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Psychedelics’ interaction with psych meds: More questions than answers
“Despite prolific psychedelic research and public interest, I was surprised to see little clinical research on how psilocybin and common psychiatric treatments interact,” study investigator Aryan Sarparast, MD, department of psychiatry, Oregon Health and Science University, Portland, told this news organization.
The review was published online March 7, 2022, in Psychopharmacology.
Need for RCTs
The Food and Drug Administration recently granted breakthrough therapy designation to psilocybin-assisted psychotherapy for major depression and treatment-resistant depression and to MDMA-assisted psychotherapy for PTSD.
The investigators assessed the volume of available research on interactions between psychedelics and traditional psychiatric medications, such as antidepressants.
They found 40 studies dating back to 1958, including 26 randomized controlled trials, 11 case reports, and 3 epidemiologic studies.
Only one randomized clinical trial evaluated the interaction between psilocybin and the most common psychiatric treatment, SSRIs, said Dr. Sarparast.
However, this study is “reassuring and overlaps with our hypothesis that there is a low risk of psilocybin and most psychiatric drugs causing harm when combined,” he noted.
Yet all of the clinical trials exclusively included young healthy adults, who were often recruited from university campuses. “We don’t have data on what happens when a depressed person on an SSRI takes psilocybin,” said Dr. Sarparast.
He added that he is concerned that the lack of evidence on drug-drug interactions will lead some providers to require patients to be tapered off existing traditional psychiatric medications before initiation of psilocybin therapy.
This may force vulnerable patients to choose between their existing therapy and psilocybin.
In addition, patients who opt for the “DIY method” of tapering risk mental health relapse and medication withdrawal effects. “That’s a very, very tough place to be,” Dr. Sarparast said.
Ideally, Dr. Sarparast would like to see a study in which depressed patients who have been receiving long-term antidepressant treatment are randomly assigned to received low, medium, and high doses of psilocybin. “This would clarify a lot of question marks.”
Evidence gap
In a comment, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, said: “The point in this article is very well taken. Indeed, more research is needed” on potential interactions between psychedelics and traditional psychiatric medications.
“Before we embark on completing research and development for psychedelics – or, for that matter, any psychoactive substance – we should endeavor to identify what the potential safety and toxicity concerns are when they are coprescribed with other prescribed medications, over-the-counter medications, and other substances (e.g., marijuana) that people take,” Dr. McIntyre said.
A case in point – a 2017 study conducted by McIntyre and colleagues revealed “significant drug-drug interactions with cannabis, which never receives that much attention.”
Also weighing in, Albert Garcia-Romeu, PhD, assistant professor of psychiatry and behavioral sciences, Johns Hopkins University, Baltimore, confirmed that there is “an evidence gap” on psilocybin’s and other psychedelic drugs’ interactions with other medications.
“This has not been formally studied for a number of reasons, but mainly because psilocybin has primarily been considered a drug of abuse. Psilocybin has only recently started to be looked at as a potential medication, and as such, research on drug-drug interactions is still limited, but growing,” Dr. Garcia-Romeu told this news organization.
He noted that studies are underway to better understand potential interactions between psilocybin and other medications.
“This will allow us to better understand how psilocybin should be used medically and what types of interactions could occur with other drugs or medications,” Dr. Garcia-Romeu added.
The study had no specific funding. Dr. Sarparast, Dr. McIntyre, and Dr. Garcia-Romeu reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“Despite prolific psychedelic research and public interest, I was surprised to see little clinical research on how psilocybin and common psychiatric treatments interact,” study investigator Aryan Sarparast, MD, department of psychiatry, Oregon Health and Science University, Portland, told this news organization.
The review was published online March 7, 2022, in Psychopharmacology.
Need for RCTs
The Food and Drug Administration recently granted breakthrough therapy designation to psilocybin-assisted psychotherapy for major depression and treatment-resistant depression and to MDMA-assisted psychotherapy for PTSD.
The investigators assessed the volume of available research on interactions between psychedelics and traditional psychiatric medications, such as antidepressants.
They found 40 studies dating back to 1958, including 26 randomized controlled trials, 11 case reports, and 3 epidemiologic studies.
Only one randomized clinical trial evaluated the interaction between psilocybin and the most common psychiatric treatment, SSRIs, said Dr. Sarparast.
However, this study is “reassuring and overlaps with our hypothesis that there is a low risk of psilocybin and most psychiatric drugs causing harm when combined,” he noted.
Yet all of the clinical trials exclusively included young healthy adults, who were often recruited from university campuses. “We don’t have data on what happens when a depressed person on an SSRI takes psilocybin,” said Dr. Sarparast.
He added that he is concerned that the lack of evidence on drug-drug interactions will lead some providers to require patients to be tapered off existing traditional psychiatric medications before initiation of psilocybin therapy.
This may force vulnerable patients to choose between their existing therapy and psilocybin.
In addition, patients who opt for the “DIY method” of tapering risk mental health relapse and medication withdrawal effects. “That’s a very, very tough place to be,” Dr. Sarparast said.
Ideally, Dr. Sarparast would like to see a study in which depressed patients who have been receiving long-term antidepressant treatment are randomly assigned to received low, medium, and high doses of psilocybin. “This would clarify a lot of question marks.”
Evidence gap
In a comment, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, said: “The point in this article is very well taken. Indeed, more research is needed” on potential interactions between psychedelics and traditional psychiatric medications.
“Before we embark on completing research and development for psychedelics – or, for that matter, any psychoactive substance – we should endeavor to identify what the potential safety and toxicity concerns are when they are coprescribed with other prescribed medications, over-the-counter medications, and other substances (e.g., marijuana) that people take,” Dr. McIntyre said.
A case in point – a 2017 study conducted by McIntyre and colleagues revealed “significant drug-drug interactions with cannabis, which never receives that much attention.”
Also weighing in, Albert Garcia-Romeu, PhD, assistant professor of psychiatry and behavioral sciences, Johns Hopkins University, Baltimore, confirmed that there is “an evidence gap” on psilocybin’s and other psychedelic drugs’ interactions with other medications.
“This has not been formally studied for a number of reasons, but mainly because psilocybin has primarily been considered a drug of abuse. Psilocybin has only recently started to be looked at as a potential medication, and as such, research on drug-drug interactions is still limited, but growing,” Dr. Garcia-Romeu told this news organization.
He noted that studies are underway to better understand potential interactions between psilocybin and other medications.
“This will allow us to better understand how psilocybin should be used medically and what types of interactions could occur with other drugs or medications,” Dr. Garcia-Romeu added.
The study had no specific funding. Dr. Sarparast, Dr. McIntyre, and Dr. Garcia-Romeu reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“Despite prolific psychedelic research and public interest, I was surprised to see little clinical research on how psilocybin and common psychiatric treatments interact,” study investigator Aryan Sarparast, MD, department of psychiatry, Oregon Health and Science University, Portland, told this news organization.
The review was published online March 7, 2022, in Psychopharmacology.
Need for RCTs
The Food and Drug Administration recently granted breakthrough therapy designation to psilocybin-assisted psychotherapy for major depression and treatment-resistant depression and to MDMA-assisted psychotherapy for PTSD.
The investigators assessed the volume of available research on interactions between psychedelics and traditional psychiatric medications, such as antidepressants.
They found 40 studies dating back to 1958, including 26 randomized controlled trials, 11 case reports, and 3 epidemiologic studies.
Only one randomized clinical trial evaluated the interaction between psilocybin and the most common psychiatric treatment, SSRIs, said Dr. Sarparast.
However, this study is “reassuring and overlaps with our hypothesis that there is a low risk of psilocybin and most psychiatric drugs causing harm when combined,” he noted.
Yet all of the clinical trials exclusively included young healthy adults, who were often recruited from university campuses. “We don’t have data on what happens when a depressed person on an SSRI takes psilocybin,” said Dr. Sarparast.
He added that he is concerned that the lack of evidence on drug-drug interactions will lead some providers to require patients to be tapered off existing traditional psychiatric medications before initiation of psilocybin therapy.
This may force vulnerable patients to choose between their existing therapy and psilocybin.
In addition, patients who opt for the “DIY method” of tapering risk mental health relapse and medication withdrawal effects. “That’s a very, very tough place to be,” Dr. Sarparast said.
Ideally, Dr. Sarparast would like to see a study in which depressed patients who have been receiving long-term antidepressant treatment are randomly assigned to received low, medium, and high doses of psilocybin. “This would clarify a lot of question marks.”
Evidence gap
In a comment, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, said: “The point in this article is very well taken. Indeed, more research is needed” on potential interactions between psychedelics and traditional psychiatric medications.
“Before we embark on completing research and development for psychedelics – or, for that matter, any psychoactive substance – we should endeavor to identify what the potential safety and toxicity concerns are when they are coprescribed with other prescribed medications, over-the-counter medications, and other substances (e.g., marijuana) that people take,” Dr. McIntyre said.
A case in point – a 2017 study conducted by McIntyre and colleagues revealed “significant drug-drug interactions with cannabis, which never receives that much attention.”
Also weighing in, Albert Garcia-Romeu, PhD, assistant professor of psychiatry and behavioral sciences, Johns Hopkins University, Baltimore, confirmed that there is “an evidence gap” on psilocybin’s and other psychedelic drugs’ interactions with other medications.
“This has not been formally studied for a number of reasons, but mainly because psilocybin has primarily been considered a drug of abuse. Psilocybin has only recently started to be looked at as a potential medication, and as such, research on drug-drug interactions is still limited, but growing,” Dr. Garcia-Romeu told this news organization.
He noted that studies are underway to better understand potential interactions between psilocybin and other medications.
“This will allow us to better understand how psilocybin should be used medically and what types of interactions could occur with other drugs or medications,” Dr. Garcia-Romeu added.
The study had no specific funding. Dr. Sarparast, Dr. McIntyre, and Dr. Garcia-Romeu reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM PSYCHOPHARMACOLOGY
Executive-function deficits a new treatment target for PTSD?
DENVER –
“To our knowledge, this study is the first to show that executive-function deficits maintain PTSD symptoms following trauma exposure,” investigators noted in research presented at the Anxiety and Depression Association of America (ADAA) Anxiety & Depression conference.
The results are important in “developing precision medicine–based approaches for alleviating [posttraumatic stress] symptoms, and improving well-established PTSD treatments for those with relative deficits in executive function,” study investigator Joseph R. Bardeen, PhD, associate professor at Auburn (Ala.) University, told meeting attendees.
The findings were published in the Journal of Anxiety Disorders.
Cognitive impairment
In earlier research, deficits in EF were associated with an increased vulnerability for PTSD symptoms. However, less is known about the role of these deficits, which can impair higher-level cognitive ability, in sustaining PTSD symptoms.
To investigate, the authors conducted a longitudinal study that included 98 participants aged 18-65 years who had been identified via phone screening as experiencing clinically significant PTSD symptoms.
Participants completed self-report measures for PTSD symptoms, as well as measures for EF deficits at baseline and 6-month (n = 92) and 12-month (n = 91) follow-up sessions.
A path analysis showed a significant relationship between baseline PTSD symptoms and EF deficits at 6 months (P < .001). Baseline PTSD symptoms were associated with 12-month PTSD symptoms (P < .04).
EF deficits at 6 months were also associated with 12-month PTSD symptoms (P = .02).
Importantly, no associations were observed between baseline or 6-month PTSD symptoms and EF deficits at 12 months. However, EF deficits at 6 months drove the relationship between PTSD symptoms at baseline and at 1 year (indirect effect = .061).
“What this suggests is that executive-function deficits are a mechanism that maintains patients’ symptoms over the course of 1 year,” Dr. Bardeen said.
“And you don’t see the reverse,” he added. “You don’t see that PTSD symptoms at [6 months] mediate the relationship between [baseline] and 6 month executive-function deficits.”
Surprising finding
The findings suggest deficits in executive functioning have a stronger role in maintaining PTSD symptoms than these symptoms have in maintaining EF deficits, Dr. Bardeen told this news organization.
“I had originally hypothesized a bidirectional relationship in which PTSD symptoms influenced future executive-function deficits and executive-function deficits influenced future PTSD symptoms,” he said.
“So, it was a surprise that, when accounting for both variables in the same model, executive-function deficits predicted future PTSD symptoms, but PTSD symptoms did not significantly predict future EF deficits,” he added.
Dr. Bardeen noted this suggests that EF deficits “may be a particularly important maintenance factor.”
In addition, he recommended the use of neuropsychological assessments prior to treatment to identify individuals with EF deficits and distinguish those deficits from PTSD symptoms.
“There is certainly overlap between executive-function deficits and PTSD symptoms,” Dr. Bardeen said. “For example, several of the symptoms of PTSD, such as concentration difficulties, may be indicators of executive-function deficits.”
He noted assessments such as the Delis Kaplan Executive Function System, and Clinician Administered PTSD Scale for DSM-5, when used as part of a larger assessment battery, can help differentiate between the EF deficits and PTSD.
“This would take several hours to administer, but in cases in which serious cognitive impairment is suspected, a comprehensive assessment is the way to go,” Dr. Bardeen said.
The standard approaches of prolonged exposure therapy and cognitive processing therapy can be effective in patients without EF deficits, while some modifications may benefit those with these deficits, he added.
“For example, it’s important to provide a more directive and structured environment in which the practitioner repeats key points frequently, uses concrete language, simplifies worksheets, and provides written summaries and reminder cards,” he said.
Further findings
In additional research presented at the meeting, Elsa Mattson, a PhD student from Case Western Reserve University, Cleveland, and colleagues reported findings further distinguishing the role of EF in PTSD.
In that study of 149 patients with chronic PTSD, those with low performing working memory, but not high working memory, had higher pre- as well as posttreatment PTSD symptom severity and depressive symptoms.
“Clinicians should consider that impairments in executive function may play a role in reduced treatment response, potentially impairing a client’s ability to learn new information in treatment,” the investigators wrote.
“Understanding how executive function processes change over the course of treatment, particularly in relation to processing the trauma memories, is an important next step,” they added.
The first study was supported by a grant from the National Institute of Mental Health. The investigators have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
DENVER –
“To our knowledge, this study is the first to show that executive-function deficits maintain PTSD symptoms following trauma exposure,” investigators noted in research presented at the Anxiety and Depression Association of America (ADAA) Anxiety & Depression conference.
The results are important in “developing precision medicine–based approaches for alleviating [posttraumatic stress] symptoms, and improving well-established PTSD treatments for those with relative deficits in executive function,” study investigator Joseph R. Bardeen, PhD, associate professor at Auburn (Ala.) University, told meeting attendees.
The findings were published in the Journal of Anxiety Disorders.
Cognitive impairment
In earlier research, deficits in EF were associated with an increased vulnerability for PTSD symptoms. However, less is known about the role of these deficits, which can impair higher-level cognitive ability, in sustaining PTSD symptoms.
To investigate, the authors conducted a longitudinal study that included 98 participants aged 18-65 years who had been identified via phone screening as experiencing clinically significant PTSD symptoms.
Participants completed self-report measures for PTSD symptoms, as well as measures for EF deficits at baseline and 6-month (n = 92) and 12-month (n = 91) follow-up sessions.
A path analysis showed a significant relationship between baseline PTSD symptoms and EF deficits at 6 months (P < .001). Baseline PTSD symptoms were associated with 12-month PTSD symptoms (P < .04).
EF deficits at 6 months were also associated with 12-month PTSD symptoms (P = .02).
Importantly, no associations were observed between baseline or 6-month PTSD symptoms and EF deficits at 12 months. However, EF deficits at 6 months drove the relationship between PTSD symptoms at baseline and at 1 year (indirect effect = .061).
“What this suggests is that executive-function deficits are a mechanism that maintains patients’ symptoms over the course of 1 year,” Dr. Bardeen said.
“And you don’t see the reverse,” he added. “You don’t see that PTSD symptoms at [6 months] mediate the relationship between [baseline] and 6 month executive-function deficits.”
Surprising finding
The findings suggest deficits in executive functioning have a stronger role in maintaining PTSD symptoms than these symptoms have in maintaining EF deficits, Dr. Bardeen told this news organization.
“I had originally hypothesized a bidirectional relationship in which PTSD symptoms influenced future executive-function deficits and executive-function deficits influenced future PTSD symptoms,” he said.
“So, it was a surprise that, when accounting for both variables in the same model, executive-function deficits predicted future PTSD symptoms, but PTSD symptoms did not significantly predict future EF deficits,” he added.
Dr. Bardeen noted this suggests that EF deficits “may be a particularly important maintenance factor.”
In addition, he recommended the use of neuropsychological assessments prior to treatment to identify individuals with EF deficits and distinguish those deficits from PTSD symptoms.
“There is certainly overlap between executive-function deficits and PTSD symptoms,” Dr. Bardeen said. “For example, several of the symptoms of PTSD, such as concentration difficulties, may be indicators of executive-function deficits.”
He noted assessments such as the Delis Kaplan Executive Function System, and Clinician Administered PTSD Scale for DSM-5, when used as part of a larger assessment battery, can help differentiate between the EF deficits and PTSD.
“This would take several hours to administer, but in cases in which serious cognitive impairment is suspected, a comprehensive assessment is the way to go,” Dr. Bardeen said.
The standard approaches of prolonged exposure therapy and cognitive processing therapy can be effective in patients without EF deficits, while some modifications may benefit those with these deficits, he added.
“For example, it’s important to provide a more directive and structured environment in which the practitioner repeats key points frequently, uses concrete language, simplifies worksheets, and provides written summaries and reminder cards,” he said.
Further findings
In additional research presented at the meeting, Elsa Mattson, a PhD student from Case Western Reserve University, Cleveland, and colleagues reported findings further distinguishing the role of EF in PTSD.
In that study of 149 patients with chronic PTSD, those with low performing working memory, but not high working memory, had higher pre- as well as posttreatment PTSD symptom severity and depressive symptoms.
“Clinicians should consider that impairments in executive function may play a role in reduced treatment response, potentially impairing a client’s ability to learn new information in treatment,” the investigators wrote.
“Understanding how executive function processes change over the course of treatment, particularly in relation to processing the trauma memories, is an important next step,” they added.
The first study was supported by a grant from the National Institute of Mental Health. The investigators have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
DENVER –
“To our knowledge, this study is the first to show that executive-function deficits maintain PTSD symptoms following trauma exposure,” investigators noted in research presented at the Anxiety and Depression Association of America (ADAA) Anxiety & Depression conference.
The results are important in “developing precision medicine–based approaches for alleviating [posttraumatic stress] symptoms, and improving well-established PTSD treatments for those with relative deficits in executive function,” study investigator Joseph R. Bardeen, PhD, associate professor at Auburn (Ala.) University, told meeting attendees.
The findings were published in the Journal of Anxiety Disorders.
Cognitive impairment
In earlier research, deficits in EF were associated with an increased vulnerability for PTSD symptoms. However, less is known about the role of these deficits, which can impair higher-level cognitive ability, in sustaining PTSD symptoms.
To investigate, the authors conducted a longitudinal study that included 98 participants aged 18-65 years who had been identified via phone screening as experiencing clinically significant PTSD symptoms.
Participants completed self-report measures for PTSD symptoms, as well as measures for EF deficits at baseline and 6-month (n = 92) and 12-month (n = 91) follow-up sessions.
A path analysis showed a significant relationship between baseline PTSD symptoms and EF deficits at 6 months (P < .001). Baseline PTSD symptoms were associated with 12-month PTSD symptoms (P < .04).
EF deficits at 6 months were also associated with 12-month PTSD symptoms (P = .02).
Importantly, no associations were observed between baseline or 6-month PTSD symptoms and EF deficits at 12 months. However, EF deficits at 6 months drove the relationship between PTSD symptoms at baseline and at 1 year (indirect effect = .061).
“What this suggests is that executive-function deficits are a mechanism that maintains patients’ symptoms over the course of 1 year,” Dr. Bardeen said.
“And you don’t see the reverse,” he added. “You don’t see that PTSD symptoms at [6 months] mediate the relationship between [baseline] and 6 month executive-function deficits.”
Surprising finding
The findings suggest deficits in executive functioning have a stronger role in maintaining PTSD symptoms than these symptoms have in maintaining EF deficits, Dr. Bardeen told this news organization.
