Well, with lucky 21 coming, 2021, that is, I have decided to finally adopt electronic prescribing. This will be a huge convenience for myself and my patients. So, why have I waited this long? Simple. I am/was afraid of hacking. I felt comfortable knowing that only I could write my prescriptions. Now, I am at the mercy of electronics. So, why am I switching? Simple again. Pharmacies and patients expect electronic transfer and so I am accepting the times that we live in. I am now a member of this paperless world where I so hope that there will be no mishap from my side or from the side of the pharmacy. You guessed it though. I am not throwing away my paper scripts.
Aiming to spark a new conversation on psychodynamic ideas and their relevance to psychiatry today. All are welcome! Image: Miró’s Femme et Oiseau dans la Nuit, 1947
Tonight…is a zoom journal club…and I am very excited to be the discussant.
I will begin with this quote from Charles McNulty in the LA Times on 10/3/20…
“Narrative is humanity’s defense against the randomness of existence. We tell ourselves stories not to sink into chaos. Would-be authors of our time on Earth, we impose order onto our lives by drawing connections between events, underscoring thematic trends, fleshing out character psychology and shoehorning our years into plots with beginnings, middles and ends.”
How we form the narrative of our lives has a lot to do with our mental health and our mental well being.
To improve mental well-being free association helps us to understand how we verbally construct our lives and in so doing it helps us to see the pivotal points of our lives. Free association is used to help understand dreams, day-dreams, hallucination, delusions and enactments.
Associating means to link a thought or a feeling with another. This involves memory, both conscious and unconscious, as well as imagination and emotion. In other words words are the essential tool of mental treatment. Freud said “the magic of words can remove the symptoms of illness.”
Free association recreates a “drama” meaning there is character, conflict and crisis. Freud said that as we encourage patients to free associate, we learn that they are “unfree” in that the associations are determined by unconscious material.
The therapist simultaneously free associates or as Freud said “While I am listening to the patient, I too, give myself over the current of my unconscious thoughts.”
Freud famously directed patients to “say whatever goes through your mind. Act as though…you were a traveler sitting next to a window in a railway carriage and describing to someone inside the carriage the changing view which you see outside. “
Dr. Lothane states “The analytic listener visualizes the images evoked in him by the patient’s words, not unlike a reader of a novel visualizes in his thoughts the scenes described by the novelist…The analytic listener relives them vicariously.”
Words are nodal points of numerous ideas such that they represent condensation and disguise of underlying processes. Symptoms therefore are determined by how words are representing distress or as Breuer and Freud stated in 1895 words are “nodal points at which two or more threads meet and thereafter proceed as one…such that a symptom is determined in several ways is overdetermined.”
Free association is the beginning of a long-term search for the history of a lifetime. Starting from the initial fragments, a person’s biography unfolds in countless free associative and cognitive communications and “yielding a picture of the patient’s forgotten years.”
In summary, an analyst and patient are a team, working together to heal the patient’s suffering by re-examine the history of their live with free associations. And there is no end to telling stories about one’s life. As Dr. Lothane says “there is no end to history and interpretations of history.”
Delivering bad news is one of the most daunting task faced by health care professionals. During this COVID-19 crisis, this often involves patients they have known for only a few hours. Additionally, they are called upon to deliver the news with little planning or training.
Historically communication skills have not been a priority in medical education. This leaves clinician unprepared for the communication complexity and emotional intensity of breaking bad news. The fear clinicians have about delivering bad news include being blamed, evoking a reaction, expressing emotion, not knowing all the answers, fear of the unknown and untaught, and personal fear of illness and death. This can lead to the clinician becoming emotionally disengaged from their patients. Additionally, bad news delivered inadequately or insensitively can impair patients’ and relatives’ long-term adjustment to the consequences of that news.
Some surveys done have shown that 85% of. both residents and attendings felt that they needed additional training to be effective when delivering bad news. Experience does help with skill-building, but learning good communication skills is always valuable, and during COVID 19, those skills are now critically important.
