self-isolation, social distancing, fear, an anticipated rise in alcohol misuse, joblessness, interrupted education, bereavement, and complicated grief. Governments can blunt the well-established effect of financial distress as a risk factor for suicide by providing safety nets in the form of supports for housing, food, and unemployment benefits. And it will be important that those mental health services that develop expertise in performing psychiatric assessments and interventions remotely via telemedicine share their insights, Dr. Gunnell said.
FROM AAS 2020
COVID-19: Calls to NYC crisis hotline soar
Calls to a mental health crisis hotline in New York City have soared during the COVID-19 pandemic, which has closed schools and businesses, put millions out of work, and ushered in stay-at-home orders.
ensuring that care is available when and where needed during a crisis, whether that be an individual crisis, a local community crisis, or a national mental health crisis like we are facing right now,” said Kimberly Williams, president and CEO of Vibrant Emotional Health.
Vibrant Emotional Health, formerly the Mental Health Association of New York City, provides crisis line services across the United States in partnership with local and federal governments and corporations. NYC Well is one of them.
Ms. Williams and two of her colleagues spoke about crisis hotlines April 25 during the American Psychiatric Association’s Virtual Spring Highlights Meeting.
Rapid crisis intervention
Crisis hotlines provide “rapid crisis intervention, delivering help immediately from trained crisis counselors who respond to unique needs, actively engage in collaborative problem solving, and assess risk for suicide,” Ms. Williams said.
They have a proven track record, she noted. Research shows that they are able to decrease emotional distress and reduce suicidality in crisis situations.
Kelly Clarke, program director of NYC Well, noted that inbound call volume has increased roughly 50% since the COVID-19 pandemic hit.
Callers to NYC Well most commonly report mood/anxiety concerns, stressful life events, and interpersonal problems. “Many people are reaching out to seek support in how to manage their own emotional well-being in light of the pandemic and the restrictions put in place,” said Ms. Clarke.
Multilingual peer support specialists and counselors with NYC Well provide free, confidential support by talk, text, or chat 24 hours per day, 7 days per week, 365 days a year. The service also provides mobile crisis teams and follow-up services. NYC Well has set up a landing page of resources specifically geared toward COVID-19.
How to cope with the rapid growth and at the same time ensure high quality of services are two key challenges for NYC Well, Ms. Clarke said.
“Absolutely essential” service
For John Draper, PhD, the experience early in his career of working on a mobile mental health crisis team in Brooklyn “changed his life.”
First, it showed him that, for people who are severely psychiatrically ill, “care has to come to them,” said Dr. Draper, executive vice president of national networks for Vibrant Emotional Health.
“So many of the people we were seeing were too depressed to get out of bed, much less get to a clinic, and I realized our system was not set up to serve its customers. It was like putting a spinal cord injury clinic at the top of a stairs,” he said.
Crisis hotlines are “absolutely essential.” Their value for communities and individuals “can’t be overestimated,” said Dr. Draper.
This was revealed after the terrorist attacks of 9/11 and now with COVID-19, said Dr. Draper. He noted, that following the attacks of 9/11, a federal report referred to crisis hotlines as “the single most important asset in the response.”
A version of this article originally appeared on Medscape.com.
Calls to a mental health crisis hotline in New York City have soared during the COVID-19 pandemic, which has closed schools and businesses, put millions out of work, and ushered in stay-at-home orders.
ensuring that care is available when and where needed during a crisis, whether that be an individual crisis, a local community crisis, or a national mental health crisis like we are facing right now,” said Kimberly Williams, president and CEO of Vibrant Emotional Health.
Vibrant Emotional Health, formerly the Mental Health Association of New York City, provides crisis line services across the United States in partnership with local and federal governments and corporations. NYC Well is one of them.
Ms. Williams and two of her colleagues spoke about crisis hotlines April 25 during the American Psychiatric Association’s Virtual Spring Highlights Meeting.
Rapid crisis intervention
Crisis hotlines provide “rapid crisis intervention, delivering help immediately from trained crisis counselors who respond to unique needs, actively engage in collaborative problem solving, and assess risk for suicide,” Ms. Williams said.
They have a proven track record, she noted. Research shows that they are able to decrease emotional distress and reduce suicidality in crisis situations.
Kelly Clarke, program director of NYC Well, noted that inbound call volume has increased roughly 50% since the COVID-19 pandemic hit.
Callers to NYC Well most commonly report mood/anxiety concerns, stressful life events, and interpersonal problems. “Many people are reaching out to seek support in how to manage their own emotional well-being in light of the pandemic and the restrictions put in place,” said Ms. Clarke.
Multilingual peer support specialists and counselors with NYC Well provide free, confidential support by talk, text, or chat 24 hours per day, 7 days per week, 365 days a year. The service also provides mobile crisis teams and follow-up services. NYC Well has set up a landing page of resources specifically geared toward COVID-19.
How to cope with the rapid growth and at the same time ensure high quality of services are two key challenges for NYC Well, Ms. Clarke said.
“Absolutely essential” service
For John Draper, PhD, the experience early in his career of working on a mobile mental health crisis team in Brooklyn “changed his life.”
First, it showed him that, for people who are severely psychiatrically ill, “care has to come to them,” said Dr. Draper, executive vice president of national networks for Vibrant Emotional Health.
“So many of the people we were seeing were too depressed to get out of bed, much less get to a clinic, and I realized our system was not set up to serve its customers. It was like putting a spinal cord injury clinic at the top of a stairs,” he said.
Crisis hotlines are “absolutely essential.” Their value for communities and individuals “can’t be overestimated,” said Dr. Draper.
This was revealed after the terrorist attacks of 9/11 and now with COVID-19, said Dr. Draper. He noted, that following the attacks of 9/11, a federal report referred to crisis hotlines as “the single most important asset in the response.”
A version of this article originally appeared on Medscape.com.
Calls to a mental health crisis hotline in New York City have soared during the COVID-19 pandemic, which has closed schools and businesses, put millions out of work, and ushered in stay-at-home orders.
ensuring that care is available when and where needed during a crisis, whether that be an individual crisis, a local community crisis, or a national mental health crisis like we are facing right now,” said Kimberly Williams, president and CEO of Vibrant Emotional Health.
Vibrant Emotional Health, formerly the Mental Health Association of New York City, provides crisis line services across the United States in partnership with local and federal governments and corporations. NYC Well is one of them.
Ms. Williams and two of her colleagues spoke about crisis hotlines April 25 during the American Psychiatric Association’s Virtual Spring Highlights Meeting.
Rapid crisis intervention
Crisis hotlines provide “rapid crisis intervention, delivering help immediately from trained crisis counselors who respond to unique needs, actively engage in collaborative problem solving, and assess risk for suicide,” Ms. Williams said.
They have a proven track record, she noted. Research shows that they are able to decrease emotional distress and reduce suicidality in crisis situations.
Kelly Clarke, program director of NYC Well, noted that inbound call volume has increased roughly 50% since the COVID-19 pandemic hit.
Callers to NYC Well most commonly report mood/anxiety concerns, stressful life events, and interpersonal problems. “Many people are reaching out to seek support in how to manage their own emotional well-being in light of the pandemic and the restrictions put in place,” said Ms. Clarke.
Multilingual peer support specialists and counselors with NYC Well provide free, confidential support by talk, text, or chat 24 hours per day, 7 days per week, 365 days a year. The service also provides mobile crisis teams and follow-up services. NYC Well has set up a landing page of resources specifically geared toward COVID-19.
How to cope with the rapid growth and at the same time ensure high quality of services are two key challenges for NYC Well, Ms. Clarke said.
“Absolutely essential” service
For John Draper, PhD, the experience early in his career of working on a mobile mental health crisis team in Brooklyn “changed his life.”
First, it showed him that, for people who are severely psychiatrically ill, “care has to come to them,” said Dr. Draper, executive vice president of national networks for Vibrant Emotional Health.
