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A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”
That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
The impact of pandemics: A historical perspective
Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.
There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.
Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”
There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.
As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
Back to the 21st century
After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.
Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
What we know; where we are
“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”
Hans Zinsser, Rats, Lice and History
We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.
The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.
The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
Update on Elvira
Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.
With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
The role of psychiatry
In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.
As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”
How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
Suggested reading
Camus A. The Plague. New York: Vintage Books,. 1991.
Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.
Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.
Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.
Emerg Infect Dis. 2005 Mar 11(3):402-96.
Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.
Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.
A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”
That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
The impact of pandemics: A historical perspective
Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.
There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.
Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”
There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.
As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
Back to the 21st century
After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.
Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
What we know; where we are
“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”
Hans Zinsser, Rats, Lice and History
We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.
The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.
The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
Update on Elvira
Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.
With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
The role of psychiatry
In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.
As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”
How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
Suggested reading
Camus A. The Plague. New York: Vintage Books,. 1991.
Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.
Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.
Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.
Emerg Infect Dis. 2005 Mar 11(3):402-96.
Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.
Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.
A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”
That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
The impact of pandemics: A historical perspective
Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.
There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.
Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”
There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.
As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
Back to the 21st century
After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.
Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
What we know; where we are
“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”
Hans Zinsser, Rats, Lice and History
We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.
The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.
The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
Update on Elvira
Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.
With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
The role of psychiatry
In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.
As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”
How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
Suggested reading
Camus A. The Plague. New York: Vintage Books,. 1991.
Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.
Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.
Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.
Emerg Infect Dis. 2005 Mar 11(3):402-96.
Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.
Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.