Given the negative consequences of delivering bad news poorly for both patient and clinician, clinician training in delivering bath news is sorely needed. The best training will include the patient’s family. When the clinician involves the patient’s family, the patient perceives the clinician to be emotional, available, expressive of hope and not dominant.
Ideally, the clinician takes into account the cultural, spiritual and religious beliefs and practices of the family. The clinician must check for understanding. This is in contrast to the clinician expressing sadness, which can hinder information exchange.
As a resource, there is a 1992 book by Rob Buckman, entitled “How to Break Bad News: A Guide for Health Care Professionals.” He suggests finding out how much the patient knows, sharing information, and assuring that the message is understood.
Further, the Irish Hospice Foundation has put together a YouTube to help clinicians deliver bad news.
In this, they describe five important steps.
1. Prepare yourself
2. Make a connection
3. Warn, then deliver the news
4. Acknowledge the impact
5. Make a plan
They also remind the clinician that there is body language, tone of voice, and word choice. All of these are important in talking to patients. COVID-19 adds the additional hardship that the clinician is masked and gowned and therefore not “seen.” However, some hospitals are creating name tags for clinicians with their photos to help the patients feel more comfortable. I think this was a wonderfully soulful intervention during this most traumatic time. Further, the PPE makes it more imperative that the clinician focus on tone of voice and word choice when giving bad news.
As with all difficult situations, the clinician must be open to a variety of responses including denial, anger, sadness, and fear for themselves and their other loved ones. The clinician must learn how to name the dominant feeling that they experience after the bad news has been conveyed. For example, the clinician could say to the patient or their family member, “I am sensing this difficult news is bringing up very angry feelings for you, which is understandable. You are likely to go through a lot of different feelings and I, and my staff, are here to help you with those feelings, as we recognize this is a very difficult time for you and for your loved ones.” The goal here is not to get defensive. Although it may seem, for example, that the patient is angry with the staff, it is more likely that they are angry over the helplessness of the situation, and understanding that helpless feelings can sometimes lead to angry feelings, will help the clinician not get defensive, and remain empathic.
Other factors to consider when delivering bad news include the physical and social setting of the message. Although hospitals may be crowded, it is important to provide a space which is quiet, comfortable, and private. It is also important that there will be no interruptions and that the clinician has set aside protected time to discuss the bad news. Even if this protected time is only 10 minutes, that is far superior than being interrupted while giving bad news.
Finally, delivering bad news requires that the clinician do self-care as a way to acknowledge the wear and tear on the clinician in giving bad news. First, the clinician must recognize that each time the clinician gives bad news, there is increased vulnerability in the clinician. This increased vulnerability may require a break from medical practice, be it ten to twenty minutes for deep breathing or meditation. If this break, still leaves the clinician feeling vulnerable, then the clinician should seek the help of a colleague to de-brief on the situation. Finally, if the clinician still feels out of sorts, or internally disrupted, then the clinician should seek out mental health care. As discussed in a previous podcast, this mental health care should be done by a specialist in COVID-19, as treating clinicians during COVID 19 is a specialty and requires extra training.
To recap, delivering bad news is a skill set which is both cognitively and emotionally demanding. Historically, this has not been a major part of health care training. Going forward, there should be training by communication specialists/mental health providers to help clinicians develop this skill set. Being prepared for a variety of affective responses is important in not becoming defensive after giving bad news. Further, after giving bad news, there should be an immediate opportunity for self-care which includes deep breathing, meditation, talking with a colleague and considering mental health intervention.