“I had originally hypothesized a bidirectional relationship in which PTSD symptoms influenced future executive-function deficits and executive-function deficits influenced future PTSD symptoms,” he said.
“So, it was a surprise that, when accounting for both variables in the same model, executive-function deficits predicted future PTSD symptoms, but PTSD symptoms did not significantly predict future EF deficits,” he added.
Dr. Bardeen noted this suggests that EF deficits “may be a particularly important maintenance factor.”
In addition, he recommended the use of neuropsychological assessments prior to treatment to identify individuals with EF deficits and distinguish those deficits from PTSD symptoms.
“There is certainly overlap between executive-function deficits and PTSD symptoms,” Dr. Bardeen said. “For example, several of the symptoms of PTSD, such as concentration difficulties, may be indicators of executive-function deficits.”
He noted assessments such as the Delis Kaplan Executive Function System, and Clinician Administered PTSD Scale for DSM-5, when used as part of a larger assessment battery, can help differentiate between the EF deficits and PTSD.
“This would take several hours to administer, but in cases in which serious cognitive impairment is suspected, a comprehensive assessment is the way to go,” Dr. Bardeen said.
The standard approaches of prolonged exposure therapy and cognitive processing therapy can be effective in patients without EF deficits, while some modifications may benefit those with these deficits, he added.
“For example, it’s important to provide a more directive and structured environment in which the practitioner repeats key points frequently, uses concrete language, simplifies worksheets, and provides written summaries and reminder cards,” he said.
Further findings
In additional research presented at the meeting, Elsa Mattson, a PhD student from Case Western Reserve University, Cleveland, and colleagues reported findings further distinguishing the role of EF in PTSD.
In that study of 149 patients with chronic PTSD, those with low performing working memory, but not high working memory, had higher pre- as well as posttreatment PTSD symptom severity and depressive symptoms.
“Clinicians should consider that impairments in executive function may play a role in reduced treatment response, potentially impairing a client’s ability to learn new information in treatment,” the investigators wrote.
“Understanding how executive function processes change over the course of treatment, particularly in relation to processing the trauma memories, is an important next step,” they added.
The first study was supported by a grant from the National Institute of Mental Health. The investigators have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
REPORTING FROM ADAA 2022
Depression, suicidal ideation continue to plague physicians: Survey
Now, as they bear the weight of a multiyear pandemic alongside the perpetual struggle to maintain some semblance of work-life balance, their resiliency has been stretched to the brink.
In 2022, the Medscape Physician Suicide Report surveyed more than 13,000 physicians in 29 specialties who were candid about their experiences with suicidal thoughts, how they support their besieged colleagues, and their go-to coping strategies.
Overall, 21% of physicians reported having feelings of depression. Of those, 24% had clinical depression and 64% had colloquial depression. Physicians who felt sad or blue decreased slightly, compared with the 2021 report, but the number of physicians experiencing severe depression rose 4%.
One in 10 physicians said they have thought about or attempted suicide. However, the number of physicians with suicidal thoughts dropped to 9%, down substantially from the 22% who reported similar feelings in 2020.
Still, there was a slight uptick in women physicians contemplating suicide, likely linked to their larger share of childcare and family responsibilities.
“They have needed to pull double duty even more than usual, and that may have increased their sense of burnout and vulnerability to suicidal thoughts,” said Andrea Giedinghagen, MD, assistant professor in the department of psychiatry at Washington University in St. Louis, and coauthor of “Physician Suicide: A Call to Action
Fighting the stigma of seeking mental health help
Although the number of physicians attempting, but not completing suicide, has remained steady at 1% for several years, the recent passage of the Dr. Lorna Breen Health Care Provider Protection Act by Congress aims to drive that figure even lower. Dr. Breen, an ED physician at New York–Presbyterian Hospital, died by suicide in April 2020. Overwhelmed by the onslaught of COVID patients, Dr. Breen was reluctant to seek mental health services for fear of being ostracized.
“Many physicians don’t seek mental health care due to fear of negative consequences in the workplace, including retribution, exclusion, loss of license, or even their job,” Gary Price, MD, president of The Physicians Foundation, told this news organization. “This was the experience of Dr. Lorna Breen. She was convinced that if she talked to a professional, she would lose her medical license. Perhaps if Dr. Breen was equipped with the accurate information – there is no mental health reporting requirement in her state’s medical license application – it might have saved her life.”
This same stigma was reflected in the survey, with one physician saying: “I’m afraid that if I spoke to a therapist, I’d have to report receiving psychiatric treatment to credentialing or licensing boards.” Roughly 40% of survey respondents, regardless of age, chose not to disclose their suicidal thoughts to anyone, not even a family member or suicide hotline. And just a tiny portion of physicians (10% of men and 13% of women) said that a colleague had discussed their suicidal thoughts with them.
“There is a longstanding culture of silence around physician mental health in the medical community,” said Dr. Price. “The strategies within the Act are critical to fixing this culture and making it acceptable and normalized for physicians to seek mental health care,” and for it to “become a fundamental and ongoing element of being a practicing physician.”
As part of the legislation, the Department of Health & Human Services must award grants to hospitals, medical associations, and other entities to facilitate mental health programs for providers. They must also establish policy recommendations and conduct campaigns to improve providers’ mental and behavioral health, encourage providers to seek mental health support and assistance, remove barriers to such treatment, and identify best practices to prevent suicide and promote resiliency
Addressing barriers to mental health
The new bill is a step in the right direction, but Dr. Price said health organizations must do more to address the six key structural barriers that are “discouraging physicians from seeking [mental health] help,” such as the inclusion of “intrusive mental health questions on medical board, hospital credentialing, and malpractice insurance applications.”
In addition, employers should allow physicians to seek out-of-network mental health services, if necessary, and not cause further humiliation by requiring them to be treated by colleagues within their hospital system. A similar proposal has recently been introduced and is gaining traction in Utah, following the suicide of ED physician Scott Jolley, MD, in 2021 after he was admitted for psychiatric care where he worked.
Diminishing the stigma surrounding physicians’ mental health encourages a more open dialogue, so if a colleague reaches out – listen. “Start by thanking the colleague for sharing the information: ‘I’m sure that wasn’t easy but I appreciate that you respect me enough to share this. Let’s talk more,’ ” said Michael F. Myers, MD, professor of clinical psychiatry at State University of New York, Brooklyn . “Then ask what you can do to help, which cuts down on the sense of isolation that colleague may feel.”
According to the survey, many physicians have developed strategies to support their happiness and mental health. Although fewer than 10% said reducing work hours or transitioning to a part-time schedule was most effective, the majority of physicians relied on spending time with family and friends (68%) – a choice that has considerable benefits.
“Close and intimate relationships are the single most protective factor for our mental health,” said Peter Yellowlees, MBBS, MD, chief wellness officer for UC Davis Health and professor of psychiatry at the University of California, Davis. “Isolation and loneliness are very important stressors, and we know that about 25% of the population reports being lonely.”
A version of this article first appeared on Medscape.com.
Now, as they bear the weight of a multiyear pandemic alongside the perpetual struggle to maintain some semblance of work-life balance, their resiliency has been stretched to the brink.
In 2022, the Medscape Physician Suicide Report surveyed more than 13,000 physicians in 29 specialties who were candid about their experiences with suicidal thoughts, how they support their besieged colleagues, and their go-to coping strategies.
Overall, 21% of physicians reported having feelings of depression. Of those, 24% had clinical depression and 64% had colloquial depression. Physicians who felt sad or blue decreased slightly, compared with the 2021 report, but the number of physicians experiencing severe depression rose 4%.
One in 10 physicians said they have thought about or attempted suicide. However, the number of physicians with suicidal thoughts dropped to 9%, down substantially from the 22% who reported similar feelings in 2020.
Still, there was a slight uptick in women physicians contemplating suicide, likely linked to their larger share of childcare and family responsibilities.
“They have needed to pull double duty even more than usual, and that may have increased their sense of burnout and vulnerability to suicidal thoughts,” said Andrea Giedinghagen, MD, assistant professor in the department of psychiatry at Washington University in St. Louis, and coauthor of “Physician Suicide: A Call to Action
Fighting the stigma of seeking mental health help
Although the number of physicians attempting, but not completing suicide, has remained steady at 1% for several years, the recent passage of the Dr. Lorna Breen Health Care Provider Protection Act by Congress aims to drive that figure even lower. Dr. Breen, an ED physician at New York–Presbyterian Hospital, died by suicide in April 2020. Overwhelmed by the onslaught of COVID patients, Dr. Breen was reluctant to seek mental health services for fear of being ostracized.
“Many physicians don’t seek mental health care due to fear of negative consequences in the workplace, including retribution, exclusion, loss of license, or even their job,” Gary Price, MD, president of The Physicians Foundation, told this news organization. “This was the experience of Dr. Lorna Breen. She was convinced that if she talked to a professional, she would lose her medical license. Perhaps if Dr. Breen was equipped with the accurate information – there is no mental health reporting requirement in her state’s medical license application – it might have saved her life.”
This same stigma was reflected in the survey, with one physician saying: “I’m afraid that if I spoke to a therapist, I’d have to report receiving psychiatric treatment to credentialing or licensing boards.” Roughly 40% of survey respondents, regardless of age, chose not to disclose their suicidal thoughts to anyone, not even a family member or suicide hotline. And just a tiny portion of physicians (10% of men and 13% of women) said that a colleague had discussed their suicidal thoughts with them.
“There is a longstanding culture of silence around physician mental health in the medical community,” said Dr. Price. “The strategies within the Act are critical to fixing this culture and making it acceptable and normalized for physicians to seek mental health care,” and for it to “become a fundamental and ongoing element of being a practicing physician.”
As part of the legislation, the Department of Health & Human Services must award grants to hospitals, medical associations, and other entities to facilitate mental health programs for providers. They must also establish policy recommendations and conduct campaigns to improve providers’ mental and behavioral health, encourage providers to seek mental health support and assistance, remove barriers to such treatment, and identify best practices to prevent suicide and promote resiliency
Addressing barriers to mental health
The new bill is a step in the right direction, but Dr. Price said health organizations must do more to address the six key structural barriers that are “discouraging physicians from seeking [mental health] help,” such as the inclusion of “intrusive mental health questions on medical board, hospital credentialing, and malpractice insurance applications.”
In addition, employers should allow physicians to seek out-of-network mental health services, if necessary, and not cause further humiliation by requiring them to be treated by colleagues within their hospital system. A similar proposal has recently been introduced and is gaining traction in Utah, following the suicide of ED physician Scott Jolley, MD, in 2021 after he was admitted for psychiatric care where he worked.
Diminishing the stigma surrounding physicians’ mental health encourages a more open dialogue, so if a colleague reaches out – listen. “Start by thanking the colleague for sharing the information: ‘I’m sure that wasn’t easy but I appreciate that you respect me enough to share this. Let’s talk more,’ ” said Michael F. Myers, MD, professor of clinical psychiatry at State University of New York, Brooklyn . “Then ask what you can do to help, which cuts down on the sense of isolation that colleague may feel.”
According to the survey, many physicians have developed strategies to support their happiness and mental health. Although fewer than 10% said reducing work hours or transitioning to a part-time schedule was most effective, the majority of physicians relied on spending time with family and friends (68%) – a choice that has considerable benefits.
“Close and intimate relationships are the single most protective factor for our mental health,” said Peter Yellowlees, MBBS, MD, chief wellness officer for UC Davis Health and professor of psychiatry at the University of California, Davis. “Isolation and loneliness are very important stressors, and we know that about 25% of the population reports being lonely.”
A version of this article first appeared on Medscape.com.
Now, as they bear the weight of a multiyear pandemic alongside the perpetual struggle to maintain some semblance of work-life balance, their resiliency has been stretched to the brink.
In 2022, the Medscape Physician Suicide Report surveyed more than 13,000 physicians in 29 specialties who were candid about their experiences with suicidal thoughts, how they support their besieged colleagues, and their go-to coping strategies.
Overall, 21% of physicians reported having feelings of depression. Of those, 24% had clinical depression and 64% had colloquial depression. Physicians who felt sad or blue decreased slightly, compared with the 2021 report, but the number of physicians experiencing severe depression rose 4%.
One in 10 physicians said they have thought about or attempted suicide. However, the number of physicians with suicidal thoughts dropped to 9%, down substantially from the 22% who reported similar feelings in 2020.
Still, there was a slight uptick in women physicians contemplating suicide, likely linked to their larger share of childcare and family responsibilities.
“They have needed to pull double duty even more than usual, and that may have increased their sense of burnout and vulnerability to suicidal thoughts,” said Andrea Giedinghagen, MD, assistant professor in the department of psychiatry at Washington University in St. Louis, and coauthor of “Physician Suicide: A Call to Action
Fighting the stigma of seeking mental health help
Although the number of physicians attempting, but not completing suicide, has remained steady at 1% for several years, the recent passage of the Dr. Lorna Breen Health Care Provider Protection Act by Congress aims to drive that figure even lower. Dr. Breen, an ED physician at New York–Presbyterian Hospital, died by suicide in April 2020. Overwhelmed by the onslaught of COVID patients, Dr. Breen was reluctant to seek mental health services for fear of being ostracized.
“Many physicians don’t seek mental health care due to fear of negative consequences in the workplace, including retribution, exclusion, loss of license, or even their job,” Gary Price, MD, president of The Physicians Foundation, told this news organization. “This was the experience of Dr. Lorna Breen. She was convinced that if she talked to a professional, she would lose her medical license. Perhaps if Dr. Breen was equipped with the accurate information – there is no mental health reporting requirement in her state’s medical license application – it might have saved her life.”
This same stigma was reflected in the survey, with one physician saying: “I’m afraid that if I spoke to a therapist, I’d have to report receiving psychiatric treatment to credentialing or licensing boards.” Roughly 40% of survey respondents, regardless of age, chose not to disclose their suicidal thoughts to anyone, not even a family member or suicide hotline. And just a tiny portion of physicians (10% of men and 13% of women) said that a colleague had discussed their suicidal thoughts with them.
“There is a longstanding culture of silence around physician mental health in the medical community,” said Dr. Price. “The strategies within the Act are critical to fixing this culture and making it acceptable and normalized for physicians to seek mental health care,” and for it to “become a fundamental and ongoing element of being a practicing physician.”
As part of the legislation, the Department of Health & Human Services must award grants to hospitals, medical associations, and other entities to facilitate mental health programs for providers. They must also establish policy recommendations and conduct campaigns to improve providers’ mental and behavioral health, encourage providers to seek mental health support and assistance, remove barriers to such treatment, and identify best practices to prevent suicide and promote resiliency
Addressing barriers to mental health
The new bill is a step in the right direction, but Dr. Price said health organizations must do more to address the six key structural barriers that are “discouraging physicians from seeking [mental health] help,” such as the inclusion of “intrusive mental health questions on medical board, hospital credentialing, and malpractice insurance applications.”
In addition, employers should allow physicians to seek out-of-network mental health services, if necessary, and not cause further humiliation by requiring them to be treated by colleagues within their hospital system. A similar proposal has recently been introduced and is gaining traction in Utah, following the suicide of ED physician Scott Jolley, MD, in 2021 after he was admitted for psychiatric care where he worked.
Diminishing the stigma surrounding physicians’ mental health encourages a more open dialogue, so if a colleague reaches out – listen. “Start by thanking the colleague for sharing the information: ‘I’m sure that wasn’t easy but I appreciate that you respect me enough to share this. Let’s talk more,’ ” said Michael F. Myers, MD, professor of clinical psychiatry at State University of New York, Brooklyn . “Then ask what you can do to help, which cuts down on the sense of isolation that colleague may feel.”
According to the survey, many physicians have developed strategies to support their happiness and mental health. Although fewer than 10% said reducing work hours or transitioning to a part-time schedule was most effective, the majority of physicians relied on spending time with family and friends (68%) – a choice that has considerable benefits.
“Close and intimate relationships are the single most protective factor for our mental health,” said Peter Yellowlees, MBBS, MD, chief wellness officer for UC Davis Health and professor of psychiatry at the University of California, Davis. “Isolation and loneliness are very important stressors, and we know that about 25% of the population reports being lonely.”
A version of this article first appeared on Medscape.com.
Self-care tips for clinicians as COVID-19 lingers
LAS VEGAS – according to Jon A. Levenson, MD.
“There are those who will need mental health treatment, so creating an easy way to reach out for help and facilitate linkage with care is critically important,” Dr. Levenson, associate professor of psychiatry at Columbia University Irving Medical Center, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “The vast majority of our workforce will thrive with proper support. But what can each of us do to take care of ourselves?”
Step one is to recognize common stress reactions as well as signs of distress. He offered the oxygen mask metaphor, the idea that before we can take care of and support anyone else, we must first take care of ourselves. “When people are stressed, they don’t always think about the oxygen mask metaphor,” Dr. Levenson said. Step two is to practice and model self-care by adopting principles often discussed in acceptance and commitment therapy: to focus on what you can control, not on what you can’t control.
“We can’t control the amount of toilet paper at the grocery store, how long the pandemic will last, or how others have reacted,” Dr. Levenson said. “We also can’t control other people’s motives, predict what will happen, or the actions of others, including whether they will follow social distancing guidelines or not.”
How about what we can control? One is a positive attitude, “which can sustain people during times of intense stress,” he said. “Other things that we can do include turn off the news and find fun and enriching activities to do at home, whether it be playing a game with family or reaching out to friends through an iPad or a smartphone. You can also follow [Centers for Disease Control and Prevention] recommendations, control your own social distancing, and limit social media activity, which can be stressful. We can also control our kindness and grace.” He added that resilience does not mean “snapping back” to how you were before the pandemic, but rather “learning to integrate the adverse experiences into who you are and growing with them, which is sometimes known as posttraumatic growth.”
Dr. Levenson encouraged health care workers to use their coping resources, connect to others, and cultivate their values and purpose in life as they navigate these challenging times. “You also want to promote realistic optimism; find a way to stay positive,” he said. “We emphasize to our staff that while you won’t forget this time, focus on what you can control – your positive relationships – and remind yourself of your values and sources of gratitude. Figure out, and reflect on, what you care about, and then care about it. Remind yourself in a deliberate, purposeful way what anchors you to your job, which in the health care setting tends to be a desire to care for others, to assist those in need, and to work in teams. We also encourage staff to refrain from judgment. Guilt is a normal and near-universal response to this stressor, but there are many ways to contribute without a judgmental or guilty tone.”
Other tips for self-support are to remind yourself that it is not selfish to take breaks. “The needs of your patients are not more important than your own needs,” Dr. Levenson said. “Working nonstop can put you at higher risk for stress, exhaustion, and illness. You may need to give yourself more time to step back and recover from workplace challenges or extended coverage for peers; this is important. We remind our staff that your work may feel more emotionally draining than usual because everything is more intense overall during the COVID-19 pandemic. This reminder helps staff normalize what they already may be experiencing, and in turn, to further support each other.”
Soothing activities to relieve stress include meditation, prayer, deep and slow breathing, relaxation exercises, yoga, mindfulness, stretching, staying hydrated, eating healthfully, exercise, and getting sufficient sleep. Other stress management tips include avoiding excessive alcohol intake, reaching out to others, asking for assistance, and delegating when possible. “We want to promote psychological flexibility: the ability to stay in contact with the present moment,” he said. “We encourage our peers to be aware of unpleasant thoughts and feelings, and to try to redirect negative thought patterns to a proactive problem-solving approach; this includes choosing one’s behaviors based on the situation and personal values.”
Dr. Levenson reported having no disclosures related to his presentation.
LAS VEGAS – according to Jon A. Levenson, MD.
“There are those who will need mental health treatment, so creating an easy way to reach out for help and facilitate linkage with care is critically important,” Dr. Levenson, associate professor of psychiatry at Columbia University Irving Medical Center, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “The vast majority of our workforce will thrive with proper support. But what can each of us do to take care of ourselves?”
Step one is to recognize common stress reactions as well as signs of distress. He offered the oxygen mask metaphor, the idea that before we can take care of and support anyone else, we must first take care of ourselves. “When people are stressed, they don’t always think about the oxygen mask metaphor,” Dr. Levenson said. Step two is to practice and model self-care by adopting principles often discussed in acceptance and commitment therapy: to focus on what you can control, not on what you can’t control.