“So many of the people we were seeing were too depressed to get out of bed, much less get to a clinic, and I realized our system was not set up to serve its customers. It was like putting a spinal cord injury clinic at the top of a stairs,” he said.
Crisis hotlines are “absolutely essential.” Their value for communities and individuals “can’t be overestimated,” said Dr. Draper.
This was revealed after the terrorist attacks of 9/11 and now with COVID-19, said Dr. Draper. He noted, that following the attacks of 9/11, a federal report referred to crisis hotlines as “the single most important asset in the response.”
A version of this article originally appeared on Medscape.com.
Drive-up pharmacotherapy during the COVID-19 pandemic
My medical career began during a tragedy. I started medical school in August 2001 at New York University, a few dozen blocks north of the World Trade Center in Manhattan. Several weeks later, the September 11 terrorist attacks devastated the city, and the rest of our country. Though we knew virtually nothing yet about practicing medicine, my entire class put on our scrubs and ran to the Bellevue Hospital emergency department to see if there was anything we could do to help. In the end, there was not much we could do that day, but the experience seared into us the notion that a physician stands tall in a crisis and does whatever it takes to help.
For me, the recent emergency we are facing with the coronavirus disease 2019 (COVID-19) pandemic has brought back bone-chilling memories of that time, especially because New York City has been one of the hardest-hit cities in the world. It’s hard for anyone to change routines on a dime, but I’m fortunate to run a solo private practice with a small administrative staff. I was able to pivot my medication management and therapy patients to 100% telepsychiatry overnight, even though I quite dislike the emotional distancing that the physical separation creates. However, I do administer some treatments that require my patients’ physical presence: long-acting injectable (LAI) antipsychotics, and intranasal esketamine. I consider both to be life-saving interventions, so I had to figure out how to continue offering those services while doing my part to keep everyone healthy.
Drive-up LAI antipsychotics
Many of my patients who receive LAIs are on formulations that are injected into the deltoid, so I transitioned to having them drive up to the front door of my office and roll up their sleeve so I could administer the injection without them leaving their car. If it was possible to convert a monthly deltoid injection to an equivalent quarterly deltoid injection, I accelerated that process. It took a little more thought to figure out how to best manage patients who had been getting gluteal injections. Deltoid injections are more convenient, but for certain antipsychotics, the only available LAI formulations that allow intervals longer than 1 month require gluteal administration due to the injection volume and pharmacokinetic considerations. Because of privacy and safety considerations, I didn’t feel gluteal injections would be feasible or appropriate for drive-up administration.
Maintaining patients on their gluteal injections would provide a longer duration between doses, but because patients would have to come inside the office to get them, there would be a higher risk of COVID-19 transmission. Converting them to a once-monthly equivalent with the same molecule and comparable dosage given in the deltoid via drive-up would reduce the risk of viral transmission, but requiring more frequent injections would increase the likelihood they might not show up for all doses during this crisis. I spoke with several other psychiatrists about this dilemma, and several of them favored lengthening the injection cycle as the top priority during this time. However, given the exponential curve of viral transmission in a pandemic, time is of the essence to “flatten the curve.” I decided that prioritizing the reduction of infection risk was paramount, and so I began switching my patients receiving gluteal injections with a longer duration to deltoid injections with a shorter duration. I can only hope I made the right decision for my patients, staff, and family.
Drive-up esketamine
Then came the hardest question—how do I continue to provide intranasal esketamine to my patients? There is an (appropriately) rigid Risk Evaluation and Mitigation Strategy protocol in place that requires patients to be monitored in a medically supervised health care setting for 2 hours after receiving esketamine. Having a patient in the office for at least 2 hours would create a tremendous risk for viral transmission, even in the best-case scenario of using personal protective equipment and stringent efforts to sterilize the space. I didn’t consider putting the treatments on hold because esketamine is indicated solely for patients with treatment-resistant depression, and these patients couldn’t be effectively managed with conventional oral antidepressants. I decided I’d have to figure out a way to adapt the drive-up LAI administration process for esketamine treatments as well.
In my practice, esketamine monitoring usually occurs in a treatment room that has a back entrance to a small, private parking lot. I realized that if I had the patients pull around the building and park in the spot right outside the window, we could maintain direct observation from inside the office while they sat in their car! Patients are not permitted to drive after receiving an esketamine treatment, so we take possession of their car keys to prevent them from driving off before the end of the monitoring period. We give them one of our automatic blood pressure cuffs to take the required blood pressure readings, and they relay the results through a video telemedicine connection. We also enlist the patient’s designated driver to provide an additional set of eyes for monitoring. When the observation period ends, the cuff is retrieved and sanitized.
Meeting our patients’ needs
Our duty to our patients is vital during a crisis, and they deserve everything in our power that we can offer them. We can’t be complacent in our routines and let our fears of what might or might not happen paralyze us from moving forward. If we are flexible and creative, we can rise to overcome any challenge to meeting our patients’ needs. Throughout this ordeal, I’ve seen some of the patients I was most worried about turn out to be some of the most resilient. When our patients have risen to the occasion, what excuse do we have not to do the same?
My medical career began during a tragedy. I started medical school in August 2001 at New York University, a few dozen blocks north of the World Trade Center in Manhattan. Several weeks later, the September 11 terrorist attacks devastated the city, and the rest of our country. Though we knew virtually nothing yet about practicing medicine, my entire class put on our scrubs and ran to the Bellevue Hospital emergency department to see if there was anything we could do to help. In the end, there was not much we could do that day, but the experience seared into us the notion that a physician stands tall in a crisis and does whatever it takes to help.
For me, the recent emergency we are facing with the coronavirus disease 2019 (COVID-19) pandemic has brought back bone-chilling memories of that time, especially because New York City has been one of the hardest-hit cities in the world. It’s hard for anyone to change routines on a dime, but I’m fortunate to run a solo private practice with a small administrative staff. I was able to pivot my medication management and therapy patients to 100% telepsychiatry overnight, even though I quite dislike the emotional distancing that the physical separation creates. However, I do administer some treatments that require my patients’ physical presence: long-acting injectable (LAI) antipsychotics, and intranasal esketamine. I consider both to be life-saving interventions, so I had to figure out how to continue offering those services while doing my part to keep everyone healthy.
Drive-up LAI antipsychotics
Many of my patients who receive LAIs are on formulations that are injected into the deltoid, so I transitioned to having them drive up to the front door of my office and roll up their sleeve so I could administer the injection without them leaving their car. If it was possible to convert a monthly deltoid injection to an equivalent quarterly deltoid injection, I accelerated that process. It took a little more thought to figure out how to best manage patients who had been getting gluteal injections. Deltoid injections are more convenient, but for certain antipsychotics, the only available LAI formulations that allow intervals longer than 1 month require gluteal administration due to the injection volume and pharmacokinetic considerations. Because of privacy and safety considerations, I didn’t feel gluteal injections would be feasible or appropriate for drive-up administration.
Maintaining patients on their gluteal injections would provide a longer duration between doses, but because patients would have to come inside the office to get them, there would be a higher risk of COVID-19 transmission. Converting them to a once-monthly equivalent with the same molecule and comparable dosage given in the deltoid via drive-up would reduce the risk of viral transmission, but requiring more frequent injections would increase the likelihood they might not show up for all doses during this crisis. I spoke with several other psychiatrists about this dilemma, and several of them favored lengthening the injection cycle as the top priority during this time. However, given the exponential curve of viral transmission in a pandemic, time is of the essence to “flatten the curve.” I decided that prioritizing the reduction of infection risk was paramount, and so I began switching my patients receiving gluteal injections with a longer duration to deltoid injections with a shorter duration. I can only hope I made the right decision for my patients, staff, and family.