References
1. Orlander JD, Fincke BG, Hermanns D, Johnson GA. Medical residents’ first clearly remembered experiences of giving bad news. J Gen Intern Med. 2002;17(11):825–831. [PMC free article] [PubMed] [Google Scholar]
2. Buckman R. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed) 1984;288(6430):1597–1599. [PMC free article] [PubMed] [Google Scholar]
3. VandeKieft GK. Breaking bad news. Am Fam Physician. 2001;64(12):1975–1978. [PubMed] [Google Scholar]
4. Fallowfield L. Giving sad and bad news. Lancet. 1993;341(8843):476–478. [PubMed] [Google Scholar]
5. Fine RL. Keeping the patient at the center of patient- and family-centered care. J Pain Symptom Manage. 2010;40(4):621–625. [PubMed] [Google Scholar]
6. Schmid Mast M, Kindlimann A, Langewitz W. Recipients’ perspective on breaking bad news: how you put it really makes a difference. Patient Educ Couns. 2005;58(3):244–251. [PubMed] [Google Scholar]
7. Fine RL. Personal choices—communication among physicians and patients when confronting critical illness. Tex Med. 1991;87(9):76–82. [PubMed] [Google Scholar]
8. Cunningham CC, Morgan PA, McGucken RB. Down’s syndrome: is dissatisfaction with disclosure of diagnosis inevitable? Dev Med Child Neurol. 1984;26(1):33–39. [PubMed] [Google Scholar]
9. Buckman R. Communication skills in palliative care: a practical guide. Neurol Clin. 2001;19(4):989–1004. [PubMed] [Google Scholar]
10. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. [PubMed] [Google Scholar]
11. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press; 1992. [Google Scholar]
12. Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. West J Med. 1999;171(4):260–263. [PMC free article] [PubMed] [Google Scholar]
13. Ptacek JT, Fries EA, Eberhardt TL, Ptacek JJ. Breaking bad news to patients: physicians’ perceptions of the process. Support Care Cancer. 1999;7(3):113–120. [PubMed] [Google Scholar]
Every year an estimated 400 US physicians take their lives (Andrew and Brenner 2015). Global studies indicate that approximately 1 in 3 physicians is experiencing burnout at any given time (Shanafelt et al 2009). This was true before the pandemic. Now, it is too soon to know the statistics, but we have all heard about Dr. Lona Breen who was the medical director of the emergency department at New York Presbyterian Allen Hospital who succumbed to self-inflicted injuries. Although we will never know the details of her mental health journey throughout her years, it seems clear that seeing the devastation of COVID-19 was a contributing factor to her suicide.
Many students, trainees, doctors and health care organizations fail to recognize, report, discuss or pursue treatment for mental distress. Healthcare workers may have too much shame to report mental distress and this is reinforced by health care organizations which demand so much from workers without acknowledging the mental toll.
The stigma of self-reporting depression seems to be magnified amongst medical professionals. Further, their greater knowledge and better access to lethal means, causes health care professionals to have a higher suicide completion rate than the general population. The most common psychiatric diagnoses among medical professionals who complete suicide are affective disorders, alcoholism and substance abuse. The most common means of suicide by health care professionals are lethal medication overdoses and firearms.
When medical professionals feel depressed and they feel less than adequate, the find it even more difficult-and when they can bring themselves to ask, the sometimes find that the help they need is remarkably difficult to obtain. Access to mental health care is a struggle for everyone, including health care professionals. It is hard to find care which meets their economic requirements, their time requirements and care that feels like a good clinician/patient match.
At the same time, some of the reluctance to receive care is self-imposed. Some health care professionals feel an obligation to appear health, perhaps as evidence of their ability to heal others. The myth of invulnerability is hard to penetrate and so it is a deep challenge to question the health care professional when they continue to state that they are “fine” even though they may not appear to be “fine”.
Unconsciously defending against this painful vulnerability, partners or significant others may also fail to notice significant depression or withdrawal, attributing behavioral changes instead to stress or overwork.
Health care professionals as a group like to be in control so situations that decrease the ability to control the environment, the workplace or employment conditions predictably play a higher role in suicide than in populations which are not used to being in control. Before COVID-19, the massive changes that have taken place in medicine in the past several decades leading to increased workloads and regulatory requirements coupled with decreased ability to control income and patient safety and liability concerns also predictably lead to higher levels of stress, job dissatisfaction, burnout and depression in physicians.