“We can’t control the amount of toilet paper at the grocery store, how long the pandemic will last, or how others have reacted,” Dr. Levenson said. “We also can’t control other people’s motives, predict what will happen, or the actions of others, including whether they will follow social distancing guidelines or not.”
How about what we can control? One is a positive attitude, “which can sustain people during times of intense stress,” he said. “Other things that we can do include turn off the news and find fun and enriching activities to do at home, whether it be playing a game with family or reaching out to friends through an iPad or a smartphone. You can also follow [Centers for Disease Control and Prevention] recommendations, control your own social distancing, and limit social media activity, which can be stressful. We can also control our kindness and grace.” He added that resilience does not mean “snapping back” to how you were before the pandemic, but rather “learning to integrate the adverse experiences into who you are and growing with them, which is sometimes known as posttraumatic growth.”
Dr. Levenson encouraged health care workers to use their coping resources, connect to others, and cultivate their values and purpose in life as they navigate these challenging times. “You also want to promote realistic optimism; find a way to stay positive,” he said. “We emphasize to our staff that while you won’t forget this time, focus on what you can control – your positive relationships – and remind yourself of your values and sources of gratitude. Figure out, and reflect on, what you care about, and then care about it. Remind yourself in a deliberate, purposeful way what anchors you to your job, which in the health care setting tends to be a desire to care for others, to assist those in need, and to work in teams. We also encourage staff to refrain from judgment. Guilt is a normal and near-universal response to this stressor, but there are many ways to contribute without a judgmental or guilty tone.”
Other tips for self-support are to remind yourself that it is not selfish to take breaks. “The needs of your patients are not more important than your own needs,” Dr. Levenson said. “Working nonstop can put you at higher risk for stress, exhaustion, and illness. You may need to give yourself more time to step back and recover from workplace challenges or extended coverage for peers; this is important. We remind our staff that your work may feel more emotionally draining than usual because everything is more intense overall during the COVID-19 pandemic. This reminder helps staff normalize what they already may be experiencing, and in turn, to further support each other.”
Soothing activities to relieve stress include meditation, prayer, deep and slow breathing, relaxation exercises, yoga, mindfulness, stretching, staying hydrated, eating healthfully, exercise, and getting sufficient sleep. Other stress management tips include avoiding excessive alcohol intake, reaching out to others, asking for assistance, and delegating when possible. “We want to promote psychological flexibility: the ability to stay in contact with the present moment,” he said. “We encourage our peers to be aware of unpleasant thoughts and feelings, and to try to redirect negative thought patterns to a proactive problem-solving approach; this includes choosing one’s behaviors based on the situation and personal values.”
Dr. Levenson reported having no disclosures related to his presentation.
LAS VEGAS – according to Jon A. Levenson, MD.
“There are those who will need mental health treatment, so creating an easy way to reach out for help and facilitate linkage with care is critically important,” Dr. Levenson, associate professor of psychiatry at Columbia University Irving Medical Center, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “The vast majority of our workforce will thrive with proper support. But what can each of us do to take care of ourselves?”
Step one is to recognize common stress reactions as well as signs of distress. He offered the oxygen mask metaphor, the idea that before we can take care of and support anyone else, we must first take care of ourselves. “When people are stressed, they don’t always think about the oxygen mask metaphor,” Dr. Levenson said. Step two is to practice and model self-care by adopting principles often discussed in acceptance and commitment therapy: to focus on what you can control, not on what you can’t control.
“We can’t control the amount of toilet paper at the grocery store, how long the pandemic will last, or how others have reacted,” Dr. Levenson said. “We also can’t control other people’s motives, predict what will happen, or the actions of others, including whether they will follow social distancing guidelines or not.”
How about what we can control? One is a positive attitude, “which can sustain people during times of intense stress,” he said. “Other things that we can do include turn off the news and find fun and enriching activities to do at home, whether it be playing a game with family or reaching out to friends through an iPad or a smartphone. You can also follow [Centers for Disease Control and Prevention] recommendations, control your own social distancing, and limit social media activity, which can be stressful. We can also control our kindness and grace.” He added that resilience does not mean “snapping back” to how you were before the pandemic, but rather “learning to integrate the adverse experiences into who you are and growing with them, which is sometimes known as posttraumatic growth.”
Dr. Levenson encouraged health care workers to use their coping resources, connect to others, and cultivate their values and purpose in life as they navigate these challenging times. “You also want to promote realistic optimism; find a way to stay positive,” he said. “We emphasize to our staff that while you won’t forget this time, focus on what you can control – your positive relationships – and remind yourself of your values and sources of gratitude. Figure out, and reflect on, what you care about, and then care about it. Remind yourself in a deliberate, purposeful way what anchors you to your job, which in the health care setting tends to be a desire to care for others, to assist those in need, and to work in teams. We also encourage staff to refrain from judgment. Guilt is a normal and near-universal response to this stressor, but there are many ways to contribute without a judgmental or guilty tone.”
Other tips for self-support are to remind yourself that it is not selfish to take breaks. “The needs of your patients are not more important than your own needs,” Dr. Levenson said. “Working nonstop can put you at higher risk for stress, exhaustion, and illness. You may need to give yourself more time to step back and recover from workplace challenges or extended coverage for peers; this is important. We remind our staff that your work may feel more emotionally draining than usual because everything is more intense overall during the COVID-19 pandemic. This reminder helps staff normalize what they already may be experiencing, and in turn, to further support each other.”
Soothing activities to relieve stress include meditation, prayer, deep and slow breathing, relaxation exercises, yoga, mindfulness, stretching, staying hydrated, eating healthfully, exercise, and getting sufficient sleep. Other stress management tips include avoiding excessive alcohol intake, reaching out to others, asking for assistance, and delegating when possible. “We want to promote psychological flexibility: the ability to stay in contact with the present moment,” he said. “We encourage our peers to be aware of unpleasant thoughts and feelings, and to try to redirect negative thought patterns to a proactive problem-solving approach; this includes choosing one’s behaviors based on the situation and personal values.”
Dr. Levenson reported having no disclosures related to his presentation.
AT NPA 2022
The importance of a post-COVID wellness program for medical staff
LAS VEGAS – , according to Jon A. Levenson, MD.
“We can learn from previous pandemics and epidemics, which will be important for us going forward from COVID-19,” Dr. Levenson, associate professor of psychiatry at Columbia University Irving Medical Center, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During the severe acute respiratory syndrome (SARS) epidemic in 2005, 68% of health care workers reported significant job-related stress, including increased workload, changing work duties, redeployment, shortage of medical supplies, concerns about insufficient personal protective equipment (PPE), lack of safety at work, absence of effective treatment protocols, inconsistent organizational support and information and misinformation from hospital management, and witnessing intense pain, isolation, and loss on a daily basis with few opportunities to take breaks (Psychiatr Serv. 2020 Oct 6. doi: 10.1176/appi.ps.202000274).
Personal concerns associated with psychopathological symptoms included spreading infection to family members; feeling responsibility for family members’ social isolation; self-isolating to avoid infecting family, which can lead to increased loneliness and sadness. “For those who were working remotely, this level of work is hard and challenging,” Dr. Levenson said. “For those who are parents, the 24-hour childcare responsibilities exist on top of work. They often found they can’t unwind with friends.”
Across SARS, MERS, Ebola, and swine flu, a wide range of prevalence in symptoms of distress, stress, anxiety, depressive symptoms, and substance use emerged, he continued. During COVID-19, at least three studies reported significant percentages of distress, depression, anxiety, insomnia, and PTSD among health care workers (JAMA Netw Open. 2020;3[3]:e203976, Front Psychol. 2020 Dec 8;11:608986., and Gen Hosp Psychiatry. Sep-Oct 2020;66:1-8).
“Who is at most-increased risk?” Dr. Levenson asked. “Women; those who are younger and have fewer years of work experience; those working on the front lines such as nurses and advanced practice professionals; and people with preexisting vulnerabilities to psychiatric disorders including anxiety, depression, obsessional symptoms, substance use, suicidal behavior, and impulse control disorders are likely to be especially vulnerable to stress-related symptoms.”
At CUIMC, there were certain “tipping points,” to the vulnerability of health care worker well-being in the early stage of the COVID-19 pandemic, he said, including the loss of an emergency medicine physician colleague from death by suicide. “On the national level there were so many other issues going on such as health care disparities of the COVID-19 infection itself, the murder of George Floyd in Minneapolis, other issues of racial injustice, a tense political climate with an upcoming election at the time, and other factors related to the natural climate concerns,” he said. This prompted several faculty members in the CUIMC department of psychiatry including Claude Ann Mellins, PhD, Laurel S. Mayer, MD, and Lourival Baptista-Neto, MD, to partner with ColumbiaDoctors and New York-Presbyterian Hospital and develop a model of care for health care workers known as CopeColumbia, a virtual program intended to address staff burnout and fatigue, with an emphasis on prevention and promotion of resilience.* It launched in March of 2020 and consists of 1:1 peer support, a peer support group program, town halls/webinars, and an active web site.
The 1:1 peer support sessions typically last 20-30 minutes and provide easy access for all distressed hospital and medical center staff. “We have a phone line staffed by Columbia psychiatrists and psychologists so that a distressed staff member can reach support directly,” he said. The format of these sessions includes a brief discussion of challenges and brainstorming around potential coping strategies. “This is not a psychotherapy session,” Dr. Levenson said. “Each session can be individualized to further assess the type of distress or to implement rating scales such as the Generalized Anxiety Disorder-7 scale to assess for signs and symptoms consistent with GAD. There are options to schedule a second or third peer support session, or a prompt referral within Columbia psychiatry when indicated.”
A typical peer support group meeting lasts about 30 minutes and comprises individual divisions or departments. Some goals of the peer groups are to discuss unique challenges of the work environment and to encourage the members of the group to come up with solutions; to promote team support and coping; to teach resilience-enhancing strategies from empirically based treatments such as CBT, “and to end each meeting with expressions of gratitude and of thanks within the group,” he said.
According to Dr. Levenson, sample questions CopeColumbia faculty use to facilitate coping, include “which coping skills are working for you?”; “Are you able to be present?”; “Have you honored loss with any specific ways or traditions?”; “Do you have any work buddies who support you and vice versa?”; “Can your work community build off each other’s individual strengths to help both the individual and the work group cope optimally?”; and “How can your work team help facilitate each other to best support each other?”
Other aspects of the CopeColumbia program include town halls/grand rounds that range from 30 to 60 minutes in length. “It may be a virtual presentation from a mental health professional on specific aspects of coping such as relaxation techniques,” he said. “The focus is how to manage stress, anxiety, trauma, loss, and grief. It also includes an active Q&A to engage staff participants. The advantage of this format is that you can reach many staff in an entire department.” The program also has an active web site for staff with both internal and external support links including mindfulness, meditation, exercise, parenting suggestions/caregiving, and other resources to promote well-being and resilience for staff and family.
To date, certain themes emerged from the 1:1 and peer support group sessions, including expressions of difficulty adapting to “such a new reality,” compared with the pre-COVID era. “Staff would often express anticipatory anxiety and uncertainty, such as is there going to be another surge of COVID-19 cases, and will there be a change in policies?” Dr. Levenson said. “There was a lot of expression of stress and frustration related to politicizing the virus and public containment strategies, both on a local and national level.”
Staff also mentioned the loss of usual coping strategies because of prolonged social isolation, especially for those doing remote work, and the loss of usual support resources that have helped them in the past. “They also reported delayed trauma and grief reactions, including symptoms of depression, anxiety, and posttraumatic stress,” he said. “Health care workers with children mentioned high levels of stress related to childcare, increased workload, and what seems like an impossible work-life balance.” Many reported exhaustion and irritability, “which could affect and cause tension within the work group and challenges to effective team cohesion,” he said. “There were also stressors related to the impact of racial injustices and the [presidential] election that could exacerbate the impact of COVID-19.”
Dr. Levenson hopes that CopeColumbia serves as a model for other health care systems looking for ways to support the mental well-being of their employees. “We want to promote the message that emotional health should have the same priority level as physical health,” he said. “The term that I like to use is total health. Addressing the well-being of health care workers is critical for a healthy workforce and for delivering high-quality patient care.”
He reported having no relevant financial disclosures related to his presentation.
Correction, 2/28/22: An earlier version of this article misstated Dr. Lourival Baptista-Neto's name.
LAS VEGAS – , according to Jon A. Levenson, MD.
“We can learn from previous pandemics and epidemics, which will be important for us going forward from COVID-19,” Dr. Levenson, associate professor of psychiatry at Columbia University Irving Medical Center, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During the severe acute respiratory syndrome (SARS) epidemic in 2005, 68% of health care workers reported significant job-related stress, including increased workload, changing work duties, redeployment, shortage of medical supplies, concerns about insufficient personal protective equipment (PPE), lack of safety at work, absence of effective treatment protocols, inconsistent organizational support and information and misinformation from hospital management, and witnessing intense pain, isolation, and loss on a daily basis with few opportunities to take breaks (Psychiatr Serv. 2020 Oct 6. doi: 10.1176/appi.ps.202000274).
Personal concerns associated with psychopathological symptoms included spreading infection to family members; feeling responsibility for family members’ social isolation; self-isolating to avoid infecting family, which can lead to increased loneliness and sadness. “For those who were working remotely, this level of work is hard and challenging,” Dr. Levenson said. “For those who are parents, the 24-hour childcare responsibilities exist on top of work. They often found they can’t unwind with friends.”
Across SARS, MERS, Ebola, and swine flu, a wide range of prevalence in symptoms of distress, stress, anxiety, depressive symptoms, and substance use emerged, he continued. During COVID-19, at least three studies reported significant percentages of distress, depression, anxiety, insomnia, and PTSD among health care workers (JAMA Netw Open. 2020;3[3]:e203976, Front Psychol. 2020 Dec 8;11:608986., and Gen Hosp Psychiatry. Sep-Oct 2020;66:1-8).
“Who is at most-increased risk?” Dr. Levenson asked. “Women; those who are younger and have fewer years of work experience; those working on the front lines such as nurses and advanced practice professionals; and people with preexisting vulnerabilities to psychiatric disorders including anxiety, depression, obsessional symptoms, substance use, suicidal behavior, and impulse control disorders are likely to be especially vulnerable to stress-related symptoms.”
At CUIMC, there were certain “tipping points,” to the vulnerability of health care worker well-being in the early stage of the COVID-19 pandemic, he said, including the loss of an emergency medicine physician colleague from death by suicide. “On the national level there were so many other issues going on such as health care disparities of the COVID-19 infection itself, the murder of George Floyd in Minneapolis, other issues of racial injustice, a tense political climate with an upcoming election at the time, and other factors related to the natural climate concerns,” he said. This prompted several faculty members in the CUIMC department of psychiatry including Claude Ann Mellins, PhD, Laurel S. Mayer, MD, and Lourival Baptista-Neto, MD, to partner with ColumbiaDoctors and New York-Presbyterian Hospital and develop a model of care for health care workers known as CopeColumbia, a virtual program intended to address staff burnout and fatigue, with an emphasis on prevention and promotion of resilience.* It launched in March of 2020 and consists of 1:1 peer support, a peer support group program, town halls/webinars, and an active web site.
The 1:1 peer support sessions typically last 20-30 minutes and provide easy access for all distressed hospital and medical center staff. “We have a phone line staffed by Columbia psychiatrists and psychologists so that a distressed staff member can reach support directly,” he said. The format of these sessions includes a brief discussion of challenges and brainstorming around potential coping strategies. “This is not a psychotherapy session,” Dr. Levenson said. “Each session can be individualized to further assess the type of distress or to implement rating scales such as the Generalized Anxiety Disorder-7 scale to assess for signs and symptoms consistent with GAD. There are options to schedule a second or third peer support session, or a prompt referral within Columbia psychiatry when indicated.”
A typical peer support group meeting lasts about 30 minutes and comprises individual divisions or departments. Some goals of the peer groups are to discuss unique challenges of the work environment and to encourage the members of the group to come up with solutions; to promote team support and coping; to teach resilience-enhancing strategies from empirically based treatments such as CBT, “and to end each meeting with expressions of gratitude and of thanks within the group,” he said.
According to Dr. Levenson, sample questions CopeColumbia faculty use to facilitate coping, include “which coping skills are working for you?”; “Are you able to be present?”; “Have you honored loss with any specific ways or traditions?”; “Do you have any work buddies who support you and vice versa?”; “Can your work community build off each other’s individual strengths to help both the individual and the work group cope optimally?”; and “How can your work team help facilitate each other to best support each other?”
Other aspects of the CopeColumbia program include town halls/grand rounds that range from 30 to 60 minutes in length. “It may be a virtual presentation from a mental health professional on specific aspects of coping such as relaxation techniques,” he said. “The focus is how to manage stress, anxiety, trauma, loss, and grief. It also includes an active Q&A to engage staff participants. The advantage of this format is that you can reach many staff in an entire department.” The program also has an active web site for staff with both internal and external support links including mindfulness, meditation, exercise, parenting suggestions/caregiving, and other resources to promote well-being and resilience for staff and family.
To date, certain themes emerged from the 1:1 and peer support group sessions, including expressions of difficulty adapting to “such a new reality,” compared with the pre-COVID era. “Staff would often express anticipatory anxiety and uncertainty, such as is there going to be another surge of COVID-19 cases, and will there be a change in policies?” Dr. Levenson said. “There was a lot of expression of stress and frustration related to politicizing the virus and public containment strategies, both on a local and national level.”
Staff also mentioned the loss of usual coping strategies because of prolonged social isolation, especially for those doing remote work, and the loss of usual support resources that have helped them in the past. “They also reported delayed trauma and grief reactions, including symptoms of depression, anxiety, and posttraumatic stress,” he said. “Health care workers with children mentioned high levels of stress related to childcare, increased workload, and what seems like an impossible work-life balance.” Many reported exhaustion and irritability, “which could affect and cause tension within the work group and challenges to effective team cohesion,” he said. “There were also stressors related to the impact of racial injustices and the [presidential] election that could exacerbate the impact of COVID-19.”
Dr. Levenson hopes that CopeColumbia serves as a model for other health care systems looking for ways to support the mental well-being of their employees. “We want to promote the message that emotional health should have the same priority level as physical health,” he said. “The term that I like to use is total health. Addressing the well-being of health care workers is critical for a healthy workforce and for delivering high-quality patient care.”
He reported having no relevant financial disclosures related to his presentation.
Correction, 2/28/22: An earlier version of this article misstated Dr. Lourival Baptista-Neto's name.
LAS VEGAS – , according to Jon A. Levenson, MD.
“We can learn from previous pandemics and epidemics, which will be important for us going forward from COVID-19,” Dr. Levenson, associate professor of psychiatry at Columbia University Irving Medical Center, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During the severe acute respiratory syndrome (SARS) epidemic in 2005, 68% of health care workers reported significant job-related stress, including increased workload, changing work duties, redeployment, shortage of medical supplies, concerns about insufficient personal protective equipment (PPE), lack of safety at work, absence of effective treatment protocols, inconsistent organizational support and information and misinformation from hospital management, and witnessing intense pain, isolation, and loss on a daily basis with few opportunities to take breaks (Psychiatr Serv. 2020 Oct 6. doi: 10.1176/appi.ps.202000274).
Personal concerns associated with psychopathological symptoms included spreading infection to family members; feeling responsibility for family members’ social isolation; self-isolating to avoid infecting family, which can lead to increased loneliness and sadness. “For those who were working remotely, this level of work is hard and challenging,” Dr. Levenson said. “For those who are parents, the 24-hour childcare responsibilities exist on top of work. They often found they can’t unwind with friends.”
Across SARS, MERS, Ebola, and swine flu, a wide range of prevalence in symptoms of distress, stress, anxiety, depressive symptoms, and substance use emerged, he continued. During COVID-19, at least three studies reported significant percentages of distress, depression, anxiety, insomnia, and PTSD among health care workers (JAMA Netw Open. 2020;3[3]:e203976, Front Psychol. 2020 Dec 8;11:608986., and Gen Hosp Psychiatry. Sep-Oct 2020;66:1-8).