Drive-up esketamine
Then came the hardest question—how do I continue to provide intranasal esketamine to my patients? There is an (appropriately) rigid Risk Evaluation and Mitigation Strategy protocol in place that requires patients to be monitored in a medically supervised health care setting for 2 hours after receiving esketamine. Having a patient in the office for at least 2 hours would create a tremendous risk for viral transmission, even in the best-case scenario of using personal protective equipment and stringent efforts to sterilize the space. I didn’t consider putting the treatments on hold because esketamine is indicated solely for patients with treatment-resistant depression, and these patients couldn’t be effectively managed with conventional oral antidepressants. I decided I’d have to figure out a way to adapt the drive-up LAI administration process for esketamine treatments as well.
In my practice, esketamine monitoring usually occurs in a treatment room that has a back entrance to a small, private parking lot. I realized that if I had the patients pull around the building and park in the spot right outside the window, we could maintain direct observation from inside the office while they sat in their car! Patients are not permitted to drive after receiving an esketamine treatment, so we take possession of their car keys to prevent them from driving off before the end of the monitoring period. We give them one of our automatic blood pressure cuffs to take the required blood pressure readings, and they relay the results through a video telemedicine connection. We also enlist the patient’s designated driver to provide an additional set of eyes for monitoring. When the observation period ends, the cuff is retrieved and sanitized.
Meeting our patients’ needs
Our duty to our patients is vital during a crisis, and they deserve everything in our power that we can offer them. We can’t be complacent in our routines and let our fears of what might or might not happen paralyze us from moving forward. If we are flexible and creative, we can rise to overcome any challenge to meeting our patients’ needs. Throughout this ordeal, I’ve seen some of the patients I was most worried about turn out to be some of the most resilient. When our patients have risen to the occasion, what excuse do we have not to do the same?
My medical career began during a tragedy. I started medical school in August 2001 at New York University, a few dozen blocks north of the World Trade Center in Manhattan. Several weeks later, the September 11 terrorist attacks devastated the city, and the rest of our country. Though we knew virtually nothing yet about practicing medicine, my entire class put on our scrubs and ran to the Bellevue Hospital emergency department to see if there was anything we could do to help. In the end, there was not much we could do that day, but the experience seared into us the notion that a physician stands tall in a crisis and does whatever it takes to help.
For me, the recent emergency we are facing with the coronavirus disease 2019 (COVID-19) pandemic has brought back bone-chilling memories of that time, especially because New York City has been one of the hardest-hit cities in the world. It’s hard for anyone to change routines on a dime, but I’m fortunate to run a solo private practice with a small administrative staff. I was able to pivot my medication management and therapy patients to 100% telepsychiatry overnight, even though I quite dislike the emotional distancing that the physical separation creates. However, I do administer some treatments that require my patients’ physical presence: long-acting injectable (LAI) antipsychotics, and intranasal esketamine. I consider both to be life-saving interventions, so I had to figure out how to continue offering those services while doing my part to keep everyone healthy.
Drive-up LAI antipsychotics
Many of my patients who receive LAIs are on formulations that are injected into the deltoid, so I transitioned to having them drive up to the front door of my office and roll up their sleeve so I could administer the injection without them leaving their car. If it was possible to convert a monthly deltoid injection to an equivalent quarterly deltoid injection, I accelerated that process. It took a little more thought to figure out how to best manage patients who had been getting gluteal injections. Deltoid injections are more convenient, but for certain antipsychotics, the only available LAI formulations that allow intervals longer than 1 month require gluteal administration due to the injection volume and pharmacokinetic considerations. Because of privacy and safety considerations, I didn’t feel gluteal injections would be feasible or appropriate for drive-up administration.
Maintaining patients on their gluteal injections would provide a longer duration between doses, but because patients would have to come inside the office to get them, there would be a higher risk of COVID-19 transmission. Converting them to a once-monthly equivalent with the same molecule and comparable dosage given in the deltoid via drive-up would reduce the risk of viral transmission, but requiring more frequent injections would increase the likelihood they might not show up for all doses during this crisis. I spoke with several other psychiatrists about this dilemma, and several of them favored lengthening the injection cycle as the top priority during this time. However, given the exponential curve of viral transmission in a pandemic, time is of the essence to “flatten the curve.” I decided that prioritizing the reduction of infection risk was paramount, and so I began switching my patients receiving gluteal injections with a longer duration to deltoid injections with a shorter duration. I can only hope I made the right decision for my patients, staff, and family.
Drive-up esketamine
Then came the hardest question—how do I continue to provide intranasal esketamine to my patients? There is an (appropriately) rigid Risk Evaluation and Mitigation Strategy protocol in place that requires patients to be monitored in a medically supervised health care setting for 2 hours after receiving esketamine. Having a patient in the office for at least 2 hours would create a tremendous risk for viral transmission, even in the best-case scenario of using personal protective equipment and stringent efforts to sterilize the space. I didn’t consider putting the treatments on hold because esketamine is indicated solely for patients with treatment-resistant depression, and these patients couldn’t be effectively managed with conventional oral antidepressants. I decided I’d have to figure out a way to adapt the drive-up LAI administration process for esketamine treatments as well.
In my practice, esketamine monitoring usually occurs in a treatment room that has a back entrance to a small, private parking lot. I realized that if I had the patients pull around the building and park in the spot right outside the window, we could maintain direct observation from inside the office while they sat in their car! Patients are not permitted to drive after receiving an esketamine treatment, so we take possession of their car keys to prevent them from driving off before the end of the monitoring period. We give them one of our automatic blood pressure cuffs to take the required blood pressure readings, and they relay the results through a video telemedicine connection. We also enlist the patient’s designated driver to provide an additional set of eyes for monitoring. When the observation period ends, the cuff is retrieved and sanitized.
Meeting our patients’ needs
Our duty to our patients is vital during a crisis, and they deserve everything in our power that we can offer them. We can’t be complacent in our routines and let our fears of what might or might not happen paralyze us from moving forward. If we are flexible and creative, we can rise to overcome any challenge to meeting our patients’ needs. Throughout this ordeal, I’ve seen some of the patients I was most worried about turn out to be some of the most resilient. When our patients have risen to the occasion, what excuse do we have not to do the same?
COVID-19: Experts call for ‘urgent’ global action to prevent suicide
A global group of suicide experts is urging governments around the world to take action to prevent a possible jump in suicide rates because of the ongoing COVID-19 pandemic.
In a commentary published online April 21 in Lancet Psychiatry, members of the International COVID-19 Suicide Prevention Research Collaboration warned that suicide rates are likely to rise as the pandemic spreads and its ensuing long-term effects on the general population, economy, and vulnerable groups emerge.
“Preventing suicide therefore needs urgent consideration. The response must capitalize on, but extend beyond, general mental health policies and practices,” the experts wrote.
The COVID-19 collaboration was started by David Gunnell, MBChB, PhD, University of Bristol, England, and includes 42 members with suicide expertise from around the world.
“We’re an ad hoc grouping of international suicide prevention researchers, research leaders, and members of larger international suicide prevention organizations. We include specialists in public health, psychiatry, psychology, and other clinical disciplines,” Dr. Gunnell said in an interview.
“Through this comment piece we hope to share our ideas and experiences about best practice, and ask others working in the field of suicide prevention at a regional, national, and international level to share our intervention and surveillance/data collection recommendations with relevant policy makers,” he added.
Lessons from the past
During times of crisis, people with existing mental health disorders may suffer worsening symptoms, whereas others may develop new mental health problems, especially depression, anxiety, and posttraumatic stress disorder (PTSD), the group notes.
There is some evidence that suicide increased in the United States during the Spanish flu pandemic of 1918 and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) outbreak.
An increase in suicide related to COVID-19 is not inevitable provided preventive action is prompt, the group notes.
In their article, the group offered several potential public health responses to mitigate suicide risk associated with the COVID-19 pandemic.
These include:
- Clear care pathways for those who are suicidal.
- Remote or digital assessments for patients currently under the care of a mental health professional.
- Staff training to support new ways of working.
- Increased support for mental health helplines.
- Providing easily accessible grief counseling for those who have lost a loved one to the virus.
- Financial safety nets and labor market programs.
- Dissemination of evidence-based online interventions.