There can be fear of treatment from another professional includes fear of loss of privacy, so using insurance to pay for treatment, can feel like an insurmountable barrier as there is fear that insurance companies can be hacked. This is especially likely when the health care professional believes that the consequences of seeking treatment may subject them to stigma, shame or job-loss. As a result, health care professionals can and do prescribe to themselves and this is a huge mistake. Failure to obtain consultation and treatment for depression needlessly and significantly increases the risk of physician suicide.
David Rothenberg MD, University of Minnesota Department of Surgery states that he relives painful moments over his long career being a physician. “I suddenly am recalling a time in February of my internship year when I was so tired, so down, so discouraged that I thought I could not possibly go on. I thought I would have to give up my dream to be a doctor.” He continues “I have lived in denial of the dark side of the medical profession and its unwritten code-the code that says medical students should keep their mouths shut; that residents can be blamed since that is how they will learn; that repeatedly being pushed to the brink of exhaustion is a necessary part of being a caring physician; and that if a few drop out along the way, it is because they were weak and somehow deficient. “He then asks “do we have the courage and will to break through the culture of silence, end institutional cover-up and commit to finding effective ways for the healing profession to care for ourselves as well as our patients?”
Angela Mathew RN, MBA, wife of a physician also speaks openly about the stresses and strains of healthcare. “I wonder about the physicians I work with and who they have to speak with after a challenging case, how they are working through the stressors of the health care culture and environment every day, and whether they bring their souls to work with them each day.
These testimonial were done before COVID-19. Now, we have testimonials from people like Dr. Lawrence Melniker, the vice chair for quality care at the the New York Presbyterian Brooklyn Methodist Hospital who said that the “corona virus presents unusual mental health challenges.” Further, he says “ doctors are accustomed to responding to all sorts of grisly tragedies, but rarely do they have to worry about getting sick themselves, or about infecting their colleagues, friends and family members. And rarely do they have to treat their own co-workers.
At the same time, other health care workers are having different kinds of struggles. They are having to lay staff off. They are worried about making payroll to their remaining staff, paying their rent, and keeping the lights on. To their physician colleagues on the front lines, it may seem trivial to worry about the economics of running a practice, but as with the virus, the downstream effects can be both severe health consequences and severe economic consequences. It is hard to be sensitive to both groups at the same time, but both groups do need compassion and understanding.
What are the action items? How can we translate our understanding of healthcare worker stress to helpful ways in which we can support our colleagues, friends and family? We call them heroes. I think that helps a little, but that also creates greater difficulty for them to admit that they need psychological assistance. The word heroes idealizes them such that the word could impede their ability to ask for help. Perhaps we need to change our language. Perhaps we need to say that healthcare workers should have limited hours, like trainees, and pilots, as a way of understanding that too many hours may be too hard on their mental well being. Perhaps we should give them hazard pay, as a way of saying we understand this is hard, and by paying them more, we are giving them permission to work less, and take more time to themselves.
We can train mental health professionals how to support healthcare workers. I think that to ask for mental health workers to volunteer to help health care professionals misses the point. We need to have mental health professionals train other mental health professionals to help health care professionals during this time. For example, we need to train therapists about how to talk about the complexity of fear going on now. The fear of one’s health, the health of their loved ones, the health of their co-workers, the health of their patients, and the fear of the economic demands stemming from this crisis. We need to train mental health professionals about how to listen to a healthcare professional without becoming more anxious. The mental health care professional needs to learn how to listen and manage their own anxiety at the same time. This skill of listening without becoming overly anxious needs to be trained through discussions, readings and role-playing. In other words, treating this population, the healthcare workers, is a specialty, and as such, special training is mandatory.
The third action item is helping the loved ones of medical professionals. Their stress is also overwhelming. To support a medical professional may mean assuming all domestic responsibilities including home schooling the children, and taking care of geriatric relatives. In addition, offering support to the medical professional is challenging since the support person also needs a lot of support, which the medical professional may not have enough bandwidth to supply. Once again, mental health professionals should receive special training to help the loved ones of medical professionals and once again, this special training should include our old-school tools of readings, case discussions and role-playing.