“Who is at most-increased risk?” Dr. Levenson asked. “Women; those who are younger and have fewer years of work experience; those working on the front lines such as nurses and advanced practice professionals; and people with preexisting vulnerabilities to psychiatric disorders including anxiety, depression, obsessional symptoms, substance use, suicidal behavior, and impulse control disorders are likely to be especially vulnerable to stress-related symptoms.”
At CUIMC, there were certain “tipping points,” to the vulnerability of health care worker well-being in the early stage of the COVID-19 pandemic, he said, including the loss of an emergency medicine physician colleague from death by suicide. “On the national level there were so many other issues going on such as health care disparities of the COVID-19 infection itself, the murder of George Floyd in Minneapolis, other issues of racial injustice, a tense political climate with an upcoming election at the time, and other factors related to the natural climate concerns,” he said. This prompted several faculty members in the CUIMC department of psychiatry including Claude Ann Mellins, PhD, Laurel S. Mayer, MD, and Lourival Baptista-Neto, MD, to partner with ColumbiaDoctors and New York-Presbyterian Hospital and develop a model of care for health care workers known as CopeColumbia, a virtual program intended to address staff burnout and fatigue, with an emphasis on prevention and promotion of resilience.* It launched in March of 2020 and consists of 1:1 peer support, a peer support group program, town halls/webinars, and an active web site.
The 1:1 peer support sessions typically last 20-30 minutes and provide easy access for all distressed hospital and medical center staff. “We have a phone line staffed by Columbia psychiatrists and psychologists so that a distressed staff member can reach support directly,” he said. The format of these sessions includes a brief discussion of challenges and brainstorming around potential coping strategies. “This is not a psychotherapy session,” Dr. Levenson said. “Each session can be individualized to further assess the type of distress or to implement rating scales such as the Generalized Anxiety Disorder-7 scale to assess for signs and symptoms consistent with GAD. There are options to schedule a second or third peer support session, or a prompt referral within Columbia psychiatry when indicated.”
A typical peer support group meeting lasts about 30 minutes and comprises individual divisions or departments. Some goals of the peer groups are to discuss unique challenges of the work environment and to encourage the members of the group to come up with solutions; to promote team support and coping; to teach resilience-enhancing strategies from empirically based treatments such as CBT, “and to end each meeting with expressions of gratitude and of thanks within the group,” he said.
According to Dr. Levenson, sample questions CopeColumbia faculty use to facilitate coping, include “which coping skills are working for you?”; “Are you able to be present?”; “Have you honored loss with any specific ways or traditions?”; “Do you have any work buddies who support you and vice versa?”; “Can your work community build off each other’s individual strengths to help both the individual and the work group cope optimally?”; and “How can your work team help facilitate each other to best support each other?”
Other aspects of the CopeColumbia program include town halls/grand rounds that range from 30 to 60 minutes in length. “It may be a virtual presentation from a mental health professional on specific aspects of coping such as relaxation techniques,” he said. “The focus is how to manage stress, anxiety, trauma, loss, and grief. It also includes an active Q&A to engage staff participants. The advantage of this format is that you can reach many staff in an entire department.” The program also has an active web site for staff with both internal and external support links including mindfulness, meditation, exercise, parenting suggestions/caregiving, and other resources to promote well-being and resilience for staff and family.
To date, certain themes emerged from the 1:1 and peer support group sessions, including expressions of difficulty adapting to “such a new reality,” compared with the pre-COVID era. “Staff would often express anticipatory anxiety and uncertainty, such as is there going to be another surge of COVID-19 cases, and will there be a change in policies?” Dr. Levenson said. “There was a lot of expression of stress and frustration related to politicizing the virus and public containment strategies, both on a local and national level.”
Staff also mentioned the loss of usual coping strategies because of prolonged social isolation, especially for those doing remote work, and the loss of usual support resources that have helped them in the past. “They also reported delayed trauma and grief reactions, including symptoms of depression, anxiety, and posttraumatic stress,” he said. “Health care workers with children mentioned high levels of stress related to childcare, increased workload, and what seems like an impossible work-life balance.” Many reported exhaustion and irritability, “which could affect and cause tension within the work group and challenges to effective team cohesion,” he said. “There were also stressors related to the impact of racial injustices and the [presidential] election that could exacerbate the impact of COVID-19.”
Dr. Levenson hopes that CopeColumbia serves as a model for other health care systems looking for ways to support the mental well-being of their employees. “We want to promote the message that emotional health should have the same priority level as physical health,” he said. “The term that I like to use is total health. Addressing the well-being of health care workers is critical for a healthy workforce and for delivering high-quality patient care.”
He reported having no relevant financial disclosures related to his presentation.
Correction, 2/28/22: An earlier version of this article misstated Dr. Lourival Baptista-Neto's name.
FROM NPA 2022
PTSD symptoms common in families of COVID-19 patients
The pandemic has significantly affected the mental health of family members of patients with COVID-19, including high rates of posttraumatic stress disorder (PTSD), anxiety, and depression, new research suggests.
They also had a higher prevalence of depression and anxiety symptoms.
The results illustrate how the mental health of families has been adversely affected by strict isolation measures instituted at the height of the COVID pandemic, lead author Elie Azoulay, MD, PhD, professor of medicine at Diderot University and director of the Medical Intensive Care Unit, Saint Louis Hospital, Paris, told this news organization.
Such restrictions were unnecessary, Dr. Azoulay noted, adding that everyone, including health care professionals, benefits when families are allowed to interact with their loved ones in the ICU.
He added the study findings also emphasize the importance of social supports.
“We need to develop and really increase what we can do for family members” of patients staying in the ICU, said Dr. Azoulay.
The findings were published online Feb. 18 in JAMA.
Twenty-three ICUs in France
The study included adult family members of patients admitted with ARDS to 23 ICUs in France from January to October 2020.
Patients had a partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) of less than 300, and bilateral opacities on chest radiography not fully explained by cardiac failure or fluid overload.
Two trained clinical psychologists interviewed family members and patients by telephone a median of 112 days after ICU discharge. During this interview, participants completed the Impact of Event Scale Revised (IES-R) and the Hospital Anxiety and Depression Scale (HADS).
The IES-R score ranges from 0 (best) to 88 (worst) with a score of more than 22 indicating presence of PTSD-related symptoms of clinical concern. The HADS has separate subscales for anxiety and depression, with a score of 7 or greater on a 21-point scale indicating symptoms of anxiety or depression.
Family members also rated social supports on a scale from 0 (extremely limited) to 10 (extremely effective). Dr. Azoulay noted that social support is the subjective perception of the extent to which friends, mental health specialists, and others are available and helpful.
Investigators divided patients into two groups depending on whether or not the cause of ARDS was COVID-19. Causes other than COVID-19 mainly included community-acquired pneumonia and influenza.
The primary outcome was the prevalence of PTSD-related symptoms among family members. Secondary outcomes were the prevalence of anxiety and depression in family members.
The analysis included 303 family members of patients with COVID-19 ARDS and 214 family members of patients with non–COVID-19 ARDS. Almost half of the family members were spouses.
Those with family members with COVID-19 were younger than the non-COVID group (median age, 50 vs. 55 years). They were less frequently allowed to visit the ICU (35% vs. 88%) and more commonly received patient information by phone (84% vs. 20%).
Better strategies needed
Results showed PTSD symptoms were significantly more common in family members of patients with than without COVID-10 (35% vs. 19%; difference of 16%; 95% confidence interval, 8%-24%; P < .001).
Anxiety symptoms were significantly more common in the COVID-19 group (41% vs. 34%; difference of 8%; 95% CI, 0%-16%; P = .05), as were depression symptoms (31% vs. 18%; difference of 13%; 95% CI, 6%-21%; P < .001).
About 26% of the hospitalized relatives died. PTSD symptoms were more common among bereaved family members of patients who died from COVID-19 than of patients without COVID-19 (63% vs. 39%; difference of 24%; 95% CI, 7%-40%; P = .008).
In the COVID-19 group, significantly fewer family members reported having attended the funeral (77% vs. 91%, P = .04). This could be because of concerns over transmitting the virus, the investigators noted.
After adjustment for age, sex, and level of social support in a multivariable analysis, COVID-19 ARDS was significantly associated with increased risk for PTSD-related symptoms in family members (odds ratio, 2.05; 95% CI, 1.30-3.23; P =.002).
Other factors independently associated with PTSD symptoms were age, level of social support, and being male.
Factors associated with anxiety included having COVID-19 ARDS, age, being male, and level of social support. COVID-19 ARDS and level of social support were independently associated with depression.
Although isolation measures were implemented to prevent viral transmission during the pandemic, severely restricting family members from interacting with their sick loved ones in the ICU is “very destructive [and] deeply distressing,” said Dr. Azoulay. “It’s almost cruel.”
Fear may be at the heart of the “psycho-trauma” experienced by family members, he said.
“I would say one of the main sources is fear of getting infected, fear of abandoning family members, fear of leaving the kids alone without any support, and fear of infecting others,” he added.
Health care providers should develop strategies to better communicate with family members, who also feel a lot of guilt when they’re unable to be with their sick loved ones, said Dr. Azoulay.
‘Element of fear’
Commenting on the findings for this news organization, O. Joseph Bienvenu, MD, PhD, professor of psychiatry and behavioral sciences at Johns Hopkins Medicine, Baltimore, called the study “solid” and noted the lead author is “a well-recognized clinical researcher.”
It was “remarkable” that investigators were able to include a control group of family members of patients with ARDS not due to COVID-19, added Dr. Bienvenu, who was not involved with the research.
“It sounds like the bottom line is COVID adds an additional element of fear in loved ones,” he said.
Dr. Bienvenu added this fits with his own clinical experience – and noted that some COVID-19 follow-up clinics now include family members in their assessments and care.
“I think this study nicely illustrates the utility of this,” he concluded.
The study received funding from the French Ministry of Health. Dr. Azoulay reported receipt of personal fees from lectures from Pfizer, Gilead, Baxter, and Alexion, and institutional research grants from Merck Sharp and Dohme, Pfizer, Baxter, and Alexion. Dr. Bienvenu has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The pandemic has significantly affected the mental health of family members of patients with COVID-19, including high rates of posttraumatic stress disorder (PTSD), anxiety, and depression, new research suggests.
They also had a higher prevalence of depression and anxiety symptoms.
The results illustrate how the mental health of families has been adversely affected by strict isolation measures instituted at the height of the COVID pandemic, lead author Elie Azoulay, MD, PhD, professor of medicine at Diderot University and director of the Medical Intensive Care Unit, Saint Louis Hospital, Paris, told this news organization.
Such restrictions were unnecessary, Dr. Azoulay noted, adding that everyone, including health care professionals, benefits when families are allowed to interact with their loved ones in the ICU.
He added the study findings also emphasize the importance of social supports.
“We need to develop and really increase what we can do for family members” of patients staying in the ICU, said Dr. Azoulay.
The findings were published online Feb. 18 in JAMA.
Twenty-three ICUs in France
The study included adult family members of patients admitted with ARDS to 23 ICUs in France from January to October 2020.
Patients had a partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) of less than 300, and bilateral opacities on chest radiography not fully explained by cardiac failure or fluid overload.
Two trained clinical psychologists interviewed family members and patients by telephone a median of 112 days after ICU discharge. During this interview, participants completed the Impact of Event Scale Revised (IES-R) and the Hospital Anxiety and Depression Scale (HADS).
The IES-R score ranges from 0 (best) to 88 (worst) with a score of more than 22 indicating presence of PTSD-related symptoms of clinical concern. The HADS has separate subscales for anxiety and depression, with a score of 7 or greater on a 21-point scale indicating symptoms of anxiety or depression.
Family members also rated social supports on a scale from 0 (extremely limited) to 10 (extremely effective). Dr. Azoulay noted that social support is the subjective perception of the extent to which friends, mental health specialists, and others are available and helpful.
Investigators divided patients into two groups depending on whether or not the cause of ARDS was COVID-19. Causes other than COVID-19 mainly included community-acquired pneumonia and influenza.
The primary outcome was the prevalence of PTSD-related symptoms among family members. Secondary outcomes were the prevalence of anxiety and depression in family members.
The analysis included 303 family members of patients with COVID-19 ARDS and 214 family members of patients with non–COVID-19 ARDS. Almost half of the family members were spouses.
Those with family members with COVID-19 were younger than the non-COVID group (median age, 50 vs. 55 years). They were less frequently allowed to visit the ICU (35% vs. 88%) and more commonly received patient information by phone (84% vs. 20%).
Better strategies needed
Results showed PTSD symptoms were significantly more common in family members of patients with than without COVID-10 (35% vs. 19%; difference of 16%; 95% confidence interval, 8%-24%; P < .001).
Anxiety symptoms were significantly more common in the COVID-19 group (41% vs. 34%; difference of 8%; 95% CI, 0%-16%; P = .05), as were depression symptoms (31% vs. 18%; difference of 13%; 95% CI, 6%-21%; P < .001).
About 26% of the hospitalized relatives died. PTSD symptoms were more common among bereaved family members of patients who died from COVID-19 than of patients without COVID-19 (63% vs. 39%; difference of 24%; 95% CI, 7%-40%; P = .008).
In the COVID-19 group, significantly fewer family members reported having attended the funeral (77% vs. 91%, P = .04). This could be because of concerns over transmitting the virus, the investigators noted.
After adjustment for age, sex, and level of social support in a multivariable analysis, COVID-19 ARDS was significantly associated with increased risk for PTSD-related symptoms in family members (odds ratio, 2.05; 95% CI, 1.30-3.23; P =.002).
Other factors independently associated with PTSD symptoms were age, level of social support, and being male.
Factors associated with anxiety included having COVID-19 ARDS, age, being male, and level of social support. COVID-19 ARDS and level of social support were independently associated with depression.
Although isolation measures were implemented to prevent viral transmission during the pandemic, severely restricting family members from interacting with their sick loved ones in the ICU is “very destructive [and] deeply distressing,” said Dr. Azoulay. “It’s almost cruel.”
Fear may be at the heart of the “psycho-trauma” experienced by family members, he said.
“I would say one of the main sources is fear of getting infected, fear of abandoning family members, fear of leaving the kids alone without any support, and fear of infecting others,” he added.
Health care providers should develop strategies to better communicate with family members, who also feel a lot of guilt when they’re unable to be with their sick loved ones, said Dr. Azoulay.
‘Element of fear’
Commenting on the findings for this news organization, O. Joseph Bienvenu, MD, PhD, professor of psychiatry and behavioral sciences at Johns Hopkins Medicine, Baltimore, called the study “solid” and noted the lead author is “a well-recognized clinical researcher.”
It was “remarkable” that investigators were able to include a control group of family members of patients with ARDS not due to COVID-19, added Dr. Bienvenu, who was not involved with the research.
“It sounds like the bottom line is COVID adds an additional element of fear in loved ones,” he said.
Dr. Bienvenu added this fits with his own clinical experience – and noted that some COVID-19 follow-up clinics now include family members in their assessments and care.
“I think this study nicely illustrates the utility of this,” he concluded.
The study received funding from the French Ministry of Health. Dr. Azoulay reported receipt of personal fees from lectures from Pfizer, Gilead, Baxter, and Alexion, and institutional research grants from Merck Sharp and Dohme, Pfizer, Baxter, and Alexion. Dr. Bienvenu has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The pandemic has significantly affected the mental health of family members of patients with COVID-19, including high rates of posttraumatic stress disorder (PTSD), anxiety, and depression, new research suggests.
They also had a higher prevalence of depression and anxiety symptoms.
The results illustrate how the mental health of families has been adversely affected by strict isolation measures instituted at the height of the COVID pandemic, lead author Elie Azoulay, MD, PhD, professor of medicine at Diderot University and director of the Medical Intensive Care Unit, Saint Louis Hospital, Paris, told this news organization.
Such restrictions were unnecessary, Dr. Azoulay noted, adding that everyone, including health care professionals, benefits when families are allowed to interact with their loved ones in the ICU.
He added the study findings also emphasize the importance of social supports.
“We need to develop and really increase what we can do for family members” of patients staying in the ICU, said Dr. Azoulay.
The findings were published online Feb. 18 in JAMA.
Twenty-three ICUs in France
The study included adult family members of patients admitted with ARDS to 23 ICUs in France from January to October 2020.
Patients had a partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) of less than 300, and bilateral opacities on chest radiography not fully explained by cardiac failure or fluid overload.
Two trained clinical psychologists interviewed family members and patients by telephone a median of 112 days after ICU discharge. During this interview, participants completed the Impact of Event Scale Revised (IES-R) and the Hospital Anxiety and Depression Scale (HADS).
The IES-R score ranges from 0 (best) to 88 (worst) with a score of more than 22 indicating presence of PTSD-related symptoms of clinical concern. The HADS has separate subscales for anxiety and depression, with a score of 7 or greater on a 21-point scale indicating symptoms of anxiety or depression.
Family members also rated social supports on a scale from 0 (extremely limited) to 10 (extremely effective). Dr. Azoulay noted that social support is the subjective perception of the extent to which friends, mental health specialists, and others are available and helpful.
Investigators divided patients into two groups depending on whether or not the cause of ARDS was COVID-19. Causes other than COVID-19 mainly included community-acquired pneumonia and influenza.
The primary outcome was the prevalence of PTSD-related symptoms among family members. Secondary outcomes were the prevalence of anxiety and depression in family members.
The analysis included 303 family members of patients with COVID-19 ARDS and 214 family members of patients with non–COVID-19 ARDS. Almost half of the family members were spouses.
Those with family members with COVID-19 were younger than the non-COVID group (median age, 50 vs. 55 years). They were less frequently allowed to visit the ICU (35% vs. 88%) and more commonly received patient information by phone (84% vs. 20%).
Better strategies needed
Results showed PTSD symptoms were significantly more common in family members of patients with than without COVID-10 (35% vs. 19%; difference of 16%; 95% confidence interval, 8%-24%; P < .001).
Anxiety symptoms were significantly more common in the COVID-19 group (41% vs. 34%; difference of 8%; 95% CI, 0%-16%; P = .05), as were depression symptoms (31% vs. 18%; difference of 13%; 95% CI, 6%-21%; P < .001).
About 26% of the hospitalized relatives died. PTSD symptoms were more common among bereaved family members of patients who died from COVID-19 than of patients without COVID-19 (63% vs. 39%; difference of 24%; 95% CI, 7%-40%; P = .008).
In the COVID-19 group, significantly fewer family members reported having attended the funeral (77% vs. 91%, P = .04). This could be because of concerns over transmitting the virus, the investigators noted.
After adjustment for age, sex, and level of social support in a multivariable analysis, COVID-19 ARDS was significantly associated with increased risk for PTSD-related symptoms in family members (odds ratio, 2.05; 95% CI, 1.30-3.23; P =.002).
Other factors independently associated with PTSD symptoms were age, level of social support, and being male.
Factors associated with anxiety included having COVID-19 ARDS, age, being male, and level of social support. COVID-19 ARDS and level of social support were independently associated with depression.
Although isolation measures were implemented to prevent viral transmission during the pandemic, severely restricting family members from interacting with their sick loved ones in the ICU is “very destructive [and] deeply distressing,” said Dr. Azoulay. “It’s almost cruel.”
Fear may be at the heart of the “psycho-trauma” experienced by family members, he said.
“I would say one of the main sources is fear of getting infected, fear of abandoning family members, fear of leaving the kids alone without any support, and fear of infecting others,” he added.
Health care providers should develop strategies to better communicate with family members, who also feel a lot of guilt when they’re unable to be with their sick loved ones, said Dr. Azoulay.
‘Element of fear’
Commenting on the findings for this news organization, O. Joseph Bienvenu, MD, PhD, professor of psychiatry and behavioral sciences at Johns Hopkins Medicine, Baltimore, called the study “solid” and noted the lead author is “a well-recognized clinical researcher.”
It was “remarkable” that investigators were able to include a control group of family members of patients with ARDS not due to COVID-19, added Dr. Bienvenu, who was not involved with the research.
“It sounds like the bottom line is COVID adds an additional element of fear in loved ones,” he said.
Dr. Bienvenu added this fits with his own clinical experience – and noted that some COVID-19 follow-up clinics now include family members in their assessments and care.
“I think this study nicely illustrates the utility of this,” he concluded.