Public health responses must also ensure that those facing domestic violence have access to support and a place to go during times of crisis, they suggested.
“These are unprecedented times. The pandemic will cause distress and leave many vulnerable. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention,” the group wrote.
Dr. Gunnell said it’s hard to predict what impact the pandemic will have on suicide rates, “but given the range of concerns, it is important to be prepared and take steps to mitigate risk as much as possible.”
Concerning spike in gun sales
Eric Fleegler, MD, MPH, and colleagues from Boston Children’s Hospital and Harvard Medical School, Boston, agreed.
“The time to act is now. Both population and individual approaches are needed to reduce the risk for suicide in the coming months,” they wrote in a commentary published online April 22 in Annals of Internal Medicine.
Dr. Fleegler and colleagues are particularly concerned about a potential increase in gun-related suicides, as gun sales in the United States have “skyrocketed” during the COVID-19 pandemic.
In March, more than 2.5 million firearms were sold, including 1.5 million handguns. That’s an 85% increase in gun sales compared with March 2019 and the highest firearm sales ever recorded in the United States, they reported.
In addition, research has shown that individuals who buy handguns have a 22-fold higher rate of firearm-related suicide within the first year vs. those who don’t purchase a handgun.
“In the best of times, increased gun ownership is associated with a heightened risk for firearm-related suicide. These are not the best of times,” the authors wrote.
Dr. Fleegler and colleagues said From 2006 to 2018, firearm-related suicide rates increased by more than 25%, according to the National Center for Injury Prevention and Control. In 2018 alone, there were 24,432 firearm-related suicides in the United States.
“The United States should take policy and clinical action to avoid a potential epidemic of firearm-related suicide in the wake of the COVID-19 pandemic,” they concluded.
This research had no specific funding. Dr. Gunnell and Dr. Fleegler disclosed no relevant financial relationships .
A version of this article originally appeared on Medscape.com.
A global group of suicide experts is urging governments around the world to take action to prevent a possible jump in suicide rates because of the ongoing COVID-19 pandemic.
In a commentary published online April 21 in Lancet Psychiatry, members of the International COVID-19 Suicide Prevention Research Collaboration warned that suicide rates are likely to rise as the pandemic spreads and its ensuing long-term effects on the general population, economy, and vulnerable groups emerge.
“Preventing suicide therefore needs urgent consideration. The response must capitalize on, but extend beyond, general mental health policies and practices,” the experts wrote.
The COVID-19 collaboration was started by David Gunnell, MBChB, PhD, University of Bristol, England, and includes 42 members with suicide expertise from around the world.
“We’re an ad hoc grouping of international suicide prevention researchers, research leaders, and members of larger international suicide prevention organizations. We include specialists in public health, psychiatry, psychology, and other clinical disciplines,” Dr. Gunnell said in an interview.
“Through this comment piece we hope to share our ideas and experiences about best practice, and ask others working in the field of suicide prevention at a regional, national, and international level to share our intervention and surveillance/data collection recommendations with relevant policy makers,” he added.
Lessons from the past
During times of crisis, people with existing mental health disorders may suffer worsening symptoms, whereas others may develop new mental health problems, especially depression, anxiety, and posttraumatic stress disorder (PTSD), the group notes.
There is some evidence that suicide increased in the United States during the Spanish flu pandemic of 1918 and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) outbreak.
An increase in suicide related to COVID-19 is not inevitable provided preventive action is prompt, the group notes.
In their article, the group offered several potential public health responses to mitigate suicide risk associated with the COVID-19 pandemic.
These include:
- Clear care pathways for those who are suicidal.
- Remote or digital assessments for patients currently under the care of a mental health professional.
- Staff training to support new ways of working.
- Increased support for mental health helplines.
- Providing easily accessible grief counseling for those who have lost a loved one to the virus.
- Financial safety nets and labor market programs.
- Dissemination of evidence-based online interventions.
Public health responses must also ensure that those facing domestic violence have access to support and a place to go during times of crisis, they suggested.
“These are unprecedented times. The pandemic will cause distress and leave many vulnerable. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention,” the group wrote.
Dr. Gunnell said it’s hard to predict what impact the pandemic will have on suicide rates, “but given the range of concerns, it is important to be prepared and take steps to mitigate risk as much as possible.”
Concerning spike in gun sales
Eric Fleegler, MD, MPH, and colleagues from Boston Children’s Hospital and Harvard Medical School, Boston, agreed.
“The time to act is now. Both population and individual approaches are needed to reduce the risk for suicide in the coming months,” they wrote in a commentary published online April 22 in Annals of Internal Medicine.
Dr. Fleegler and colleagues are particularly concerned about a potential increase in gun-related suicides, as gun sales in the United States have “skyrocketed” during the COVID-19 pandemic.
In March, more than 2.5 million firearms were sold, including 1.5 million handguns. That’s an 85% increase in gun sales compared with March 2019 and the highest firearm sales ever recorded in the United States, they reported.
In addition, research has shown that individuals who buy handguns have a 22-fold higher rate of firearm-related suicide within the first year vs. those who don’t purchase a handgun.
“In the best of times, increased gun ownership is associated with a heightened risk for firearm-related suicide. These are not the best of times,” the authors wrote.
Dr. Fleegler and colleagues said From 2006 to 2018, firearm-related suicide rates increased by more than 25%, according to the National Center for Injury Prevention and Control. In 2018 alone, there were 24,432 firearm-related suicides in the United States.
“The United States should take policy and clinical action to avoid a potential epidemic of firearm-related suicide in the wake of the COVID-19 pandemic,” they concluded.
This research had no specific funding. Dr. Gunnell and Dr. Fleegler disclosed no relevant financial relationships .
A version of this article originally appeared on Medscape.com.
A global group of suicide experts is urging governments around the world to take action to prevent a possible jump in suicide rates because of the ongoing COVID-19 pandemic.
In a commentary published online April 21 in Lancet Psychiatry, members of the International COVID-19 Suicide Prevention Research Collaboration warned that suicide rates are likely to rise as the pandemic spreads and its ensuing long-term effects on the general population, economy, and vulnerable groups emerge.
“Preventing suicide therefore needs urgent consideration. The response must capitalize on, but extend beyond, general mental health policies and practices,” the experts wrote.
The COVID-19 collaboration was started by David Gunnell, MBChB, PhD, University of Bristol, England, and includes 42 members with suicide expertise from around the world.
“We’re an ad hoc grouping of international suicide prevention researchers, research leaders, and members of larger international suicide prevention organizations. We include specialists in public health, psychiatry, psychology, and other clinical disciplines,” Dr. Gunnell said in an interview.
“Through this comment piece we hope to share our ideas and experiences about best practice, and ask others working in the field of suicide prevention at a regional, national, and international level to share our intervention and surveillance/data collection recommendations with relevant policy makers,” he added.
Lessons from the past
During times of crisis, people with existing mental health disorders may suffer worsening symptoms, whereas others may develop new mental health problems, especially depression, anxiety, and posttraumatic stress disorder (PTSD), the group notes.
There is some evidence that suicide increased in the United States during the Spanish flu pandemic of 1918 and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) outbreak.
An increase in suicide related to COVID-19 is not inevitable provided preventive action is prompt, the group notes.
In their article, the group offered several potential public health responses to mitigate suicide risk associated with the COVID-19 pandemic.
These include:
- Clear care pathways for those who are suicidal.
- Remote or digital assessments for patients currently under the care of a mental health professional.
- Staff training to support new ways of working.
- Increased support for mental health helplines.
- Providing easily accessible grief counseling for those who have lost a loved one to the virus.
- Financial safety nets and labor market programs.
- Dissemination of evidence-based online interventions.
Public health responses must also ensure that those facing domestic violence have access to support and a place to go during times of crisis, they suggested.
“These are unprecedented times. The pandemic will cause distress and leave many vulnerable. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention,” the group wrote.