Finally, there are resources available that we should have handy. There is the National Suicide Prevention Lifeline at 1-800-273-8255. There is SpeakingOfSuicide.com/resources for a list of additional resources.
Council on Scientific Affairs. 1987. Results and implications of the AMA-APA physician mortality project: Stage ii. Journal of the American Medical Association 257(21):2949–2953.
Shanafelt, T. D., C. M. Balch, G. J. Bechamps, T. Russell, L. Dyrbye, D. Satele, P. Collicott, P. J. Novotny, J. Sloan, and J. A. Freischlag. 2009. Burnout and career satisfaction among American surgeons. Annals of Surgery 250(3):463–471.
In this podcast, psychiatrist Dr. Shirah Vollmer will explore the unique aspects of referring patients to online psychiatry. She will weigh the potential advantages and disadvantages of mental health care moving to an online platform and discuss techniques for providing online mental health care.
Please note that any data, indications, and guidelines presented in this activity are current as of the recording on 04/27/2020 and they are subject to change as new information is published.
— Read on www.pri-med.com/online-education/podcast/covid-19-mental-health-6
What about the children? How are they doing during COVID 19? What are the issues? What are the action items?
Some children are and will continue to suffer as a result of Covid-19. Let’s talk about three ways in which children might be suffering, and let’s talk about how we can develop a greater sensitivity to children who are living through this pandemic.
1. There is very likely to be an increase in child abuse, including verbal, physical and sexual abuse. The increase in child abuse is likely to be a result of greater family stress, more time together, and economic uncertainties. Parents have become de facto home school teachers, with little preparation or training to educate their children. In addition, some parents are trying to maintain full time jobs while home-schooling their children. Other parents are laid off from work, and are looking for a new job, and they are home-schooling their children. Babysitters, tutors, housekeepers are all not allowed in quarantine, so the family tension has increased significantly, which can lead to poor impulse control in both the parents and the children. Online education is limited by how much time a child can spend in front of a computer screen, and the younger the child, and the more immature the child’s nervous system, the more it is unlikely that the child can have sustained attention for online learning, thereby adding even more stress to unprepared parents.
In addition, in the absence of children physically attending school, there is less of an opportunity for teachers or school counselors to report abuse to social services. For children in loving families, this can be a special and precious time together, which will cause loving and long-lasting memories. For children in previously abusive families, this can cause unmitigated abuse, without the presence of previous safety nets. For most children, it will be a combination of loving times, alternating with unloving, and impatient times, alternating again with mean/abusive times. Although in ordinary times, all of the above is true, what is unique about COVID-19 is that a child’s life is deeply compressed because there is no physical school, there are no after-school activities outside the house, and there are no trips to friends houses or to grandparents houses.
The family unit is a closed unit, and so we, as healthcare professionals need to be prepared to advocate for these children who are in environments which are harmful to their emotional growth and development. We cannot assume that each parent is coping “as best as they can” because “as best as they can” may be causing long-lasting damage to the innocent child who literally has no where to escape to.
Suggested action item: Each clinician, including pediatrics, family medicine and obstetrician/gynecologists need to be mindful about how the children are coping during this pandemic. Pediatric clinicians should ask every parent, and every child (without the parent present) about how they are doing during this time. More specifically, the pediatrician needs to take private time with the child, ages 4 and up, and ask directly, if their parents are ever mean to them, or if their parents beat them up, or if there is any inappropriate touching. I know these are delicate questions, and they may not be needed for every child, but at the very least, each pediatric clinician needs to be ready to ask these questions, if the child suggests there may be abuse at home or if there is known prior abuse. A positive response may prompt a report to children’s services, but if the response is vague, it could prompt a referral to a child mental health professional for further investigation.