The study received funding from the French Ministry of Health. Dr. Azoulay reported receipt of personal fees from lectures from Pfizer, Gilead, Baxter, and Alexion, and institutional research grants from Merck Sharp and Dohme, Pfizer, Baxter, and Alexion. Dr. Bienvenu has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA
PTSD Disability Examination Reports: A Comparison of Veterans Health Administration and Contract Examiners
Updated June 17, 2022
The US Department of Veterans Affairs (VA) provides health care for > 9 million military veterans, nearly half of all former service members.1 Over the past 15 years, there has been a steady and substantial increase in the frequency of disability awards for veterans with post-9/11 military service. Recent data from the Bureau of Labor Statistics indicate that 41% of veterans who served after 9/11 receive service-connected disability benefits compared with 28% of veterans overall.2 More than 5 million veterans receive VA service-related disability benefits.2,3 More than half of the VA $243 billion budget for fiscal year (FY) 2021 ($135.5 billion) was allocated to the Veterans Benefits Administration (VBA), of which $115.7 billion (85%) was allocated specifically for service-related compensation claims payments.4
The VA predicted that VBA will have completed 1.4 million ratings for disability claims in 2021.5 A substantial percentage of these claims will be for mental disorders, specifically posttraumatic stress disorder (PTSD). VA officials testifying before Congress in 2017 noted that the number of PTSD claims had nearly tripled in the previous 10 years.6 As far back as 2013, McNally and Frueh analyzed “the skyrocketing of disability claims,” particularly for PTSD, among veterans who served in Iraq and Afghanistan.7
This large increase has placed an unprecedented burden on the VBA to expand its capacity to conduct initial PTSD disability evaluations that by regulations are completed by psychologists or psychiatrists. This need has led the VBA to make significant changes in the compensation and pension (C&P) process, including a reduced role for Veterans Health Administration (VHA) examiners and increased reliance on non-VA (contract) examiners through the Contract Medical Disability Examination (MDE) program. In 2019, the MDE budget was $1.23 billion; in 2020, it was increased to $1.79 billion, and for 2021, it was $2.23 billion, reflecting the increasing investment of resources in non-VA examiners, ostensibly to both increase capacity and save costs.5
Anecdotally, concerns have been raised regarding inadequate training of contract examiners as well as inadequate reports by these examiners. A 2018 Government Accountability Office (GAO) report concluded that VA lacked the data to determine whether contract examiners were meeting standards for quality, timeliness, and accuracy.8 The GAO report noted that VA required 92% of contractor reports contained no obvious errors, a relatively low target; however, in the first half of 2017, only 1 contractor group met that target. The report noted further that “VBA does not verify if examiners have completed training nor does it collect information to assess training effectiveness in preparing examiners.”8 A subsequent analysis of contract examinations completed by the VA Office of the Inspector General (OIG) in 2019 concluded that the MDE program was “hampered in their ability to provide oversight because of limitations with VBA’s electronic examination management systems, the lack of reliable data, and inadequate staffing of the program.”9
These reports have focused almost exclusively on simple performance metrics, such as timeliness of examination completion. However, the 2018 GAO report referenced isolated “focused reviews” of complaints about the quality of examinations by contract examiners and gave as an example an isolated “review of one contracted examiner who had high rates of diagnosing severe posttraumatic stress disorder.”8 After review indicated the examiner’s reports were of poor quality, the VBA discontinued the examiner’s contract.
Unfortunately, despite such anecdotal reports and isolated actions, to date there are no published reports examining and comparing the quality of PTSD examination reports completed by VHA and contract examiners or the subsequent disability determinations made by the VBA as a result of these evaluations. In a November 2020 letter to the VA Secretary, 11 US Senators expressed “grave concerns” regarding the VA decision to privatize C&P programs noting, among other concerns, that there were “no clinical quality measurement for, or evaluation of, contractor examinations.”10 The letter cited anecdotal evidence of contract examiners not reviewing veteran’s medical records and diagnosing conditions “without supporting evidence.”10
The purpose of the present evaluation was to provide a systematic comparison of the content and quality of initial PTSD disability examinations conducted by VHA and non-VA contract examiners. In addition, this study compared the disability rating decisions resulting from VHA and contract examinations.
Methods
A random sample of 100 Initial PTSD Disability Benefits Questionnaires (DBQs)—structured forms completed by all examiners—were obtained from a list supplied by the VA Office of Performance Analysis and Integrity. All examinations were from the Veterans Integrated Service Network (VISN) 1, encompassing the New England region and were conducted in 2019 and 2020. Two of the 100 cases were excluded for technical reasons, resulting in 98 examination reports. However, the final pool yielded 62 contract examinations and only 36 VHA examinations. To make the sample sizes more comparable, an additional 15 examinations were randomly selected from the local examination database (also VISN 1) to complement the original examination pool.
Once DBQs were retrieved, all identifying information was deleted, and cases were analyzed using assigned record numbers. All coding was completed by the 2 principal investigators, both VA psychologists with extensive training and experience in C&P evaluation and treatment of veterans with PTSD. Due to inherent structural differences between the forms used for VA and contract examinations, raters could not be masked/blinded to the source of the report.
A number of measures were taken to reduce bias and enhance objectivity of rating. First, objectively coded variables (eg, age and sex of veteran, period of service, trauma type, diagnoses rendered by the examiner, impairment category endorsed, number and type of symptoms) were transcribed directly from the DBQ as recorded by the examiner. Second, to rate report quality, an initial categorical rating scale was developed based on predetermined elements of examination quality that were considered essential. After refinement and preliminary analysis of interrater reliabilities, 3 quality-related indices were identified: (1) level of detail in description of key content areas (history before service, service trauma, after service social and vocational history, mental health history, substance use); (2) synthesis of history and findings in explaining opinion rendered; and (3) clarity of opinion regarding causation required “at least as likely as not” degree of confidence. The first 2 quality ratings were based on a 3-point scale (poor, fair, good), and the third variable was coded as yes or no. (eAppendix available at doi:10.12788/fp.0225). Interrater reliabilities calculated based on a subsample of 18 cases, randomly selected and rated by both raters, yielded Cohen κ in the acceptable range (.61, .72, and .89 for detail, synthesis, and clarity, respectively). Finally, for information regarding VBA decision making, rating decision documents contained in the Veterans Benefit Management System database were reviewed to determine whether the veteran was granted service connection for PTSD or another mental disorder based on the examination report in question and, if so, the disability rating percentage awarded. These were recorded independently after all other coding had been completed.
Results
Comparison of VHA and contract examinations revealed no significant differences between groups on relevant sociodemographic and other measures (Table). Missing data were not obtained from other records or sources, and for this study, reflect only what is recorded in the examination reports except for age, which was calculated using veteran’s date of birth and the date of examination.
To examine differences between VHA and contract examinations, the groups were first compared on a set of predetermined objectively coded variables taken directly from the DBQ. The frequency of PTSD diagnoses by VHA (57%) and contract (71%) examiners was not significantly different nor were rates of non-PTSD diagnoses by VHA (51%) and contract (73%) examiners. There also was no difference in the mean number of PTSD symptoms endorsed across PTSD diagnostic criteria B, C, D, and E (maximum of 20) recorded by VHA (9.4) and contract (10.9) examiners.
Contract examiners recorded a significantly greater mean number of “other symptoms” on a checklist of 31 possible symptoms as compared to VHA examiners: 7.3 vs 5.8, respectively (t[104] = 2.27, P < .05). An initial analysis of overall social/vocational impairment ratings coded by examiners did not reveal significant differences between examiner groups. However, when the 2 most severe impairment categories were combined to create a pooled “severe” category, 31% of contract examiners rated veterans as severely impaired compared with only 12% of VHA examiners (χ2 = 5.79, 1 df, P < .05) (Figure 1).
VHA and contract examinations were compared on 3 measures of report quality. Significant differences were found for both level of detail (χ2 = 16.44, 2 df, P < .01) and synthesis (χ2 = 6.68, 2 df, P < .05). Contract examinations were more likely to be rated as poor and less likely to be rated good, with a similar proportion of fair ratings for the 2 examination types (Figures 2 and 3). There was no significant difference in the proportion of VHA and contract examinations providing clear statement of opinion regarding causation (ie, whether or not the diagnosed condition was service related), with the majority rendering an adequate opinion in both examiner groups (VHA, 78%; contract, 79%).
Qualitative review revealed examples of markedly deficient examinations among contract examinations, including several reports that contained no review of records, no report of relevant background, and no mention or assessment of social and vocational function needed to inform opinions about diagnosis and impairment.
Finally, the VBA database was used to compare the resulting disability award decisions made by VBA based on the examination reports in question. Examination by contractors resulted in significantly higher mean service-connected disability ratings for examinees compared with VHA examiners (46.8 vs 33.5, respectively; t[108] = 2.3, P < .05).
Discussion
The present study provides the first reported systematic comparison of VA disability examinations for PTSD completed by examiners employed by the VHA and those hired as contract examiners through the MDE program. Although the frequency of PTSD diagnoses by contract examiners was higher than that of VHA examiners (71% vs 57%, respectively), the difference was not statistically significant. However, contract examiners recorded significantly more symptoms for examinees and rated them as severely impaired more frequently than did their VHA counterparts. In keeping with rating guidelines used by the VBA, these differences in examination content resulted in higher disability ratings for veterans seen by contract examiners.
Along with these elevated reports in symptom and severity ratings, contract examiners were less likely to provide adequate detail in the narrative sections of their reports and less frequently provided a satisfactory explanation and synthesis of relevant history and findings in support of their conclusions. Although not reflected in the statistical analysis, case-by-case review revealed some startlingly inadequate examination reports by contract examiners, several of which contained no review of records, no report or discussion of relevant background, and no discussion or analysis of social and vocational function to inform and support their opinion about level of impairment. None of the VHA examination reports reviewed lacked information to that degree.
Such deficiencies in detail and synthesis run counter to accepted guidelines for the adequate assessment of psychological injury in general and in VA disability claims specifically.11,12 For example, Watson and colleagues proposed that a minimum of 3 hours was required to conduct an initial PTSD examination, with more complex cases possibly taking longer.11 There is no information available about how long contract examiners take to complete their examinations and how that compares with the time taken by VA examiners. The VBA failure to monitor whether or not examiners follow accepted guidelines for PTSD examination has not previously been evaluated. Historically, a large number of clinicians, researchers, and policy critics have raised concerns about the potential for exaggeration or malingering among VA PTSD disability claimants and have urged the need to adequately assess for unreliable reporting and presentation.13,14 However, the possibility of systematic examiner deficiency and/or bias increasing the frequency of false or inflated claims being approved has received little empirical attention.
Although contract examiners did not diagnose PTSD significantly more frequently than VHA examiners (71% vs 57%, respectively), the overall frequency of PTSD diagnosis across both groups (65%) was substantially higher than previous figures that have, on average, estimated the lifetime prevalence of PTSD in trauma-exposed veterans to be about 31%.15 A re-analysis of the same National Vietnam Veterans Readjustment Survey data, but applying more conservative diagnostic criteria, reduced the lifetime prevalence to just under 19%, with point prevalence estimates even lower.15,16
In a study of concordance rates between service connection for PTSD and both current and lifetime diagnosis by independent, structured assessment, Marx and colleagues found that a “significant minority” of veterans who were already receiving service-connected disability for PTSD did not meet lifetime and/or current diagnostic criteria.17 Although it is possible that the group of veterans who were applying for disability benefits in our study had a higher rate of PTSD, it also is possible if not likely that the PTSD examination process overall yields inflated rates of diagnosis and levels of impairment. This speaks to the concern raised by Marx and colleagues who found that veterans with service connection for PTSD who received related benefits “may not have the disorder.”17
Limitations
A methodological limitation of the present study was that, due to structural differences in the DBQ forms used for VHA and contract examinations, the reports could not be de-identified as to examiner type and thus raters could not be masked/blinded. To mitigate bias, a predetermined, piloted, and refined coding and rating plan for report quality metrics was adhered to strictly, and interrater reliabilities were acceptable. Future study is suggested in which all report content is standardized for coding using the same format, which at present would require a complete rewriting of the entire report; this problem could be resolved by having the VBA adopt a more coherent system in which all reports, regardless of examiner type, use a single, standardized template. Further study using larger data sets and expanding to other VA regions also is needed.
Conclusions
The present study suggests that poor examination and report quality—by contract examiners and to a lesser degree VHA examiners—are not uncommon. The findings confirm and extend previous anecdotal reports of deficiencies in PTSD examinations performed by contract examiners and provide empirical support for concerns raised of global deficiencies in the VBA oversight of the MDE program. Such deficiencies have significant implications for the quality and integrity of the VA disability determination process for veterans claiming PTSD related to military service.
The current findings support and strengthen the call for development and management of a structured and enforced training and quality assurance/improvement program for VA PTSD disability examinations. Such training and oversight will be critical to improve the quality and integrity of these examinations, reduce error and waste in VBA’s Compensation and Pension process, and in doing so optimize VA financial resources to best serve veterans’ benefits and health care needs.
1. US Department of Veterans Affairs, Veterans Health Adminstration. About VHA. Updated April 23, 2021. Accessed January 6, 2022. www.va.gov/health/aboutvha.asp
2. US Department of Labor, Bureau of Labor Statistics. News release. Employment situation of veterans—2020. Published March 18, 2020. Accessed January 6, 2022. https://www.bls.gov/news.release/pdf/vet.pdf
3. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Department of Veterans Affairs statistics at a glance. Updated December 31, 2020. Accessed January 6, 2022. https://www.va.gov/vetdata/docs/Quickfacts/Stats_at_a_glance_12_31_20.PDF
4. US Department of Veterans Affairs. FY 2021 Budget submission: budget in brief. Published February 2020. Accessed January 6, 2022. https://www.va.gov/budget/docs/summary/archive/FY-2021-VA-BudgetSubmission.zip
5. US Department of Veterans Affairs. FY 2021 budget submission: benefits and burial programs and Departmental Administration volume 3 of 4:178. Published February 2020. Accessed January 6, 2022. https://www.va.gov/budget/docs/summary/archive/FY-2021-VA-BudgetSubmission.zip
6. Statement of Ronald Burke, assistant deputy under secretary, office of field operations Veterans Benefits Administration before the Subcommittee on Disability And Memorial Affairs of the House Committee on Veterans’ Affairs. Published July 25, 2017. Accessed January 6, 2022. https://www.congress.gov/115/meeting/house/106322/witnesses/HHRG-115-VR09-Wstate-BurkeR-20170725.pdf
7. McNally RJ, Frueh BC. Why are Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates? J Anxiety Disord. 2013;27(5):520-526. doi:10.1016/j.janxdis.2013.07.002
8. US Government Accountability Office. VA disability exams: improved performance analysis and training oversight needed for contracted exams. GAO-19-13. Published October 2018. Accessed January 6, 2022. https://www.gao.gov/assets/gao-19-13.pdf
9. US Department of Veterans Affairs, Office of Inspector General. Inadequate oversight of contracted disability exam cancellations. Report #18-04266-115. Published June 10, 2019. Accessed January 6, 2022. https://www.va.gov/oig/pubs/VAOIG-18-04266-115.pdf
10. Letter to VA Secretary Wilkie. Published November 11, 2020. Accessed January 6, 2022. https://www.veterans.senate.gov/download/candp-exam-va-letter
11. Watson PW, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane TM, Hamblen JL (2005). Best practice manual for posttraumatic stress disorder (PTSD) compensation and pension examinations. Portland, OR: Northwest Network Mental Illness Research, Education, and Clinical Center, VA Puget Sound Healthcare System.
12. Worthen MD, Moering RG. A practical guide to conducting VA compensation and pension exams for PTSD and other mental disorders. Psychol Inj and Law. 2011;4:187-216. doi:10.1007/s12207-011-9115-2
13. DeViva JC, Bloem WD. Symptom exaggeration and compensation seeking among combat veterans with posttraumatic stress disorder. J Trauma Stress. 2003;16(5):503-507. doi:10.1023/A:1025766713188
14. Ray CL. Feigning screeners in VA PTSD compensation and pension examinations. Psychol Inj and Law. 2014;7:370-387. doi:10.1007/s12207-014-9210-2
15. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. Brunner Mazel Publishers; 1990.
16. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, Marshall R. The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods. Science. 2006;313(5789):979-982. doi:10.1126/science.1128944
17. Marx BP, Bovin MJ, Szafranski DD, et al. Validity of posttraumatic stress disorder service connection status in Veterans Affairs electronic records of Iraq and Afghanistan Veterans. J Clin Psychiatry. 2016;77(4):517-522. doi:10.4088/JCP.14m09666
Updated June 17, 2022
The US Department of Veterans Affairs (VA) provides health care for > 9 million military veterans, nearly half of all former service members.1 Over the past 15 years, there has been a steady and substantial increase in the frequency of disability awards for veterans with post-9/11 military service. Recent data from the Bureau of Labor Statistics indicate that 41% of veterans who served after 9/11 receive service-connected disability benefits compared with 28% of veterans overall.2 More than 5 million veterans receive VA service-related disability benefits.2,3 More than half of the VA $243 billion budget for fiscal year (FY) 2021 ($135.5 billion) was allocated to the Veterans Benefits Administration (VBA), of which $115.7 billion (85%) was allocated specifically for service-related compensation claims payments.4
The VA predicted that VBA will have completed 1.4 million ratings for disability claims in 2021.5 A substantial percentage of these claims will be for mental disorders, specifically posttraumatic stress disorder (PTSD). VA officials testifying before Congress in 2017 noted that the number of PTSD claims had nearly tripled in the previous 10 years.6 As far back as 2013, McNally and Frueh analyzed “the skyrocketing of disability claims,” particularly for PTSD, among veterans who served in Iraq and Afghanistan.7
This large increase has placed an unprecedented burden on the VBA to expand its capacity to conduct initial PTSD disability evaluations that by regulations are completed by psychologists or psychiatrists. This need has led the VBA to make significant changes in the compensation and pension (C&P) process, including a reduced role for Veterans Health Administration (VHA) examiners and increased reliance on non-VA (contract) examiners through the Contract Medical Disability Examination (MDE) program. In 2019, the MDE budget was $1.23 billion; in 2020, it was increased to $1.79 billion, and for 2021, it was $2.23 billion, reflecting the increasing investment of resources in non-VA examiners, ostensibly to both increase capacity and save costs.5
Anecdotally, concerns have been raised regarding inadequate training of contract examiners as well as inadequate reports by these examiners. A 2018 Government Accountability Office (GAO) report concluded that VA lacked the data to determine whether contract examiners were meeting standards for quality, timeliness, and accuracy.8 The GAO report noted that VA required 92% of contractor reports contained no obvious errors, a relatively low target; however, in the first half of 2017, only 1 contractor group met that target. The report noted further that “VBA does not verify if examiners have completed training nor does it collect information to assess training effectiveness in preparing examiners.”8 A subsequent analysis of contract examinations completed by the VA Office of the Inspector General (OIG) in 2019 concluded that the MDE program was “hampered in their ability to provide oversight because of limitations with VBA’s electronic examination management systems, the lack of reliable data, and inadequate staffing of the program.”9
These reports have focused almost exclusively on simple performance metrics, such as timeliness of examination completion. However, the 2018 GAO report referenced isolated “focused reviews” of complaints about the quality of examinations by contract examiners and gave as an example an isolated “review of one contracted examiner who had high rates of diagnosing severe posttraumatic stress disorder.”8 After review indicated the examiner’s reports were of poor quality, the VBA discontinued the examiner’s contract.
Unfortunately, despite such anecdotal reports and isolated actions, to date there are no published reports examining and comparing the quality of PTSD examination reports completed by VHA and contract examiners or the subsequent disability determinations made by the VBA as a result of these evaluations. In a November 2020 letter to the VA Secretary, 11 US Senators expressed “grave concerns” regarding the VA decision to privatize C&P programs noting, among other concerns, that there were “no clinical quality measurement for, or evaluation of, contractor examinations.”10 The letter cited anecdotal evidence of contract examiners not reviewing veteran’s medical records and diagnosing conditions “without supporting evidence.”10
The purpose of the present evaluation was to provide a systematic comparison of the content and quality of initial PTSD disability examinations conducted by VHA and non-VA contract examiners. In addition, this study compared the disability rating decisions resulting from VHA and contract examinations.