Dr. Gunnell said it’s hard to predict what impact the pandemic will have on suicide rates, “but given the range of concerns, it is important to be prepared and take steps to mitigate risk as much as possible.”
Concerning spike in gun sales
Eric Fleegler, MD, MPH, and colleagues from Boston Children’s Hospital and Harvard Medical School, Boston, agreed.
“The time to act is now. Both population and individual approaches are needed to reduce the risk for suicide in the coming months,” they wrote in a commentary published online April 22 in Annals of Internal Medicine.
Dr. Fleegler and colleagues are particularly concerned about a potential increase in gun-related suicides, as gun sales in the United States have “skyrocketed” during the COVID-19 pandemic.
In March, more than 2.5 million firearms were sold, including 1.5 million handguns. That’s an 85% increase in gun sales compared with March 2019 and the highest firearm sales ever recorded in the United States, they reported.
In addition, research has shown that individuals who buy handguns have a 22-fold higher rate of firearm-related suicide within the first year vs. those who don’t purchase a handgun.
“In the best of times, increased gun ownership is associated with a heightened risk for firearm-related suicide. These are not the best of times,” the authors wrote.
Dr. Fleegler and colleagues said From 2006 to 2018, firearm-related suicide rates increased by more than 25%, according to the National Center for Injury Prevention and Control. In 2018 alone, there were 24,432 firearm-related suicides in the United States.
“The United States should take policy and clinical action to avoid a potential epidemic of firearm-related suicide in the wake of the COVID-19 pandemic,” they concluded.
This research had no specific funding. Dr. Gunnell and Dr. Fleegler disclosed no relevant financial relationships .
A version of this article originally appeared on Medscape.com.
‘When reason sleeps’: Suicide risk peaks at night
The risk for suicide is higher at night than at any other time of day, new research shows.
In findings that may offer an opportunity for suicide prevention, investigators found that the risk of dying by suicide between midnight and 6:00 a.m. was roughly three times higher than at other times of day regardless of month, method of suicide, or a wide range of other factors.
“The take-home message is that helping at-risk patients sleep through the night may be an excellent way to reduce suicide risk,” lead author Andrew Tubbs, an MD/PhD candidate at the Sleep and Health Research Program, department of psychiatry, University of Arizona, Tucson, said in an interview.
The study was published in the March/April issue of the Journal of Clinical Psychiatry.
Time, method of suicide
Previous research suggests that waking at night is linked to a heightened risk for suicidal thoughts and behaviors, the investigators note.
“The motivation for this study was to expand our understanding of factors that increase suicide risk at night. Since night length changes across seasons, we wondered if suicide risk at night would be lower during summer months and higher during winter months,” he said.
“Similarly, we thought the availability of some suicide methods may vary by time of day — for example, perhaps nighttime would involve more ‘silent’ methods, such as poisoning or asphyxiation, over ‘louder methods,’ such as firearms or vehicle suicides,” Mr. Tubbs added.
The investigators also examined whether the risk for nocturnal suicide was influenced by demographic or geographic factors.
They analyzed data on 35,338 suicides from the U.S. National Violent Death Reporting System for the years 2003-2010.
Time of suicide was divided into four categories: night (12:00 a.m.–5:59 a.m.), morning (6:00 a.m.–11:59 a.m.), afternoon (12:00 p.m.–5:59 p.m.), and evening (6:00 p.m.–11:59 p.m.).
Suicide methods included guns, asphyxiation, poisons, falls, vehicles, sharp weapons, drowning, and fire. Demographics included sex, age, race, and ethnicity. Geographic analyses were based on latitude (at or above 40° N or below 35° N) and region (West, Midwest, South, and Northeast).
Raw data revealed that more males than females died by suicide (n = 28,700 vs. 6636), that most suicides occurred in May (n = 3196), and that the most common method of suicide was by firearms (n = 21,937). Most suicides occurred in those aged 45-54 years (n = 7252) and in whites (n = 31,239) and non-Hispanics (33,384).
Mr. Tubbs explained that suicides are more common during the day, typically around midday, when most people are awake, “so the ‘eligible’ population for suicide is highest at noon,” he said. However, this does not translate into level of risk, so the researchers accounted for nocturnal wakefulness in the analyses.
“When reason sleeps”
The incidence rate ratio at night was 3.18, significantly higher than at any other time of day across all months. The highest IRR was in May (3.90), and the lowest was in November (2.74).
An analysis of variance (ANOVA) for month and time of day indicated that the IRR varied significantly only by time of day (P < .001), not across months (P = .33) or by interaction (P = 1.00).
Initially, a two-way ANOVA showed that the risk for suicide varied both by time of day and by suicide method (both Ps < .001), but the interaction between them was not significant (P = .3026). The mean (SD) nocturnal IRR was 3.09 (.472) across all methods.
Although more than half of suicides involved firearms, “no method had a significantly higher risk at a specific time than any other method at that same time,” the authors note. In addition, an analysis of nocturnal risk by method showed no differences on the basis of sex, age, ethnicity, latitude, and region.
“There are probably many overlapping reasons why the risk of suicide is highest at night. Certainly, social and family supports are minimized if you are awake and everyone you know and love is asleep – you’re isolated, no one’s reaching out to you, and there’s no one there to stop you,” said Mr. Tubbs.
On the other hand, “recent evidence indicates nighttime changes in brain function can impair impulse control, decision making, and long-term planning, which can definitely increase suicidal behaviors.
“Whether these changes are due to sleep deprivation or circadian rhythms is unknown, but it is clearly dangerous to be awake when reason sleeps,” he said.
Clinicians who treat suicidal patients, said Mr. Tubbs, should ask about sleep. If a patient has a problem with sleep, cognitive-behavioral therapy for insomnia should be initiated. This first-line treatment, he said, is more effective and much safer than prescribing a hypnotic.
Difficult hours
Commenting on the study, Christopher W. Drapeau, PhD, of the department of education, Valparaiso University, Indiana, said that sleep disturbances “may be a modifiable risk factor for suicide, especially when sleep disturbances are cited by patients as a primary reason for wanting to attempt suicide.”
Dr. Drapeau, who was not involved in the study, said that this “presents an area for health professionals to focus on when developing treatment approaches based on patient information collected during suicide-risk screenings and comprehensive risk assessments.”
Also commenting on the study, Michael Nadorff, PhD, of the department of psychology, Mississippi State University, Starkville, who was not involved with the study, said the study findings are clinically relevant.
These data, he said, inform clinicians about when patients are most likely to be struggling with suicide intent and offer an opportunity to develop safety plans to mitigate suicide risk during these “difficult hours” when coping mechanisms are at a low ebb and sources of support are unavailable.
Support for the study was provided by grants from the National Institutes of Health and the Veterans Administration. Mr. Tubbs and Dr. Drapeau, and Dr. Nadorff report no relevant financial relationships.
This article first appeared on Medscape.com.
The risk for suicide is higher at night than at any other time of day, new research shows.
In findings that may offer an opportunity for suicide prevention, investigators found that the risk of dying by suicide between midnight and 6:00 a.m. was roughly three times higher than at other times of day regardless of month, method of suicide, or a wide range of other factors.
“The take-home message is that helping at-risk patients sleep through the night may be an excellent way to reduce suicide risk,” lead author Andrew Tubbs, an MD/PhD candidate at the Sleep and Health Research Program, department of psychiatry, University of Arizona, Tucson, said in an interview.
The study was published in the March/April issue of the Journal of Clinical Psychiatry.
Time, method of suicide
Previous research suggests that waking at night is linked to a heightened risk for suicidal thoughts and behaviors, the investigators note.
“The motivation for this study was to expand our understanding of factors that increase suicide risk at night. Since night length changes across seasons, we wondered if suicide risk at night would be lower during summer months and higher during winter months,” he said.
“Similarly, we thought the availability of some suicide methods may vary by time of day — for example, perhaps nighttime would involve more ‘silent’ methods, such as poisoning or asphyxiation, over ‘louder methods,’ such as firearms or vehicle suicides,” Mr. Tubbs added.