Pediatric clinicians need to embrace mental health assessments as part of their job, as there are fewer eyeballs on our children, and so clinicians need to step up during this time.
Family medicine clinicians must also check in with the children, but since the parents may also be their patients, they should also check in with each parent, specifically about how their parenting is going, and asking directly, if the parent feels they are maintaining or losing control with their children? Allow the parent to ask for help for their parenting, and have resources on the ready, for parents who are feeling at loose ends. An example of a good resource, is one put out by NYU https://nyulangone.org/news/schools-out-parents-guide-meeting-challenge-during-covid-19-pandemic.
Obstetricians/Gynecologists should inquire about new mothers, specifically inquiring about how the attachment is going, as stressed mothers may have trouble bonding with their newborns.
2. Children with special needs, particularly less verbal children, might propose a huge challenge during this period. Special needs children often have multiple specialists who help them, but during this time, not all specialists can help these children with online work. Special needs children may not have the motivation or the attention span to stay in front of a computer screen, and so vital learning may not be taking place. There is no easy answer to this problem, as parents are not usually special education teachers, and so these children might simply miss out on important parts of their education during this time. However, as time progresses, it is possible that some special education teachers can be considered essential services, and as such, learning can resume with the proper protective equipment.
3. Each child has an emotional growth curve which is dependent on their peers for social learning. The age of the child will determine the needs of that child, but as a general principle, the isolation of these children from in-person play is going to hamper their emotional development. The degree to which this will harm a child is individualized, and as children are resilient, most children will bounce back as social isolation recedes. Having said that, as clinicians, it is our job to watch out for those few children that have trouble bouncing back. Some children will develop anxiety disorders, and in particular, social anxiety disorder, in which being with people is a source of enormous stress. Although in the context of the virus, that makes sense now, if social anxiety persists long after the virus threat is gone, then clinicians must identify and treat this as we would any other form of social anxiety disorder.
In summary, we, society, we, primary care clinicians, must think about our children. The children we see, the children of our patients, our own children, and our friends’ children. It is easy to lapse into cliche that “children are resilient” but we must avoid this lapse, because it is our job as stewards of health care to make sure children grow and develop in the best possible way. The kids may not be all right.
In this podcast, psychiatrist Dr. Shirah Vollmer will discuss how those on the front lines can approach the challenges of dealing with death and loss. She will identify coping-skills and practices that healthcare professionals can use to deal with grief and process the emotional burden of their work.
Please note that any data, indications, and guidelines presented in this activity are current as of the recording on 04/20/2020 and they are subject to change as new information is published.
— Read on www.pri-med.com/online-education/podcast/covid-19-mental-health-5
Let’s talk about symptoms. Symptoms are a sign of the existence of something, especially of an undesirable situation. Examples of symptoms include not eating well, not sleeping well, apathy, and ruminative thinking. When mental symptoms cluster and persist, then psychiatrists sometimes suggest that a particular cluster of symptoms warrant a diagnosis of, for example, major depression, anxiety disorder, or obsessive compulsive disorder.
Symptoms are subjective. They are told to us by our patients. Mental health providers try to alleviate symptoms both pharmacologically, with our tool box from psychopharmacology and with our psychotherapeutic tool box which includes cognitive-behavioral therapy and insight oriented psychotherapy.
When symptoms are relieved, then the patient has more energy and more vitality. Generally speaking, the patient with manageable symptoms can engage with the world in a deeper and more meaningful way, through engaging in relationships and/or creative projects. There can be a fluidity to symptoms meaning that they come and go, depending on the general stressors of life, including health, economics, and family dynamics. Bouncing through these stressors challenges coping skills, and so patients learn to deal with unforeseen events to minimize symptom formation.
COVID-19 introduces multiple stressors at once, making it almost inevitable that prior symptoms will re-emerge and/or worsen. Coping skills are useful, but may be overwhelmed, making them only partially effective in symptom management.
Let’s first talk about the stressors which COVID-19 brings to our functioning status. First, there is the threat of disease, a potentially fatal disease. Life could be over in a short period of time. For a young, relatively healthy person, how do they face this new reality? Second, there is the threat of being a vector, transmitting this disease to one or more loved ones. For a person, who in general feels guilty for both conscious and unconscious reasons, this idea of being a vector, may simply be intolerable. Third, for many, there is the economic stress of no work and no opportunity to work, along with the uncertainty as to if/when work will return. This economic stress can lead to further guilt of not providing for a family, and thereby causing further feelings of guilt about causing harm to innocent others. Fifth, there is the social distancing, which for many means they cannot draw on the support of their children, their grandchildren, or their community. Yes, technology aids with helping folks feel connected to loved ones, but for some, not being able to hold their grandchild, for example, is a particularly painful reality which no technology can make better. The absence of touch in general, is another source of stress, which is poorly studied, but intuitively we know that touch is vital for a sense of well-being.
Now, let’s talk about how those with mental suffering, those with mental symptoms of distress before COVID-19 might be dealing with the pandemic. Essentially, prior symptoms are likely to worsen. For example, a person with obsessive compulsive disorder, who washes their hands frequently, could increase this compulsive behavior to the point where they cannot engage in any other activity, including not being able to sleep. Another example, a person with an eating disorder who is restricting eating in order to gain control over their life, will increase the restriction since life feels more out of control than it did before. A third example, a person with depression, who has fought a deep sense of apathy, might feel even more apathetic in the face of a safer at home mandate.
In other words, although COVID-19 might create new symptoms, the more likely outcome is that folks will experience an exacerbation of their pre-Covid-19 symptoms.
What does this mean for the primary care professional or for a loved one who is concerned for another? This means that general questions, such as “how are you doing in this pandemic” are ok, but might lead to a superficial/socially acceptable response. In that case, the follow-up question, needs to be, “I know in the past you have struggled with obsessive thinking, how is that going for you now?” This questions suggests deep understanding that Covid-19, although stressful for all of us, is going to hit each individual differently, and more specifically, it will hit each person in their vulnerable area, which means their area where they have exhibited symptoms previously.
If I could make a wish today, my wish would be for all primary care professionals to initiate contact with each patient to ask them how they are coping, and more specifically, to ask based on the history with the patient, knowing how they have previously coped with stress. If that wish was too grandiose, then my second wish is for all primary care professionals to initiate contact with each patient that they have ever prescribed a psychotropic drug, including anxiety medication, and sleep medication, and reach out to those patients inquiring about how they are coping during this time. In other words, do not wait for the patient to reach out to you. The initiating of contact would by itself be enormously therapeutic. The understanding of how they have coped in the past, and reminding them that you are concerned that their previous symptoms may now be worse, is also therapeutic. My third wish, given the constraints of time, is that for patients who reach out to primary care for mental health assistance, then there is a deep understanding that symptoms are likely to be prominent, and that understanding symptoms is the first step to take, before initiating symptoms management tools.
Let me conclude by reminding all the symptoms of distress that we need to look out for in our patients and our loved ones, with the reminder, that these symptoms were likely there before Covid-19, and now, might be much worse.
Feelings of numbness, disbelief, anxiety or fear.
Changes in appetite, energy, and activity levels.
Difficulty concentrating.
Difficulty sleeping or nightmares and upsetting thoughts and images.
Physical reactions, such as headaches, body pains, stomach problems, and skin rashes.
Worsening of chronic health problems.
Anger or short-temper.
Increased use of alcohol, tobacco, or other drugs.
Once these symptoms are identified, then please refer to podcast 6, about referring for online mental heath care. The take-away point for today is that mental health symptoms during Covid 19 are most likely previous symptoms that were previously well-managed but are now sprouting again. Covid 19 is an unprecedented experience in our lifetime, and yet, old-school principles of helping others with mental suffering still apply. That is, understanding symptoms in context, both past and present, is the key to a good provider/patient relationship, and thereby to alleviating suffering.
Shirah Vollmer MD 