Methods
A random sample of 100 Initial PTSD Disability Benefits Questionnaires (DBQs)—structured forms completed by all examiners—were obtained from a list supplied by the VA Office of Performance Analysis and Integrity. All examinations were from the Veterans Integrated Service Network (VISN) 1, encompassing the New England region and were conducted in 2019 and 2020. Two of the 100 cases were excluded for technical reasons, resulting in 98 examination reports. However, the final pool yielded 62 contract examinations and only 36 VHA examinations. To make the sample sizes more comparable, an additional 15 examinations were randomly selected from the local examination database (also VISN 1) to complement the original examination pool.
Once DBQs were retrieved, all identifying information was deleted, and cases were analyzed using assigned record numbers. All coding was completed by the 2 principal investigators, both VA psychologists with extensive training and experience in C&P evaluation and treatment of veterans with PTSD. Due to inherent structural differences between the forms used for VA and contract examinations, raters could not be masked/blinded to the source of the report.
A number of measures were taken to reduce bias and enhance objectivity of rating. First, objectively coded variables (eg, age and sex of veteran, period of service, trauma type, diagnoses rendered by the examiner, impairment category endorsed, number and type of symptoms) were transcribed directly from the DBQ as recorded by the examiner. Second, to rate report quality, an initial categorical rating scale was developed based on predetermined elements of examination quality that were considered essential. After refinement and preliminary analysis of interrater reliabilities, 3 quality-related indices were identified: (1) level of detail in description of key content areas (history before service, service trauma, after service social and vocational history, mental health history, substance use); (2) synthesis of history and findings in explaining opinion rendered; and (3) clarity of opinion regarding causation required “at least as likely as not” degree of confidence. The first 2 quality ratings were based on a 3-point scale (poor, fair, good), and the third variable was coded as yes or no. (eAppendix available at doi:10.12788/fp.0225). Interrater reliabilities calculated based on a subsample of 18 cases, randomly selected and rated by both raters, yielded Cohen κ in the acceptable range (.61, .72, and .89 for detail, synthesis, and clarity, respectively). Finally, for information regarding VBA decision making, rating decision documents contained in the Veterans Benefit Management System database were reviewed to determine whether the veteran was granted service connection for PTSD or another mental disorder based on the examination report in question and, if so, the disability rating percentage awarded. These were recorded independently after all other coding had been completed.
Results
Comparison of VHA and contract examinations revealed no significant differences between groups on relevant sociodemographic and other measures (Table). Missing data were not obtained from other records or sources, and for this study, reflect only what is recorded in the examination reports except for age, which was calculated using veteran’s date of birth and the date of examination.
To examine differences between VHA and contract examinations, the groups were first compared on a set of predetermined objectively coded variables taken directly from the DBQ. The frequency of PTSD diagnoses by VHA (57%) and contract (71%) examiners was not significantly different nor were rates of non-PTSD diagnoses by VHA (51%) and contract (73%) examiners. There also was no difference in the mean number of PTSD symptoms endorsed across PTSD diagnostic criteria B, C, D, and E (maximum of 20) recorded by VHA (9.4) and contract (10.9) examiners.
Contract examiners recorded a significantly greater mean number of “other symptoms” on a checklist of 31 possible symptoms as compared to VHA examiners: 7.3 vs 5.8, respectively (t[104] = 2.27, P < .05). An initial analysis of overall social/vocational impairment ratings coded by examiners did not reveal significant differences between examiner groups. However, when the 2 most severe impairment categories were combined to create a pooled “severe” category, 31% of contract examiners rated veterans as severely impaired compared with only 12% of VHA examiners (χ2 = 5.79, 1 df, P < .05) (Figure 1).
VHA and contract examinations were compared on 3 measures of report quality. Significant differences were found for both level of detail (χ2 = 16.44, 2 df, P < .01) and synthesis (χ2 = 6.68, 2 df, P < .05). Contract examinations were more likely to be rated as poor and less likely to be rated good, with a similar proportion of fair ratings for the 2 examination types (Figures 2 and 3). There was no significant difference in the proportion of VHA and contract examinations providing clear statement of opinion regarding causation (ie, whether or not the diagnosed condition was service related), with the majority rendering an adequate opinion in both examiner groups (VHA, 78%; contract, 79%).
Qualitative review revealed examples of markedly deficient examinations among contract examinations, including several reports that contained no review of records, no report of relevant background, and no mention or assessment of social and vocational function needed to inform opinions about diagnosis and impairment.
Finally, the VBA database was used to compare the resulting disability award decisions made by VBA based on the examination reports in question. Examination by contractors resulted in significantly higher mean service-connected disability ratings for examinees compared with VHA examiners (46.8 vs 33.5, respectively; t[108] = 2.3, P < .05).
Discussion
The present study provides the first reported systematic comparison of VA disability examinations for PTSD completed by examiners employed by the VHA and those hired as contract examiners through the MDE program. Although the frequency of PTSD diagnoses by contract examiners was higher than that of VHA examiners (71% vs 57%, respectively), the difference was not statistically significant. However, contract examiners recorded significantly more symptoms for examinees and rated them as severely impaired more frequently than did their VHA counterparts. In keeping with rating guidelines used by the VBA, these differences in examination content resulted in higher disability ratings for veterans seen by contract examiners.
Along with these elevated reports in symptom and severity ratings, contract examiners were less likely to provide adequate detail in the narrative sections of their reports and less frequently provided a satisfactory explanation and synthesis of relevant history and findings in support of their conclusions. Although not reflected in the statistical analysis, case-by-case review revealed some startlingly inadequate examination reports by contract examiners, several of which contained no review of records, no report or discussion of relevant background, and no discussion or analysis of social and vocational function to inform and support their opinion about level of impairment. None of the VHA examination reports reviewed lacked information to that degree.
Such deficiencies in detail and synthesis run counter to accepted guidelines for the adequate assessment of psychological injury in general and in VA disability claims specifically.11,12 For example, Watson and colleagues proposed that a minimum of 3 hours was required to conduct an initial PTSD examination, with more complex cases possibly taking longer.11 There is no information available about how long contract examiners take to complete their examinations and how that compares with the time taken by VA examiners. The VBA failure to monitor whether or not examiners follow accepted guidelines for PTSD examination has not previously been evaluated. Historically, a large number of clinicians, researchers, and policy critics have raised concerns about the potential for exaggeration or malingering among VA PTSD disability claimants and have urged the need to adequately assess for unreliable reporting and presentation.13,14 However, the possibility of systematic examiner deficiency and/or bias increasing the frequency of false or inflated claims being approved has received little empirical attention.
Although contract examiners did not diagnose PTSD significantly more frequently than VHA examiners (71% vs 57%, respectively), the overall frequency of PTSD diagnosis across both groups (65%) was substantially higher than previous figures that have, on average, estimated the lifetime prevalence of PTSD in trauma-exposed veterans to be about 31%.15 A re-analysis of the same National Vietnam Veterans Readjustment Survey data, but applying more conservative diagnostic criteria, reduced the lifetime prevalence to just under 19%, with point prevalence estimates even lower.15,16
In a study of concordance rates between service connection for PTSD and both current and lifetime diagnosis by independent, structured assessment, Marx and colleagues found that a “significant minority” of veterans who were already receiving service-connected disability for PTSD did not meet lifetime and/or current diagnostic criteria.17 Although it is possible that the group of veterans who were applying for disability benefits in our study had a higher rate of PTSD, it also is possible if not likely that the PTSD examination process overall yields inflated rates of diagnosis and levels of impairment. This speaks to the concern raised by Marx and colleagues who found that veterans with service connection for PTSD who received related benefits “may not have the disorder.”17
Limitations
A methodological limitation of the present study was that, due to structural differences in the DBQ forms used for VHA and contract examinations, the reports could not be de-identified as to examiner type and thus raters could not be masked/blinded. To mitigate bias, a predetermined, piloted, and refined coding and rating plan for report quality metrics was adhered to strictly, and interrater reliabilities were acceptable. Future study is suggested in which all report content is standardized for coding using the same format, which at present would require a complete rewriting of the entire report; this problem could be resolved by having the VBA adopt a more coherent system in which all reports, regardless of examiner type, use a single, standardized template. Further study using larger data sets and expanding to other VA regions also is needed.
Conclusions
The present study suggests that poor examination and report quality—by contract examiners and to a lesser degree VHA examiners—are not uncommon. The findings confirm and extend previous anecdotal reports of deficiencies in PTSD examinations performed by contract examiners and provide empirical support for concerns raised of global deficiencies in the VBA oversight of the MDE program. Such deficiencies have significant implications for the quality and integrity of the VA disability determination process for veterans claiming PTSD related to military service.
The current findings support and strengthen the call for development and management of a structured and enforced training and quality assurance/improvement program for VA PTSD disability examinations. Such training and oversight will be critical to improve the quality and integrity of these examinations, reduce error and waste in VBA’s Compensation and Pension process, and in doing so optimize VA financial resources to best serve veterans’ benefits and health care needs.
Updated June 17, 2022
The US Department of Veterans Affairs (VA) provides health care for > 9 million military veterans, nearly half of all former service members.1 Over the past 15 years, there has been a steady and substantial increase in the frequency of disability awards for veterans with post-9/11 military service. Recent data from the Bureau of Labor Statistics indicate that 41% of veterans who served after 9/11 receive service-connected disability benefits compared with 28% of veterans overall.2 More than 5 million veterans receive VA service-related disability benefits.2,3 More than half of the VA $243 billion budget for fiscal year (FY) 2021 ($135.5 billion) was allocated to the Veterans Benefits Administration (VBA), of which $115.7 billion (85%) was allocated specifically for service-related compensation claims payments.4
The VA predicted that VBA will have completed 1.4 million ratings for disability claims in 2021.5 A substantial percentage of these claims will be for mental disorders, specifically posttraumatic stress disorder (PTSD). VA officials testifying before Congress in 2017 noted that the number of PTSD claims had nearly tripled in the previous 10 years.6 As far back as 2013, McNally and Frueh analyzed “the skyrocketing of disability claims,” particularly for PTSD, among veterans who served in Iraq and Afghanistan.7
This large increase has placed an unprecedented burden on the VBA to expand its capacity to conduct initial PTSD disability evaluations that by regulations are completed by psychologists or psychiatrists. This need has led the VBA to make significant changes in the compensation and pension (C&P) process, including a reduced role for Veterans Health Administration (VHA) examiners and increased reliance on non-VA (contract) examiners through the Contract Medical Disability Examination (MDE) program. In 2019, the MDE budget was $1.23 billion; in 2020, it was increased to $1.79 billion, and for 2021, it was $2.23 billion, reflecting the increasing investment of resources in non-VA examiners, ostensibly to both increase capacity and save costs.5
Anecdotally, concerns have been raised regarding inadequate training of contract examiners as well as inadequate reports by these examiners. A 2018 Government Accountability Office (GAO) report concluded that VA lacked the data to determine whether contract examiners were meeting standards for quality, timeliness, and accuracy.8 The GAO report noted that VA required 92% of contractor reports contained no obvious errors, a relatively low target; however, in the first half of 2017, only 1 contractor group met that target. The report noted further that “VBA does not verify if examiners have completed training nor does it collect information to assess training effectiveness in preparing examiners.”8 A subsequent analysis of contract examinations completed by the VA Office of the Inspector General (OIG) in 2019 concluded that the MDE program was “hampered in their ability to provide oversight because of limitations with VBA’s electronic examination management systems, the lack of reliable data, and inadequate staffing of the program.”9
These reports have focused almost exclusively on simple performance metrics, such as timeliness of examination completion. However, the 2018 GAO report referenced isolated “focused reviews” of complaints about the quality of examinations by contract examiners and gave as an example an isolated “review of one contracted examiner who had high rates of diagnosing severe posttraumatic stress disorder.”8 After review indicated the examiner’s reports were of poor quality, the VBA discontinued the examiner’s contract.
Unfortunately, despite such anecdotal reports and isolated actions, to date there are no published reports examining and comparing the quality of PTSD examination reports completed by VHA and contract examiners or the subsequent disability determinations made by the VBA as a result of these evaluations. In a November 2020 letter to the VA Secretary, 11 US Senators expressed “grave concerns” regarding the VA decision to privatize C&P programs noting, among other concerns, that there were “no clinical quality measurement for, or evaluation of, contractor examinations.”10 The letter cited anecdotal evidence of contract examiners not reviewing veteran’s medical records and diagnosing conditions “without supporting evidence.”10
The purpose of the present evaluation was to provide a systematic comparison of the content and quality of initial PTSD disability examinations conducted by VHA and non-VA contract examiners. In addition, this study compared the disability rating decisions resulting from VHA and contract examinations.
Methods
A random sample of 100 Initial PTSD Disability Benefits Questionnaires (DBQs)—structured forms completed by all examiners—were obtained from a list supplied by the VA Office of Performance Analysis and Integrity. All examinations were from the Veterans Integrated Service Network (VISN) 1, encompassing the New England region and were conducted in 2019 and 2020. Two of the 100 cases were excluded for technical reasons, resulting in 98 examination reports. However, the final pool yielded 62 contract examinations and only 36 VHA examinations. To make the sample sizes more comparable, an additional 15 examinations were randomly selected from the local examination database (also VISN 1) to complement the original examination pool.
Once DBQs were retrieved, all identifying information was deleted, and cases were analyzed using assigned record numbers. All coding was completed by the 2 principal investigators, both VA psychologists with extensive training and experience in C&P evaluation and treatment of veterans with PTSD. Due to inherent structural differences between the forms used for VA and contract examinations, raters could not be masked/blinded to the source of the report.
A number of measures were taken to reduce bias and enhance objectivity of rating. First, objectively coded variables (eg, age and sex of veteran, period of service, trauma type, diagnoses rendered by the examiner, impairment category endorsed, number and type of symptoms) were transcribed directly from the DBQ as recorded by the examiner. Second, to rate report quality, an initial categorical rating scale was developed based on predetermined elements of examination quality that were considered essential. After refinement and preliminary analysis of interrater reliabilities, 3 quality-related indices were identified: (1) level of detail in description of key content areas (history before service, service trauma, after service social and vocational history, mental health history, substance use); (2) synthesis of history and findings in explaining opinion rendered; and (3) clarity of opinion regarding causation required “at least as likely as not” degree of confidence. The first 2 quality ratings were based on a 3-point scale (poor, fair, good), and the third variable was coded as yes or no. (eAppendix available at doi:10.12788/fp.0225). Interrater reliabilities calculated based on a subsample of 18 cases, randomly selected and rated by both raters, yielded Cohen κ in the acceptable range (.61, .72, and .89 for detail, synthesis, and clarity, respectively). Finally, for information regarding VBA decision making, rating decision documents contained in the Veterans Benefit Management System database were reviewed to determine whether the veteran was granted service connection for PTSD or another mental disorder based on the examination report in question and, if so, the disability rating percentage awarded. These were recorded independently after all other coding had been completed.
Results
Comparison of VHA and contract examinations revealed no significant differences between groups on relevant sociodemographic and other measures (Table). Missing data were not obtained from other records or sources, and for this study, reflect only what is recorded in the examination reports except for age, which was calculated using veteran’s date of birth and the date of examination.
To examine differences between VHA and contract examinations, the groups were first compared on a set of predetermined objectively coded variables taken directly from the DBQ. The frequency of PTSD diagnoses by VHA (57%) and contract (71%) examiners was not significantly different nor were rates of non-PTSD diagnoses by VHA (51%) and contract (73%) examiners. There also was no difference in the mean number of PTSD symptoms endorsed across PTSD diagnostic criteria B, C, D, and E (maximum of 20) recorded by VHA (9.4) and contract (10.9) examiners.
Contract examiners recorded a significantly greater mean number of “other symptoms” on a checklist of 31 possible symptoms as compared to VHA examiners: 7.3 vs 5.8, respectively (t[104] = 2.27, P < .05). An initial analysis of overall social/vocational impairment ratings coded by examiners did not reveal significant differences between examiner groups. However, when the 2 most severe impairment categories were combined to create a pooled “severe” category, 31% of contract examiners rated veterans as severely impaired compared with only 12% of VHA examiners (χ2 = 5.79, 1 df, P < .05) (Figure 1).
VHA and contract examinations were compared on 3 measures of report quality. Significant differences were found for both level of detail (χ2 = 16.44, 2 df, P < .01) and synthesis (χ2 = 6.68, 2 df, P < .05). Contract examinations were more likely to be rated as poor and less likely to be rated good, with a similar proportion of fair ratings for the 2 examination types (Figures 2 and 3). There was no significant difference in the proportion of VHA and contract examinations providing clear statement of opinion regarding causation (ie, whether or not the diagnosed condition was service related), with the majority rendering an adequate opinion in both examiner groups (VHA, 78%; contract, 79%).
Qualitative review revealed examples of markedly deficient examinations among contract examinations, including several reports that contained no review of records, no report of relevant background, and no mention or assessment of social and vocational function needed to inform opinions about diagnosis and impairment.
Finally, the VBA database was used to compare the resulting disability award decisions made by VBA based on the examination reports in question. Examination by contractors resulted in significantly higher mean service-connected disability ratings for examinees compared with VHA examiners (46.8 vs 33.5, respectively; t[108] = 2.3, P < .05).
Discussion
The present study provides the first reported systematic comparison of VA disability examinations for PTSD completed by examiners employed by the VHA and those hired as contract examiners through the MDE program. Although the frequency of PTSD diagnoses by contract examiners was higher than that of VHA examiners (71% vs 57%, respectively), the difference was not statistically significant. However, contract examiners recorded significantly more symptoms for examinees and rated them as severely impaired more frequently than did their VHA counterparts. In keeping with rating guidelines used by the VBA, these differences in examination content resulted in higher disability ratings for veterans seen by contract examiners.
Along with these elevated reports in symptom and severity ratings, contract examiners were less likely to provide adequate detail in the narrative sections of their reports and less frequently provided a satisfactory explanation and synthesis of relevant history and findings in support of their conclusions. Although not reflected in the statistical analysis, case-by-case review revealed some startlingly inadequate examination reports by contract examiners, several of which contained no review of records, no report or discussion of relevant background, and no discussion or analysis of social and vocational function to inform and support their opinion about level of impairment. None of the VHA examination reports reviewed lacked information to that degree.
Such deficiencies in detail and synthesis run counter to accepted guidelines for the adequate assessment of psychological injury in general and in VA disability claims specifically.11,12 For example, Watson and colleagues proposed that a minimum of 3 hours was required to conduct an initial PTSD examination, with more complex cases possibly taking longer.11 There is no information available about how long contract examiners take to complete their examinations and how that compares with the time taken by VA examiners. The VBA failure to monitor whether or not examiners follow accepted guidelines for PTSD examination has not previously been evaluated. Historically, a large number of clinicians, researchers, and policy critics have raised concerns about the potential for exaggeration or malingering among VA PTSD disability claimants and have urged the need to adequately assess for unreliable reporting and presentation.13,14 However, the possibility of systematic examiner deficiency and/or bias increasing the frequency of false or inflated claims being approved has received little empirical attention.
Although contract examiners did not diagnose PTSD significantly more frequently than VHA examiners (71% vs 57%, respectively), the overall frequency of PTSD diagnosis across both groups (65%) was substantially higher than previous figures that have, on average, estimated the lifetime prevalence of PTSD in trauma-exposed veterans to be about 31%.15 A re-analysis of the same National Vietnam Veterans Readjustment Survey data, but applying more conservative diagnostic criteria, reduced the lifetime prevalence to just under 19%, with point prevalence estimates even lower.15,16
In a study of concordance rates between service connection for PTSD and both current and lifetime diagnosis by independent, structured assessment, Marx and colleagues found that a “significant minority” of veterans who were already receiving service-connected disability for PTSD did not meet lifetime and/or current diagnostic criteria.17 Although it is possible that the group of veterans who were applying for disability benefits in our study had a higher rate of PTSD, it also is possible if not likely that the PTSD examination process overall yields inflated rates of diagnosis and levels of impairment. This speaks to the concern raised by Marx and colleagues who found that veterans with service connection for PTSD who received related benefits “may not have the disorder.”17
Limitations
A methodological limitation of the present study was that, due to structural differences in the DBQ forms used for VHA and contract examinations, the reports could not be de-identified as to examiner type and thus raters could not be masked/blinded. To mitigate bias, a predetermined, piloted, and refined coding and rating plan for report quality metrics was adhered to strictly, and interrater reliabilities were acceptable. Future study is suggested in which all report content is standardized for coding using the same format, which at present would require a complete rewriting of the entire report; this problem could be resolved by having the VBA adopt a more coherent system in which all reports, regardless of examiner type, use a single, standardized template. Further study using larger data sets and expanding to other VA regions also is needed.