The investigators also examined whether the risk for nocturnal suicide was influenced by demographic or geographic factors.
They analyzed data on 35,338 suicides from the U.S. National Violent Death Reporting System for the years 2003-2010.
Time of suicide was divided into four categories: night (12:00 a.m.–5:59 a.m.), morning (6:00 a.m.–11:59 a.m.), afternoon (12:00 p.m.–5:59 p.m.), and evening (6:00 p.m.–11:59 p.m.).
Suicide methods included guns, asphyxiation, poisons, falls, vehicles, sharp weapons, drowning, and fire. Demographics included sex, age, race, and ethnicity. Geographic analyses were based on latitude (at or above 40° N or below 35° N) and region (West, Midwest, South, and Northeast).
Raw data revealed that more males than females died by suicide (n = 28,700 vs. 6636), that most suicides occurred in May (n = 3196), and that the most common method of suicide was by firearms (n = 21,937). Most suicides occurred in those aged 45-54 years (n = 7252) and in whites (n = 31,239) and non-Hispanics (33,384).
Mr. Tubbs explained that suicides are more common during the day, typically around midday, when most people are awake, “so the ‘eligible’ population for suicide is highest at noon,” he said. However, this does not translate into level of risk, so the researchers accounted for nocturnal wakefulness in the analyses.
“When reason sleeps”
The incidence rate ratio at night was 3.18, significantly higher than at any other time of day across all months. The highest IRR was in May (3.90), and the lowest was in November (2.74).
An analysis of variance (ANOVA) for month and time of day indicated that the IRR varied significantly only by time of day (P < .001), not across months (P = .33) or by interaction (P = 1.00).
Initially, a two-way ANOVA showed that the risk for suicide varied both by time of day and by suicide method (both Ps < .001), but the interaction between them was not significant (P = .3026). The mean (SD) nocturnal IRR was 3.09 (.472) across all methods.
Although more than half of suicides involved firearms, “no method had a significantly higher risk at a specific time than any other method at that same time,” the authors note. In addition, an analysis of nocturnal risk by method showed no differences on the basis of sex, age, ethnicity, latitude, and region.
“There are probably many overlapping reasons why the risk of suicide is highest at night. Certainly, social and family supports are minimized if you are awake and everyone you know and love is asleep – you’re isolated, no one’s reaching out to you, and there’s no one there to stop you,” said Mr. Tubbs.
On the other hand, “recent evidence indicates nighttime changes in brain function can impair impulse control, decision making, and long-term planning, which can definitely increase suicidal behaviors.
“Whether these changes are due to sleep deprivation or circadian rhythms is unknown, but it is clearly dangerous to be awake when reason sleeps,” he said.
Clinicians who treat suicidal patients, said Mr. Tubbs, should ask about sleep. If a patient has a problem with sleep, cognitive-behavioral therapy for insomnia should be initiated. This first-line treatment, he said, is more effective and much safer than prescribing a hypnotic.
Difficult hours
Commenting on the study, Christopher W. Drapeau, PhD, of the department of education, Valparaiso University, Indiana, said that sleep disturbances “may be a modifiable risk factor for suicide, especially when sleep disturbances are cited by patients as a primary reason for wanting to attempt suicide.”
Dr. Drapeau, who was not involved in the study, said that this “presents an area for health professionals to focus on when developing treatment approaches based on patient information collected during suicide-risk screenings and comprehensive risk assessments.”
Also commenting on the study, Michael Nadorff, PhD, of the department of psychology, Mississippi State University, Starkville, who was not involved with the study, said the study findings are clinically relevant.
These data, he said, inform clinicians about when patients are most likely to be struggling with suicide intent and offer an opportunity to develop safety plans to mitigate suicide risk during these “difficult hours” when coping mechanisms are at a low ebb and sources of support are unavailable.
Support for the study was provided by grants from the National Institutes of Health and the Veterans Administration. Mr. Tubbs and Dr. Drapeau, and Dr. Nadorff report no relevant financial relationships.
This article first appeared on Medscape.com.
The risk for suicide is higher at night than at any other time of day, new research shows.
In findings that may offer an opportunity for suicide prevention, investigators found that the risk of dying by suicide between midnight and 6:00 a.m. was roughly three times higher than at other times of day regardless of month, method of suicide, or a wide range of other factors.
“The take-home message is that helping at-risk patients sleep through the night may be an excellent way to reduce suicide risk,” lead author Andrew Tubbs, an MD/PhD candidate at the Sleep and Health Research Program, department of psychiatry, University of Arizona, Tucson, said in an interview.
The study was published in the March/April issue of the Journal of Clinical Psychiatry.
Time, method of suicide
Previous research suggests that waking at night is linked to a heightened risk for suicidal thoughts and behaviors, the investigators note.
“The motivation for this study was to expand our understanding of factors that increase suicide risk at night. Since night length changes across seasons, we wondered if suicide risk at night would be lower during summer months and higher during winter months,” he said.
“Similarly, we thought the availability of some suicide methods may vary by time of day — for example, perhaps nighttime would involve more ‘silent’ methods, such as poisoning or asphyxiation, over ‘louder methods,’ such as firearms or vehicle suicides,” Mr. Tubbs added.
The investigators also examined whether the risk for nocturnal suicide was influenced by demographic or geographic factors.
They analyzed data on 35,338 suicides from the U.S. National Violent Death Reporting System for the years 2003-2010.
Time of suicide was divided into four categories: night (12:00 a.m.–5:59 a.m.), morning (6:00 a.m.–11:59 a.m.), afternoon (12:00 p.m.–5:59 p.m.), and evening (6:00 p.m.–11:59 p.m.).
Suicide methods included guns, asphyxiation, poisons, falls, vehicles, sharp weapons, drowning, and fire. Demographics included sex, age, race, and ethnicity. Geographic analyses were based on latitude (at or above 40° N or below 35° N) and region (West, Midwest, South, and Northeast).
Raw data revealed that more males than females died by suicide (n = 28,700 vs. 6636), that most suicides occurred in May (n = 3196), and that the most common method of suicide was by firearms (n = 21,937). Most suicides occurred in those aged 45-54 years (n = 7252) and in whites (n = 31,239) and non-Hispanics (33,384).
Mr. Tubbs explained that suicides are more common during the day, typically around midday, when most people are awake, “so the ‘eligible’ population for suicide is highest at noon,” he said. However, this does not translate into level of risk, so the researchers accounted for nocturnal wakefulness in the analyses.
“When reason sleeps”
The incidence rate ratio at night was 3.18, significantly higher than at any other time of day across all months. The highest IRR was in May (3.90), and the lowest was in November (2.74).
An analysis of variance (ANOVA) for month and time of day indicated that the IRR varied significantly only by time of day (P < .001), not across months (P = .33) or by interaction (P = 1.00).
Initially, a two-way ANOVA showed that the risk for suicide varied both by time of day and by suicide method (both Ps < .001), but the interaction between them was not significant (P = .3026). The mean (SD) nocturnal IRR was 3.09 (.472) across all methods.
Although more than half of suicides involved firearms, “no method had a significantly higher risk at a specific time than any other method at that same time,” the authors note. In addition, an analysis of nocturnal risk by method showed no differences on the basis of sex, age, ethnicity, latitude, and region.
“There are probably many overlapping reasons why the risk of suicide is highest at night. Certainly, social and family supports are minimized if you are awake and everyone you know and love is asleep – you’re isolated, no one’s reaching out to you, and there’s no one there to stop you,” said Mr. Tubbs.
On the other hand, “recent evidence indicates nighttime changes in brain function can impair impulse control, decision making, and long-term planning, which can definitely increase suicidal behaviors.
“Whether these changes are due to sleep deprivation or circadian rhythms is unknown, but it is clearly dangerous to be awake when reason sleeps,” he said.
Clinicians who treat suicidal patients, said Mr. Tubbs, should ask about sleep. If a patient has a problem with sleep, cognitive-behavioral therapy for insomnia should be initiated. This first-line treatment, he said, is more effective and much safer than prescribing a hypnotic.
Difficult hours
Commenting on the study, Christopher W. Drapeau, PhD, of the department of education, Valparaiso University, Indiana, said that sleep disturbances “may be a modifiable risk factor for suicide, especially when sleep disturbances are cited by patients as a primary reason for wanting to attempt suicide.”
Dr. Drapeau, who was not involved in the study, said that this “presents an area for health professionals to focus on when developing treatment approaches based on patient information collected during suicide-risk screenings and comprehensive risk assessments.”
Also commenting on the study, Michael Nadorff, PhD, of the department of psychology, Mississippi State University, Starkville, who was not involved with the study, said the study findings are clinically relevant.
These data, he said, inform clinicians about when patients are most likely to be struggling with suicide intent and offer an opportunity to develop safety plans to mitigate suicide risk during these “difficult hours” when coping mechanisms are at a low ebb and sources of support are unavailable.
Support for the study was provided by grants from the National Institutes of Health and the Veterans Administration. Mr. Tubbs and Dr. Drapeau, and Dr. Nadorff report no relevant financial relationships.
This article first appeared on Medscape.com.
COVID-19 & Mental Health
Join us on Thursday, April 23, at 8:30 p.m. EST as we discuss how the COVID-19 pandemic is affecting the mental health of psychiatry patients and providers around the world.
Our special guests include two psychiatry educators with expertise in therapeutic psychotherapy and solutions on how to help our most vulnerable populations being affected by COVID-19, Dinah Miller, MD (@shrinkraphdinah), and Elizabeth Ryznar, MD (@RyznarMD). We hope you will participate in our Twitter chat this evening, at 8:30 p.m. EST on #MDedgeChats.
Public health emergencies can affect the well-being of individuals and communities causing possible feelings of insecurity, confusion, and emotional isolation. These effects may translate into a range of emotional reactions affecting current psychiatric conditions and creating new ones, according to the New England Journal of Medicine.
According to the Kaiser Family Foundation, “nearly 45% of adults across the country say that worry and stress related to the coronavirus pandemic are hurting their mental health.”
In this chat, we will discuss this topic and how COVID-19 is affecting your patients and practice. Join us tonight and feel free to share what you have experienced during this pandemic at 8:30 pm EST on #MDedgeChats.
Topics of Conversation
Question 1: How are pre-pandemic patients doing during the crisis?
Question 2: How has COVID-19 affected inpatient and outpatient care for you?
Question 3: How are our most vulnerable populations being affected by COVID-19?
Question 4: How are you doing personally and professionally as a medical professional and psychiatrist amidst this pandemic?
Question 5: What psychiatric manifestations are you seeing in your patients who have had COVID-19?
About Dr. Dinah Miller
Dr. Dinah Miller (@shrinkrapdinah) a psychiatrist with a private practice and an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. Dr. Miller is also a columnist for and a member of the Editorial Advisory Board of Clinical Psychiatry News. She is the co-author of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016) and “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University, 2011).
About Dr. Elizabeth Ryznar
Dr. Elizabeth Ryznar (@RyznarMD) is a psychiatry clinician-educator research fellow and an assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She completed her medical training at Harvard Medical School in Boston and her residency training at Northwestern University in Chicago. Dr. Ryznar is co-editor of the new book “Landmark Papers in Psychiatry,” published by Oxford University Press, and has several peer-reviewed articles.
Resources
- Mental health and the COVID-19 pandemic
- Brief examines the COVID-19 crisis’ implications for Americans’ mental health
- COVID-19: Helping health care workers on the front lines
- Overcoming COVID-related stress
- Confessions of an outpatient psychiatrist during the pandemic
- Psychiatric patients may be among the hardest hit
- Experts hasten to head off mental health crisis
Join us on Thursday, April 23, at 8:30 p.m. EST as we discuss how the COVID-19 pandemic is affecting the mental health of psychiatry patients and providers around the world.
Our special guests include two psychiatry educators with expertise in therapeutic psychotherapy and solutions on how to help our most vulnerable populations being affected by COVID-19, Dinah Miller, MD (@shrinkraphdinah), and Elizabeth Ryznar, MD (@RyznarMD). We hope you will participate in our Twitter chat this evening, at 8:30 p.m. EST on #MDedgeChats.
Public health emergencies can affect the well-being of individuals and communities causing possible feelings of insecurity, confusion, and emotional isolation. These effects may translate into a range of emotional reactions affecting current psychiatric conditions and creating new ones, according to the New England Journal of Medicine.
According to the Kaiser Family Foundation, “nearly 45% of adults across the country say that worry and stress related to the coronavirus pandemic are hurting their mental health.”
In this chat, we will discuss this topic and how COVID-19 is affecting your patients and practice. Join us tonight and feel free to share what you have experienced during this pandemic at 8:30 pm EST on #MDedgeChats.
Topics of Conversation
Question 1: How are pre-pandemic patients doing during the crisis?
Question 2: How has COVID-19 affected inpatient and outpatient care for you?
Question 3: How are our most vulnerable populations being affected by COVID-19?
Question 4: How are you doing personally and professionally as a medical professional and psychiatrist amidst this pandemic?
Question 5: What psychiatric manifestations are you seeing in your patients who have had COVID-19?
About Dr. Dinah Miller
Dr. Dinah Miller (@shrinkrapdinah) a psychiatrist with a private practice and an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. Dr. Miller is also a columnist for and a member of the Editorial Advisory Board of Clinical Psychiatry News. She is the co-author of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016) and “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University, 2011).
About Dr. Elizabeth Ryznar
Dr. Elizabeth Ryznar (@RyznarMD) is a psychiatry clinician-educator research fellow and an assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She completed her medical training at Harvard Medical School in Boston and her residency training at Northwestern University in Chicago. Dr. Ryznar is co-editor of the new book “Landmark Papers in Psychiatry,” published by Oxford University Press, and has several peer-reviewed articles.
Resources
- Mental health and the COVID-19 pandemic
- Brief examines the COVID-19 crisis’ implications for Americans’ mental health
- COVID-19: Helping health care workers on the front lines
- Overcoming COVID-related stress
- Confessions of an outpatient psychiatrist during the pandemic
- Psychiatric patients may be among the hardest hit
- Experts hasten to head off mental health crisis
Join us on Thursday, April 23, at 8:30 p.m. EST as we discuss how the COVID-19 pandemic is affecting the mental health of psychiatry patients and providers around the world.
Our special guests include two psychiatry educators with expertise in therapeutic psychotherapy and solutions on how to help our most vulnerable populations being affected by COVID-19, Dinah Miller, MD (@shrinkraphdinah), and Elizabeth Ryznar, MD (@RyznarMD). We hope you will participate in our Twitter chat this evening, at 8:30 p.m. EST on #MDedgeChats.
Public health emergencies can affect the well-being of individuals and communities causing possible feelings of insecurity, confusion, and emotional isolation. These effects may translate into a range of emotional reactions affecting current psychiatric conditions and creating new ones, according to the New England Journal of Medicine.
According to the Kaiser Family Foundation, “nearly 45% of adults across the country say that worry and stress related to the coronavirus pandemic are hurting their mental health.”
In this chat, we will discuss this topic and how COVID-19 is affecting your patients and practice. Join us tonight and feel free to share what you have experienced during this pandemic at 8:30 pm EST on #MDedgeChats.
Topics of Conversation
Question 1: How are pre-pandemic patients doing during the crisis?
Question 2: How has COVID-19 affected inpatient and outpatient care for you?
Question 3: How are our most vulnerable populations being affected by COVID-19?
Question 4: How are you doing personally and professionally as a medical professional and psychiatrist amidst this pandemic?
Question 5: What psychiatric manifestations are you seeing in your patients who have had COVID-19?
About Dr. Dinah Miller
Dr. Dinah Miller (@shrinkrapdinah) a psychiatrist with a private practice and an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. Dr. Miller is also a columnist for and a member of the Editorial Advisory Board of Clinical Psychiatry News. She is the co-author of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016) and “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University, 2011).
About Dr. Elizabeth Ryznar
Dr. Elizabeth Ryznar (@RyznarMD) is a psychiatry clinician-educator research fellow and an assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She completed her medical training at Harvard Medical School in Boston and her residency training at Northwestern University in Chicago. Dr. Ryznar is co-editor of the new book “Landmark Papers in Psychiatry,” published by Oxford University Press, and has several peer-reviewed articles.
Resources
- Mental health and the COVID-19 pandemic
- Brief examines the COVID-19 crisis’ implications for Americans’ mental health
- COVID-19: Helping health care workers on the front lines
- Overcoming COVID-related stress
- Confessions of an outpatient psychiatrist during the pandemic
- Psychiatric patients may be among the hardest hit
- Experts hasten to head off mental health crisis
COPD, smoking independently associated with developing depression
People with chronic obstructive pulmonary disorder (COPD) and those who smoke are at an increased risk of developing depression, results of a population-based cohort study of more than 3 million patients show.
Using data from the Veterans Affairs Corporate Data Warehouse, Natalie B. Riblet, MD, MPH, and colleagues conducted the study on 3,284,496 patients who accessed VA health care during 2004-2014 and had a negative depression screen. About 95% of this population was male, 83.4% were white, and the average age was 61.3 years. Just under 40,000 people were patients with COPD, reported Dr. Riblet, of the Veterans Affairs Medical Center in White River Junction, Vt., and the Geisel School of Medicine at Dartmouth, Hanover, N.H. The study was published in General Hospital Psychiatry.
The investigators found that current, former, and never smokers were split fairly evenly at 32.1%, 32.4%, and 30.3% of the total study population, respectively. Of those with COPD, 53.6% were current smokers, 27% were former smokers, and 11.6% were never smokers.
The odds of developing depression in a year were 2.3%, 1.5%, and 1.4% in current, former, and never smokers without COPD, respectively; for those with COPD, the odds were 2.9%, 2.2%, and 2% for current, former, and never smokers, respectively. Overall, the odds ratio of patients with COPD developing depression, compared with those without COPD, was 1.57 (95% confidence interval, 1.54-1.61). Current smokers also were at an increased risk, compared with never smokers (OR, 1.83; 95% CI, 1.81-1.85), though the effect was somewhat mitigated after adjusting for confounders (OR, 1.56; 95% CI, 1.55-1.58).
as this may guide the development and implementation of new treatments for depression in the COPD population,” the investigators concluded. “If COPD-related depression is due, at least in part, to adverse physiological effects related to chronic hypoxia, these patients may require new or more tailored interventions.”
No disclosures or conflicts of interest were reported.
SOURCE: Riblet NB et al. Gen Hosp Psychiatry. 2020 May-Jun;64:72-9.
People with chronic obstructive pulmonary disorder (COPD) and those who smoke are at an increased risk of developing depression, results of a population-based cohort study of more than 3 million patients show.
Using data from the Veterans Affairs Corporate Data Warehouse, Natalie B. Riblet, MD, MPH, and colleagues conducted the study on 3,284,496 patients who accessed VA health care during 2004-2014 and had a negative depression screen. About 95% of this population was male, 83.4% were white, and the average age was 61.3 years. Just under 40,000 people were patients with COPD, reported Dr. Riblet, of the Veterans Affairs Medical Center in White River Junction, Vt., and the Geisel School of Medicine at Dartmouth, Hanover, N.H. The study was published in General Hospital Psychiatry.
The investigators found that current, former, and never smokers were split fairly evenly at 32.1%, 32.4%, and 30.3% of the total study population, respectively. Of those with COPD, 53.6% were current smokers, 27% were former smokers, and 11.6% were never smokers.
The odds of developing depression in a year were 2.3%, 1.5%, and 1.4% in current, former, and never smokers without COPD, respectively; for those with COPD, the odds were 2.9%, 2.2%, and 2% for current, former, and never smokers, respectively. Overall, the odds ratio of patients with COPD developing depression, compared with those without COPD, was 1.57 (95% confidence interval, 1.54-1.61). Current smokers also were at an increased risk, compared with never smokers (OR, 1.83; 95% CI, 1.81-1.85), though the effect was somewhat mitigated after adjusting for confounders (OR, 1.56; 95% CI, 1.55-1.58).
as this may guide the development and implementation of new treatments for depression in the COPD population,” the investigators concluded. “If COPD-related depression is due, at least in part, to adverse physiological effects related to chronic hypoxia, these patients may require new or more tailored interventions.”
No disclosures or conflicts of interest were reported.
SOURCE: Riblet NB et al. Gen Hosp Psychiatry. 2020 May-Jun;64:72-9.
People with chronic obstructive pulmonary disorder (COPD) and those who smoke are at an increased risk of developing depression, results of a population-based cohort study of more than 3 million patients show.
Using data from the Veterans Affairs Corporate Data Warehouse, Natalie B. Riblet, MD, MPH, and colleagues conducted the study on 3,284,496 patients who accessed VA health care during 2004-2014 and had a negative depression screen. About 95% of this population was male, 83.4% were white, and the average age was 61.3 years. Just under 40,000 people were patients with COPD, reported Dr. Riblet, of the Veterans Affairs Medical Center in White River Junction, Vt., and the Geisel School of Medicine at Dartmouth, Hanover, N.H. The study was published in General Hospital Psychiatry.
The investigators found that current, former, and never smokers were split fairly evenly at 32.1%, 32.4%, and 30.3% of the total study population, respectively. Of those with COPD, 53.6% were current smokers, 27% were former smokers, and 11.6% were never smokers.
The odds of developing depression in a year were 2.3%, 1.5%, and 1.4% in current, former, and never smokers without COPD, respectively; for those with COPD, the odds were 2.9%, 2.2%, and 2% for current, former, and never smokers, respectively. Overall, the odds ratio of patients with COPD developing depression, compared with those without COPD, was 1.57 (95% confidence interval, 1.54-1.61). Current smokers also were at an increased risk, compared with never smokers (OR, 1.83; 95% CI, 1.81-1.85), though the effect was somewhat mitigated after adjusting for confounders (OR, 1.56; 95% CI, 1.55-1.58).
as this may guide the development and implementation of new treatments for depression in the COPD population,” the investigators concluded. “If COPD-related depression is due, at least in part, to adverse physiological effects related to chronic hypoxia, these patients may require new or more tailored interventions.”
No disclosures or conflicts of interest were reported.
SOURCE: Riblet NB et al. Gen Hosp Psychiatry. 2020 May-Jun;64:72-9.
FROM GENERAL HOSPITAL PSYCHIATRY
COVID-19: Mental illness the ‘inevitable’ next pandemic?
Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.
In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.
“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.
“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
Anxiety, depression, child abuse
The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.
As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.
from the pandemic.
The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.
To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.
Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.
“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.
Need for creative thinking
The authors noted the second “critical” step is to 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,” they wrote.
“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 noted.
Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.
“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.
“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.”
Invaluable advice
Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”
Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”
Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article
Dr. Galea and Dr. Sederer have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.
In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.
“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.
“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
Anxiety, depression, child abuse
The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.
As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.
from the pandemic.
The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.
To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.
Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.
“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.
Need for creative thinking
The authors noted the second “critical” step is to 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,” they wrote.
“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 noted.
Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.
“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.
“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.”
Invaluable advice
Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”
Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”
Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article
Dr. Galea and Dr. Sederer have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.
In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.
“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.
“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
Anxiety, depression, child abuse
The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.
As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.
from the pandemic.
The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.
To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.
Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.
“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.
Need for creative thinking
The authors noted the second “critical” step is to 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,” they wrote.
“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 noted.
Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.
“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.
“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.”
Invaluable advice
Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”
Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”
Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article
Dr. Galea and Dr. Sederer have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.