Conclusions
The present study suggests that poor examination and report quality—by contract examiners and to a lesser degree VHA examiners—are not uncommon. The findings confirm and extend previous anecdotal reports of deficiencies in PTSD examinations performed by contract examiners and provide empirical support for concerns raised of global deficiencies in the VBA oversight of the MDE program. Such deficiencies have significant implications for the quality and integrity of the VA disability determination process for veterans claiming PTSD related to military service.
The current findings support and strengthen the call for development and management of a structured and enforced training and quality assurance/improvement program for VA PTSD disability examinations. Such training and oversight will be critical to improve the quality and integrity of these examinations, reduce error and waste in VBA’s Compensation and Pension process, and in doing so optimize VA financial resources to best serve veterans’ benefits and health care needs.
1. US Department of Veterans Affairs, Veterans Health Adminstration. About VHA. Updated April 23, 2021. Accessed January 6, 2022. www.va.gov/health/aboutvha.asp
2. US Department of Labor, Bureau of Labor Statistics. News release. Employment situation of veterans—2020. Published March 18, 2020. Accessed January 6, 2022. https://www.bls.gov/news.release/pdf/vet.pdf
3. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Department of Veterans Affairs statistics at a glance. Updated December 31, 2020. Accessed January 6, 2022. https://www.va.gov/vetdata/docs/Quickfacts/Stats_at_a_glance_12_31_20.PDF
4. US Department of Veterans Affairs. FY 2021 Budget submission: budget in brief. Published February 2020. Accessed January 6, 2022. https://www.va.gov/budget/docs/summary/archive/FY-2021-VA-BudgetSubmission.zip
5. US Department of Veterans Affairs. FY 2021 budget submission: benefits and burial programs and Departmental Administration volume 3 of 4:178. Published February 2020. Accessed January 6, 2022. https://www.va.gov/budget/docs/summary/archive/FY-2021-VA-BudgetSubmission.zip
6. Statement of Ronald Burke, assistant deputy under secretary, office of field operations Veterans Benefits Administration before the Subcommittee on Disability And Memorial Affairs of the House Committee on Veterans’ Affairs. Published July 25, 2017. Accessed January 6, 2022. https://www.congress.gov/115/meeting/house/106322/witnesses/HHRG-115-VR09-Wstate-BurkeR-20170725.pdf
7. McNally RJ, Frueh BC. Why are Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates? J Anxiety Disord. 2013;27(5):520-526. doi:10.1016/j.janxdis.2013.07.002
8. US Government Accountability Office. VA disability exams: improved performance analysis and training oversight needed for contracted exams. GAO-19-13. Published October 2018. Accessed January 6, 2022. https://www.gao.gov/assets/gao-19-13.pdf
9. US Department of Veterans Affairs, Office of Inspector General. Inadequate oversight of contracted disability exam cancellations. Report #18-04266-115. Published June 10, 2019. Accessed January 6, 2022. https://www.va.gov/oig/pubs/VAOIG-18-04266-115.pdf
10. Letter to VA Secretary Wilkie. Published November 11, 2020. Accessed January 6, 2022. https://www.veterans.senate.gov/download/candp-exam-va-letter
11. Watson PW, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane TM, Hamblen JL (2005). Best practice manual for posttraumatic stress disorder (PTSD) compensation and pension examinations. Portland, OR: Northwest Network Mental Illness Research, Education, and Clinical Center, VA Puget Sound Healthcare System.
12. Worthen MD, Moering RG. A practical guide to conducting VA compensation and pension exams for PTSD and other mental disorders. Psychol Inj and Law. 2011;4:187-216. doi:10.1007/s12207-011-9115-2
13. DeViva JC, Bloem WD. Symptom exaggeration and compensation seeking among combat veterans with posttraumatic stress disorder. J Trauma Stress. 2003;16(5):503-507. doi:10.1023/A:1025766713188
14. Ray CL. Feigning screeners in VA PTSD compensation and pension examinations. Psychol Inj and Law. 2014;7:370-387. doi:10.1007/s12207-014-9210-2
15. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. Brunner Mazel Publishers; 1990.
16. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, Marshall R. The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods. Science. 2006;313(5789):979-982. doi:10.1126/science.1128944
17. Marx BP, Bovin MJ, Szafranski DD, et al. Validity of posttraumatic stress disorder service connection status in Veterans Affairs electronic records of Iraq and Afghanistan Veterans. J Clin Psychiatry. 2016;77(4):517-522. doi:10.4088/JCP.14m09666
1. US Department of Veterans Affairs, Veterans Health Adminstration. About VHA. Updated April 23, 2021. Accessed January 6, 2022. www.va.gov/health/aboutvha.asp
2. US Department of Labor, Bureau of Labor Statistics. News release. Employment situation of veterans—2020. Published March 18, 2020. Accessed January 6, 2022. https://www.bls.gov/news.release/pdf/vet.pdf
3. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Department of Veterans Affairs statistics at a glance. Updated December 31, 2020. Accessed January 6, 2022. https://www.va.gov/vetdata/docs/Quickfacts/Stats_at_a_glance_12_31_20.PDF
4. US Department of Veterans Affairs. FY 2021 Budget submission: budget in brief. Published February 2020. Accessed January 6, 2022. https://www.va.gov/budget/docs/summary/archive/FY-2021-VA-BudgetSubmission.zip
5. US Department of Veterans Affairs. FY 2021 budget submission: benefits and burial programs and Departmental Administration volume 3 of 4:178. Published February 2020. Accessed January 6, 2022. https://www.va.gov/budget/docs/summary/archive/FY-2021-VA-BudgetSubmission.zip
6. Statement of Ronald Burke, assistant deputy under secretary, office of field operations Veterans Benefits Administration before the Subcommittee on Disability And Memorial Affairs of the House Committee on Veterans’ Affairs. Published July 25, 2017. Accessed January 6, 2022. https://www.congress.gov/115/meeting/house/106322/witnesses/HHRG-115-VR09-Wstate-BurkeR-20170725.pdf
7. McNally RJ, Frueh BC. Why are Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates? J Anxiety Disord. 2013;27(5):520-526. doi:10.1016/j.janxdis.2013.07.002
8. US Government Accountability Office. VA disability exams: improved performance analysis and training oversight needed for contracted exams. GAO-19-13. Published October 2018. Accessed January 6, 2022. https://www.gao.gov/assets/gao-19-13.pdf
9. US Department of Veterans Affairs, Office of Inspector General. Inadequate oversight of contracted disability exam cancellations. Report #18-04266-115. Published June 10, 2019. Accessed January 6, 2022. https://www.va.gov/oig/pubs/VAOIG-18-04266-115.pdf
10. Letter to VA Secretary Wilkie. Published November 11, 2020. Accessed January 6, 2022. https://www.veterans.senate.gov/download/candp-exam-va-letter
11. Watson PW, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane TM, Hamblen JL (2005). Best practice manual for posttraumatic stress disorder (PTSD) compensation and pension examinations. Portland, OR: Northwest Network Mental Illness Research, Education, and Clinical Center, VA Puget Sound Healthcare System.
12. Worthen MD, Moering RG. A practical guide to conducting VA compensation and pension exams for PTSD and other mental disorders. Psychol Inj and Law. 2011;4:187-216. doi:10.1007/s12207-011-9115-2
13. DeViva JC, Bloem WD. Symptom exaggeration and compensation seeking among combat veterans with posttraumatic stress disorder. J Trauma Stress. 2003;16(5):503-507. doi:10.1023/A:1025766713188
14. Ray CL. Feigning screeners in VA PTSD compensation and pension examinations. Psychol Inj and Law. 2014;7:370-387. doi:10.1007/s12207-014-9210-2
15. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. Brunner Mazel Publishers; 1990.
16. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, Marshall R. The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods. Science. 2006;313(5789):979-982. doi:10.1126/science.1128944
17. Marx BP, Bovin MJ, Szafranski DD, et al. Validity of posttraumatic stress disorder service connection status in Veterans Affairs electronic records of Iraq and Afghanistan Veterans. J Clin Psychiatry. 2016;77(4):517-522. doi:10.4088/JCP.14m09666
Emotions, science, and the politics of COVID
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.
Treating homeless patients: Book offers key insights
As a psychiatrist dedicated to working with people who are experiencing homelessness, I was very impressed with the new book edited by Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, and Maria D. Llorente, MD, about treating and providing services to this vulnerable population.
The book, “Clinical Management of the Homeless Patient: Social, Psychiatric, and Medical Issues” (Cham, Switzerland: Springer Nature Switzerland, 2021), offers an in-depth review and analysis of the biopsychosocial complexities that affect how medical and behavioral health conditions present in those who are unhoused. Notably, the book recommends with great sensitivity best practices to address these conditions with care, understanding, and love.
This text, invaluable in particular for those of us clinicians who work with people experiencing homelessness (PEH), provides a historical context of homelessness in the United States, an evaluation of the current state, and indispensable guidance for medical and behavioral health practitioners, case managers, housing navigators, and policy makers alike. It also serves as an inspiring source for those who are considering work in the public sector while reminding those of us in the field why we continue to do this challenging and rewarding work.
Tips can provide hope to clinicians
The volume is divided into four clear sections that are easy to navigate depending on your area of expertise and interest. Each chapter consolidates an extensive literature review into an intriguing and thought-provoking analysis. Part I, “The Big Picture – Social and Medical Issues,” focuses on conditions that disproportionately affect those who are unhoused. The authors offer a glimpse into the unique challenges of managing routine health conditions. They also detail the practical knowledge that’s needed to best care for our most vulnerable neighbors; for example, promoting a shared decision-making model; simplifying treatment plans; prescribing, when possible, medications that are dosed daily – instead of multiple times per day; allowing for walk-in appointments; and addressing cultural, linguistic, and educational barriers.
Most chapters highlight informative case examples that bring the text to life. It can be heartbreaking to recognize and witness the inhumane conditions in which PEH live, and these practical tips and suggestions for future policies based on best practices can help prevent burnout and provide hope for those who care for this community.
Part II, “Psychiatric Issues and Treatments,” presents a brief yet comprehensive history on homelessness, beginning with the deep shame that PEH experienced in Colonial times as the result of cultural and religious influences. Sadly, that negative judgment continues to this day.
The authors also explain how deinstitutionalization and transinstitutionalization have shaped the current state of homelessness, including why many PEH receive their care in emergency departments while incarcerated. This section highlights the barriers of care that are created not just by the patient, but also by the clinicians and systems of care – and what’s needed practically to overcome those challenges.
I appreciate the chapter on substance use disorders. It reminds us that the most commonly used substance among PEH is tobacco, which has serious health effects and for which we have treatment; nevertheless, . This section also provides examples of the trauma-informed language to use when addressing difficult and sometimes stigmatizing topics, such as survival sex and trauma history.
The evidence-based discussion continues in Part III with a focus on topics that everyone working with PEH should understand, including food insecurity, the criminal justice system, and sex trafficking. Part IV highlights best practices that should be replicated in every community, including Housing First approaches, medical respite care, and multiple Veterans Administration programs.
Throughout the text, major themes reverberate across the chapters, beginning with empathy. All who work with PEH must understand the conditions and challenges PEH face every day that affect their physical and mental health. The authors offer a stark and pointed reminder that being unhoused amounts to a full-time job just to meet basic needs. In addition, the devastating role of trauma and structural racism in creating and promoting the conditions that lead someone to be unhoused cannot be underestimated.
Fortunately, the primary aim of the book is to highlight solutions, and it’s here that the book shines. While some interventions are well-known, such as the importance of working in multidisciplinary teams, building trust and rapport with our patients, and urging clinicians and institutions to examine their own judgments and biases that might interfere with humane treatment, other suggestions will lead some readers into new territory. The authors, for example, maintain that we need more data and evidence-based research that include PEH. They also make a case for more preventive care and enhanced professional education for all health care workers that centers on trauma-informed care, social determinants of health, and the unique needs of especially vulnerable communities, such as the unhoused LBGTQ+ community and policies that promote best practices, such as Housing First. The book is a stirring read. It offers both inspiration and practical guidance for all who are currently working with or interested in caring for people experiencing homelessness.
Dr. Bird is a psychiatrist with Alameda County Health Care for the Homeless and the TRUST Clinic in Oakland, Calif. She also is a cofounder of StreetHealth, a backpack street medicine team that provides psychiatric and substance use disorder treatment to people experiencing homelessness in downtown Oakland.
Dr. Bird has no disclosures.
As a psychiatrist dedicated to working with people who are experiencing homelessness, I was very impressed with the new book edited by Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, and Maria D. Llorente, MD, about treating and providing services to this vulnerable population.
The book, “Clinical Management of the Homeless Patient: Social, Psychiatric, and Medical Issues” (Cham, Switzerland: Springer Nature Switzerland, 2021), offers an in-depth review and analysis of the biopsychosocial complexities that affect how medical and behavioral health conditions present in those who are unhoused. Notably, the book recommends with great sensitivity best practices to address these conditions with care, understanding, and love.
This text, invaluable in particular for those of us clinicians who work with people experiencing homelessness (PEH), provides a historical context of homelessness in the United States, an evaluation of the current state, and indispensable guidance for medical and behavioral health practitioners, case managers, housing navigators, and policy makers alike. It also serves as an inspiring source for those who are considering work in the public sector while reminding those of us in the field why we continue to do this challenging and rewarding work.
Tips can provide hope to clinicians
The volume is divided into four clear sections that are easy to navigate depending on your area of expertise and interest. Each chapter consolidates an extensive literature review into an intriguing and thought-provoking analysis. Part I, “The Big Picture – Social and Medical Issues,” focuses on conditions that disproportionately affect those who are unhoused. The authors offer a glimpse into the unique challenges of managing routine health conditions. They also detail the practical knowledge that’s needed to best care for our most vulnerable neighbors; for example, promoting a shared decision-making model; simplifying treatment plans; prescribing, when possible, medications that are dosed daily – instead of multiple times per day; allowing for walk-in appointments; and addressing cultural, linguistic, and educational barriers.
Most chapters highlight informative case examples that bring the text to life. It can be heartbreaking to recognize and witness the inhumane conditions in which PEH live, and these practical tips and suggestions for future policies based on best practices can help prevent burnout and provide hope for those who care for this community.
Part II, “Psychiatric Issues and Treatments,” presents a brief yet comprehensive history on homelessness, beginning with the deep shame that PEH experienced in Colonial times as the result of cultural and religious influences. Sadly, that negative judgment continues to this day.
The authors also explain how deinstitutionalization and transinstitutionalization have shaped the current state of homelessness, including why many PEH receive their care in emergency departments while incarcerated. This section highlights the barriers of care that are created not just by the patient, but also by the clinicians and systems of care – and what’s needed practically to overcome those challenges.
I appreciate the chapter on substance use disorders. It reminds us that the most commonly used substance among PEH is tobacco, which has serious health effects and for which we have treatment; nevertheless, . This section also provides examples of the trauma-informed language to use when addressing difficult and sometimes stigmatizing topics, such as survival sex and trauma history.
The evidence-based discussion continues in Part III with a focus on topics that everyone working with PEH should understand, including food insecurity, the criminal justice system, and sex trafficking. Part IV highlights best practices that should be replicated in every community, including Housing First approaches, medical respite care, and multiple Veterans Administration programs.
Throughout the text, major themes reverberate across the chapters, beginning with empathy. All who work with PEH must understand the conditions and challenges PEH face every day that affect their physical and mental health. The authors offer a stark and pointed reminder that being unhoused amounts to a full-time job just to meet basic needs. In addition, the devastating role of trauma and structural racism in creating and promoting the conditions that lead someone to be unhoused cannot be underestimated.
Fortunately, the primary aim of the book is to highlight solutions, and it’s here that the book shines. While some interventions are well-known, such as the importance of working in multidisciplinary teams, building trust and rapport with our patients, and urging clinicians and institutions to examine their own judgments and biases that might interfere with humane treatment, other suggestions will lead some readers into new territory. The authors, for example, maintain that we need more data and evidence-based research that include PEH. They also make a case for more preventive care and enhanced professional education for all health care workers that centers on trauma-informed care, social determinants of health, and the unique needs of especially vulnerable communities, such as the unhoused LBGTQ+ community and policies that promote best practices, such as Housing First. The book is a stirring read. It offers both inspiration and practical guidance for all who are currently working with or interested in caring for people experiencing homelessness.
Dr. Bird is a psychiatrist with Alameda County Health Care for the Homeless and the TRUST Clinic in Oakland, Calif. She also is a cofounder of StreetHealth, a backpack street medicine team that provides psychiatric and substance use disorder treatment to people experiencing homelessness in downtown Oakland.
Dr. Bird has no disclosures.
As a psychiatrist dedicated to working with people who are experiencing homelessness, I was very impressed with the new book edited by Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, and Maria D. Llorente, MD, about treating and providing services to this vulnerable population.
The book, “Clinical Management of the Homeless Patient: Social, Psychiatric, and Medical Issues” (Cham, Switzerland: Springer Nature Switzerland, 2021), offers an in-depth review and analysis of the biopsychosocial complexities that affect how medical and behavioral health conditions present in those who are unhoused. Notably, the book recommends with great sensitivity best practices to address these conditions with care, understanding, and love.
This text, invaluable in particular for those of us clinicians who work with people experiencing homelessness (PEH), provides a historical context of homelessness in the United States, an evaluation of the current state, and indispensable guidance for medical and behavioral health practitioners, case managers, housing navigators, and policy makers alike. It also serves as an inspiring source for those who are considering work in the public sector while reminding those of us in the field why we continue to do this challenging and rewarding work.
Tips can provide hope to clinicians
The volume is divided into four clear sections that are easy to navigate depending on your area of expertise and interest. Each chapter consolidates an extensive literature review into an intriguing and thought-provoking analysis. Part I, “The Big Picture – Social and Medical Issues,” focuses on conditions that disproportionately affect those who are unhoused. The authors offer a glimpse into the unique challenges of managing routine health conditions. They also detail the practical knowledge that’s needed to best care for our most vulnerable neighbors; for example, promoting a shared decision-making model; simplifying treatment plans; prescribing, when possible, medications that are dosed daily – instead of multiple times per day; allowing for walk-in appointments; and addressing cultural, linguistic, and educational barriers.
Most chapters highlight informative case examples that bring the text to life. It can be heartbreaking to recognize and witness the inhumane conditions in which PEH live, and these practical tips and suggestions for future policies based on best practices can help prevent burnout and provide hope for those who care for this community.
Part II, “Psychiatric Issues and Treatments,” presents a brief yet comprehensive history on homelessness, beginning with the deep shame that PEH experienced in Colonial times as the result of cultural and religious influences. Sadly, that negative judgment continues to this day.
The authors also explain how deinstitutionalization and transinstitutionalization have shaped the current state of homelessness, including why many PEH receive their care in emergency departments while incarcerated. This section highlights the barriers of care that are created not just by the patient, but also by the clinicians and systems of care – and what’s needed practically to overcome those challenges.
I appreciate the chapter on substance use disorders. It reminds us that the most commonly used substance among PEH is tobacco, which has serious health effects and for which we have treatment; nevertheless, . This section also provides examples of the trauma-informed language to use when addressing difficult and sometimes stigmatizing topics, such as survival sex and trauma history.
The evidence-based discussion continues in Part III with a focus on topics that everyone working with PEH should understand, including food insecurity, the criminal justice system, and sex trafficking. Part IV highlights best practices that should be replicated in every community, including Housing First approaches, medical respite care, and multiple Veterans Administration programs.
Throughout the text, major themes reverberate across the chapters, beginning with empathy. All who work with PEH must understand the conditions and challenges PEH face every day that affect their physical and mental health. The authors offer a stark and pointed reminder that being unhoused amounts to a full-time job just to meet basic needs. In addition, the devastating role of trauma and structural racism in creating and promoting the conditions that lead someone to be unhoused cannot be underestimated.
Fortunately, the primary aim of the book is to highlight solutions, and it’s here that the book shines. While some interventions are well-known, such as the importance of working in multidisciplinary teams, building trust and rapport with our patients, and urging clinicians and institutions to examine their own judgments and biases that might interfere with humane treatment, other suggestions will lead some readers into new territory. The authors, for example, maintain that we need more data and evidence-based research that include PEH. They also make a case for more preventive care and enhanced professional education for all health care workers that centers on trauma-informed care, social determinants of health, and the unique needs of especially vulnerable communities, such as the unhoused LBGTQ+ community and policies that promote best practices, such as Housing First. The book is a stirring read. It offers both inspiration and practical guidance for all who are currently working with or interested in caring for people experiencing homelessness.
Dr. Bird is a psychiatrist with Alameda County Health Care for the Homeless and the TRUST Clinic in Oakland, Calif. She also is a cofounder of StreetHealth, a backpack street medicine team that provides psychiatric and substance use disorder treatment to people experiencing homelessness in downtown Oakland.
Dr. Bird has no disclosures.
COVID-19 and coping with superimposed traumas
While 2022 is lurking around the corner, many of us still have 2020 on our minds. Social media posts are already emerging: “No new years resolutions. It is the circumstances turn to improve [sic],” one post declares. Others proclaim that it is difficult coming to terms with the idea that 2022 is actually pronounced “2020 too.” A critical difference exists between then and now – we have experienced months of living in limbo and rolling with the punches of pandemic life.
In some ways, it has become easy to think of the early pandemic days as a distant memory, yet respect that the impact of 2020 has been indelible for virtually all of us and feels palpable as if it were yesterday.
The year 2020 was marked by the beginning of the COVID-19 pandemic, which was accompanied by extreme uncertainty, loss of all kinds, and emotional turmoil. The early pandemic had a profound economic and social impact, with added stress tethered to political and race-related division in America that created divides among families and friends, and yielded ceaseless discourse related to divergent perspectives. This only exacerbated the stress that came with the pandemic, given that providing support and leaning on one another was more important than ever. All of this was compounded by natural disasters that have plagued the country.
So much was unprecedented. There was a collective sense of feeling “worn down,” and the burnout that was felt was quite profound. Enormous amounts of mental and physical effort were allocated to simply surviving, getting basic needs met, having enough food and supplies, and completing basic tasks. Ordinary relating felt taxing. At this stage of the pandemic, the COVID-19 experience can be conceived of as a traumatic stressor capable of eliciting a traumatic response and exacerbating other mental health symptoms. Our capacity to cope has been diminished. Anxiety rates have soared, as have rates of clinical depression. Those most affected have had lower household incomes, are unmarried, and have experienced pandemic-related stressors. The links between the impact of the pandemic on mental health have been clear.
The pandemic has forced the landscape of social support to dramatically change. Initially, we felt pulled to connect and we leaned into the use of virtual platforms to connect for all matters (simple social gatherings, big birthday events, family reunions, celebration of holidays, work duties, and academic work). However, “Zoom fatigue” began to set in, and our screen time was maxed out. There has been the added dynamic of frontline workers who did not have the option to work virtually or from home. This group largely has felt disconnected from others who didn’t understand the depth of their anxiety and loneliness of their experience. Health care workers have had to make challenging, life-and-death, patient-related decisions that called into question personal morals and ethics all while their own lives were at risk.
Fast-forward to the present, and support systems have either strengthened or worn down – which has yielded a unique dichotomy. Maintaining friendships has either felt of utmost importance given the impact of the disconnect and physical distance or has felt challenging given the mental energy expended from working and connecting virtually. Empathy burnout is also a real and important facet in the equation. We begin to ask the question: Are we checking in with others in the spirit of authentic relating, to cultivate real connection, or to check a box?
Impact of layered traumas
It is interesting to think about the pandemic’s traumatic impact being “superimposed” on top of the “ordinary traumas” experienced outside of the pandemic. We are essentially at the 2-year mark, in some ways have cultivated a sense of resilience and found ways to adapt, and in other ways at times feel right back where we were in early 2020. There were moments that felt hopeful, glimmers of normalcy, and setbacks that all ebbed and flowed – but even so, there have not been many “mental breaks,” only temporary and transient reprieves. Some got sick and died; some recovered; and others are still experiencing long-hauler syndrome and have lingering sequelae. Despite adaptation and resilience, one can’t help but wonder the impact of superimposed traumas on top of this collective trauma. Many of us have not even rebounded from the pandemic, and then are faced with loss, grief, challenges, illness, hard and big life decisions. We are challenged to answer the question: How do we endure in the face of this trauma inception?
It has been a challenging time for all, including those who are ordinarily happy-go-lucky, resilient, and see the glass half-full and are struggling with the idea of struggling. I am no “resilience expert” but gleaned much wisdom from responding to the Surfside, Fla., building collapse. This was a collective trauma that took place in the summer of 2021, and the wisdom of this event highlighted the value of collective healing and unification even in spite of the times. What happened in Surfside was a shock, and the loss was felt by those directly affected, the surrounding community, and those who were part of the disaster response efforts. All of those parties had been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and this community tragedy was yet another loss to disentangle on top of a period in U.S. history demarcated by a great lack of unity, divisiveness, anger, and hatred. The collapse highlighted the small size yet interconnectedness of the community and the power of connection and authentic relating. It was overwhelming in the moment but extremely heartening and beautiful to see the amount of willingness to drop everything and help. Despite feeling worn down from the pandemic, people drew upon their internal resources, natural goodness, and kindness “reserves” to provide support.
Responding to the collapse highlighted that resilience in the context of collective trauma requires flexibility, embracing uncertainty, cultivating unity, and paying attention to meeting basic needs/self-care. The role of kindness cannot be overemphasized. In the realm of reflecting on the notion of kindness, it is worth noting how much power there is to bearing witness to someone’s experience, especially when they are in pain. People often diminish the role or at the very least do not recognize the power of showing up for someone and just listening. Pandemic resilience, and coping with coalescing traumas, is likely composed of these same facets that were essential in the context of coping with the collapse.
It is not only the immediate impact of a trauma as much as the aftermath that needs to processed and worked through. In one sense, people feel that they should be adjusted to and accustomed to this new reality, and at the same time, one has to remember and reflect on how unnatural this experience has been. There is an impact of a cumulative onslaught of negative events, and it is hard to imagine not being phased, remaining unchanged, or not feeling affected. We may feel hardened and that there are limits to the compassion we have to offer others. We may be feel empathic. There can be desensitization and an apathy to others’ suffering when our patience is worn down and we have limited bandwidth. There are data to support the idea that a level of habituation occurs to individuals who experience multiple traumas, which yields a level of “sensitization” to the negative impact of subsequent events. It becomes easy to make comparisons of suffering. The challenge will be to rise above these and make a conscious effort to connect with who and how we were before we were worn down.
I am still in awe about how much I learned from the victims’ families, survivors, and my colleagues at Surfside – about pain, suffering, loss, resilience, coping, fortitude, and meaning making. We were all forced to think beyond ourselves, show up for others, and unify in a way that remedied this period of fragmentation. With respect to the pandemic and “where we are at now,” some elements of our lives are stabilizing; other aspects feel volatile from the fatigue of what we have been experiencing. This pandemic has not fully abated, but we can find some clarity in the value of setting boundaries and knowing our limits – but not overlooking the power of unity and kindness and the value of the reciprocating those qualities.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of the Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures.
While 2022 is lurking around the corner, many of us still have 2020 on our minds. Social media posts are already emerging: “No new years resolutions. It is the circumstances turn to improve [sic],” one post declares. Others proclaim that it is difficult coming to terms with the idea that 2022 is actually pronounced “2020 too.” A critical difference exists between then and now – we have experienced months of living in limbo and rolling with the punches of pandemic life.
In some ways, it has become easy to think of the early pandemic days as a distant memory, yet respect that the impact of 2020 has been indelible for virtually all of us and feels palpable as if it were yesterday.
The year 2020 was marked by the beginning of the COVID-19 pandemic, which was accompanied by extreme uncertainty, loss of all kinds, and emotional turmoil. The early pandemic had a profound economic and social impact, with added stress tethered to political and race-related division in America that created divides among families and friends, and yielded ceaseless discourse related to divergent perspectives. This only exacerbated the stress that came with the pandemic, given that providing support and leaning on one another was more important than ever. All of this was compounded by natural disasters that have plagued the country.
So much was unprecedented. There was a collective sense of feeling “worn down,” and the burnout that was felt was quite profound. Enormous amounts of mental and physical effort were allocated to simply surviving, getting basic needs met, having enough food and supplies, and completing basic tasks. Ordinary relating felt taxing. At this stage of the pandemic, the COVID-19 experience can be conceived of as a traumatic stressor capable of eliciting a traumatic response and exacerbating other mental health symptoms. Our capacity to cope has been diminished. Anxiety rates have soared, as have rates of clinical depression. Those most affected have had lower household incomes, are unmarried, and have experienced pandemic-related stressors. The links between the impact of the pandemic on mental health have been clear.
The pandemic has forced the landscape of social support to dramatically change. Initially, we felt pulled to connect and we leaned into the use of virtual platforms to connect for all matters (simple social gatherings, big birthday events, family reunions, celebration of holidays, work duties, and academic work). However, “Zoom fatigue” began to set in, and our screen time was maxed out. There has been the added dynamic of frontline workers who did not have the option to work virtually or from home. This group largely has felt disconnected from others who didn’t understand the depth of their anxiety and loneliness of their experience. Health care workers have had to make challenging, life-and-death, patient-related decisions that called into question personal morals and ethics all while their own lives were at risk.
Fast-forward to the present, and support systems have either strengthened or worn down – which has yielded a unique dichotomy. Maintaining friendships has either felt of utmost importance given the impact of the disconnect and physical distance or has felt challenging given the mental energy expended from working and connecting virtually. Empathy burnout is also a real and important facet in the equation. We begin to ask the question: Are we checking in with others in the spirit of authentic relating, to cultivate real connection, or to check a box?
Impact of layered traumas
It is interesting to think about the pandemic’s traumatic impact being “superimposed” on top of the “ordinary traumas” experienced outside of the pandemic. We are essentially at the 2-year mark, in some ways have cultivated a sense of resilience and found ways to adapt, and in other ways at times feel right back where we were in early 2020. There were moments that felt hopeful, glimmers of normalcy, and setbacks that all ebbed and flowed – but even so, there have not been many “mental breaks,” only temporary and transient reprieves. Some got sick and died; some recovered; and others are still experiencing long-hauler syndrome and have lingering sequelae. Despite adaptation and resilience, one can’t help but wonder the impact of superimposed traumas on top of this collective trauma. Many of us have not even rebounded from the pandemic, and then are faced with loss, grief, challenges, illness, hard and big life decisions. We are challenged to answer the question: How do we endure in the face of this trauma inception?
It has been a challenging time for all, including those who are ordinarily happy-go-lucky, resilient, and see the glass half-full and are struggling with the idea of struggling. I am no “resilience expert” but gleaned much wisdom from responding to the Surfside, Fla., building collapse. This was a collective trauma that took place in the summer of 2021, and the wisdom of this event highlighted the value of collective healing and unification even in spite of the times. What happened in Surfside was a shock, and the loss was felt by those directly affected, the surrounding community, and those who were part of the disaster response efforts. All of those parties had been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and this community tragedy was yet another loss to disentangle on top of a period in U.S. history demarcated by a great lack of unity, divisiveness, anger, and hatred. The collapse highlighted the small size yet interconnectedness of the community and the power of connection and authentic relating. It was overwhelming in the moment but extremely heartening and beautiful to see the amount of willingness to drop everything and help. Despite feeling worn down from the pandemic, people drew upon their internal resources, natural goodness, and kindness “reserves” to provide support.
Responding to the collapse highlighted that resilience in the context of collective trauma requires flexibility, embracing uncertainty, cultivating unity, and paying attention to meeting basic needs/self-care. The role of kindness cannot be overemphasized. In the realm of reflecting on the notion of kindness, it is worth noting how much power there is to bearing witness to someone’s experience, especially when they are in pain. People often diminish the role or at the very least do not recognize the power of showing up for someone and just listening. Pandemic resilience, and coping with coalescing traumas, is likely composed of these same facets that were essential in the context of coping with the collapse.
It is not only the immediate impact of a trauma as much as the aftermath that needs to processed and worked through. In one sense, people feel that they should be adjusted to and accustomed to this new reality, and at the same time, one has to remember and reflect on how unnatural this experience has been. There is an impact of a cumulative onslaught of negative events, and it is hard to imagine not being phased, remaining unchanged, or not feeling affected. We may feel hardened and that there are limits to the compassion we have to offer others. We may be feel empathic. There can be desensitization and an apathy to others’ suffering when our patience is worn down and we have limited bandwidth. There are data to support the idea that a level of habituation occurs to individuals who experience multiple traumas, which yields a level of “sensitization” to the negative impact of subsequent events. It becomes easy to make comparisons of suffering. The challenge will be to rise above these and make a conscious effort to connect with who and how we were before we were worn down.
I am still in awe about how much I learned from the victims’ families, survivors, and my colleagues at Surfside – about pain, suffering, loss, resilience, coping, fortitude, and meaning making. We were all forced to think beyond ourselves, show up for others, and unify in a way that remedied this period of fragmentation. With respect to the pandemic and “where we are at now,” some elements of our lives are stabilizing; other aspects feel volatile from the fatigue of what we have been experiencing. This pandemic has not fully abated, but we can find some clarity in the value of setting boundaries and knowing our limits – but not overlooking the power of unity and kindness and the value of the reciprocating those qualities.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of the Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures.
While 2022 is lurking around the corner, many of us still have 2020 on our minds. Social media posts are already emerging: “No new years resolutions. It is the circumstances turn to improve [sic],” one post declares. Others proclaim that it is difficult coming to terms with the idea that 2022 is actually pronounced “2020 too.” A critical difference exists between then and now – we have experienced months of living in limbo and rolling with the punches of pandemic life.
In some ways, it has become easy to think of the early pandemic days as a distant memory, yet respect that the impact of 2020 has been indelible for virtually all of us and feels palpable as if it were yesterday.
The year 2020 was marked by the beginning of the COVID-19 pandemic, which was accompanied by extreme uncertainty, loss of all kinds, and emotional turmoil. The early pandemic had a profound economic and social impact, with added stress tethered to political and race-related division in America that created divides among families and friends, and yielded ceaseless discourse related to divergent perspectives. This only exacerbated the stress that came with the pandemic, given that providing support and leaning on one another was more important than ever. All of this was compounded by natural disasters that have plagued the country.
So much was unprecedented. There was a collective sense of feeling “worn down,” and the burnout that was felt was quite profound. Enormous amounts of mental and physical effort were allocated to simply surviving, getting basic needs met, having enough food and supplies, and completing basic tasks. Ordinary relating felt taxing. At this stage of the pandemic, the COVID-19 experience can be conceived of as a traumatic stressor capable of eliciting a traumatic response and exacerbating other mental health symptoms. Our capacity to cope has been diminished. Anxiety rates have soared, as have rates of clinical depression. Those most affected have had lower household incomes, are unmarried, and have experienced pandemic-related stressors. The links between the impact of the pandemic on mental health have been clear.
The pandemic has forced the landscape of social support to dramatically change. Initially, we felt pulled to connect and we leaned into the use of virtual platforms to connect for all matters (simple social gatherings, big birthday events, family reunions, celebration of holidays, work duties, and academic work). However, “Zoom fatigue” began to set in, and our screen time was maxed out. There has been the added dynamic of frontline workers who did not have the option to work virtually or from home. This group largely has felt disconnected from others who didn’t understand the depth of their anxiety and loneliness of their experience. Health care workers have had to make challenging, life-and-death, patient-related decisions that called into question personal morals and ethics all while their own lives were at risk.
Fast-forward to the present, and support systems have either strengthened or worn down – which has yielded a unique dichotomy. Maintaining friendships has either felt of utmost importance given the impact of the disconnect and physical distance or has felt challenging given the mental energy expended from working and connecting virtually. Empathy burnout is also a real and important facet in the equation. We begin to ask the question: Are we checking in with others in the spirit of authentic relating, to cultivate real connection, or to check a box?
Impact of layered traumas
It is interesting to think about the pandemic’s traumatic impact being “superimposed” on top of the “ordinary traumas” experienced outside of the pandemic. We are essentially at the 2-year mark, in some ways have cultivated a sense of resilience and found ways to adapt, and in other ways at times feel right back where we were in early 2020. There were moments that felt hopeful, glimmers of normalcy, and setbacks that all ebbed and flowed – but even so, there have not been many “mental breaks,” only temporary and transient reprieves. Some got sick and died; some recovered; and others are still experiencing long-hauler syndrome and have lingering sequelae. Despite adaptation and resilience, one can’t help but wonder the impact of superimposed traumas on top of this collective trauma. Many of us have not even rebounded from the pandemic, and then are faced with loss, grief, challenges, illness, hard and big life decisions. We are challenged to answer the question: How do we endure in the face of this trauma inception?
It has been a challenging time for all, including those who are ordinarily happy-go-lucky, resilient, and see the glass half-full and are struggling with the idea of struggling. I am no “resilience expert” but gleaned much wisdom from responding to the Surfside, Fla., building collapse. This was a collective trauma that took place in the summer of 2021, and the wisdom of this event highlighted the value of collective healing and unification even in spite of the times. What happened in Surfside was a shock, and the loss was felt by those directly affected, the surrounding community, and those who were part of the disaster response efforts. All of those parties had been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and this community tragedy was yet another loss to disentangle on top of a period in U.S. history demarcated by a great lack of unity, divisiveness, anger, and hatred. The collapse highlighted the small size yet interconnectedness of the community and the power of connection and authentic relating. It was overwhelming in the moment but extremely heartening and beautiful to see the amount of willingness to drop everything and help. Despite feeling worn down from the pandemic, people drew upon their internal resources, natural goodness, and kindness “reserves” to provide support.
Responding to the collapse highlighted that resilience in the context of collective trauma requires flexibility, embracing uncertainty, cultivating unity, and paying attention to meeting basic needs/self-care. The role of kindness cannot be overemphasized. In the realm of reflecting on the notion of kindness, it is worth noting how much power there is to bearing witness to someone’s experience, especially when they are in pain. People often diminish the role or at the very least do not recognize the power of showing up for someone and just listening. Pandemic resilience, and coping with coalescing traumas, is likely composed of these same facets that were essential in the context of coping with the collapse.
It is not only the immediate impact of a trauma as much as the aftermath that needs to processed and worked through. In one sense, people feel that they should be adjusted to and accustomed to this new reality, and at the same time, one has to remember and reflect on how unnatural this experience has been. There is an impact of a cumulative onslaught of negative events, and it is hard to imagine not being phased, remaining unchanged, or not feeling affected. We may feel hardened and that there are limits to the compassion we have to offer others. We may be feel empathic. There can be desensitization and an apathy to others’ suffering when our patience is worn down and we have limited bandwidth. There are data to support the idea that a level of habituation occurs to individuals who experience multiple traumas, which yields a level of “sensitization” to the negative impact of subsequent events. It becomes easy to make comparisons of suffering. The challenge will be to rise above these and make a conscious effort to connect with who and how we were before we were worn down.
I am still in awe about how much I learned from the victims’ families, survivors, and my colleagues at Surfside – about pain, suffering, loss, resilience, coping, fortitude, and meaning making. We were all forced to think beyond ourselves, show up for others, and unify in a way that remedied this period of fragmentation. With respect to the pandemic and “where we are at now,” some elements of our lives are stabilizing; other aspects feel volatile from the fatigue of what we have been experiencing. This pandemic has not fully abated, but we can find some clarity in the value of setting boundaries and knowing our limits – but not overlooking the power of unity and kindness and the value of the reciprocating those qualities.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of the Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures.