Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for April, 2020

Mental Health During the COVID-19 Pandemic: Online Mental Health Care (Recorded 4/24/20) | Pri-Med

Posted by Dr. Vollmer on April 27, 2020

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

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Mental Health During Covid-19: Child Mental Health Crisis

Posted by Dr. Vollmer on April 24, 2020

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

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.

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Mental Health During the COVID-19 Pandemic: Coping with Death and Loss (Recorded 4/20/20) | Pri-Med

Posted by Dr. Vollmer on April 20, 2020

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

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COVID-19: Mentally Suffering: Before and During

Posted by Dr. Vollmer on April 18, 2020

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.

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Vollmer, Shirah | Pri-Med

Posted by Dr. Vollmer on April 15, 2020

Vollmer, Shirah | Pri-Med
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Mental Health During the COVID-19 Pandemic: A Mentally Healthy Media Diet (Recorded 4/10/20) | Pri-Med

Posted by Dr. Vollmer on April 14, 2020

Join psychiatrist Dr. Shirah Vollmer for her fourth episode on mental health during COVID-19. In this episode she will discuss strategies for media consumption during this anxious time. She will explain how media during a crisis can perpetuate anxiety and requires intentional consumption to maintain mental health.

Please note that any data, indications, and guidelines presented in this activity are current as of the recording on 04/05/2020 and they are subject to change as new information is published.
— Read on

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Tele-Psychiatry: Obtaining Mental Health Online

Posted by Dr. Vollmer on April 10, 2020

How can providers or patients access mental health in the time of Covid-19? Telemental health is behavioral health services provided through technology. It allows psychiatrists, therapists and other mental health professionals to reach their clients despite long distance, the client’s inability to come to the office, or more recently during a pandemic. The hope is that with greater access, there will be less barriers to mental health care. Having said that, there is still a nationwide shortage of psychiatrists, and so tele-mental health for psychiatry could still be in short supply.

Now, during the pandemic, tele-mental health is the option for mental health care, but as the pandemic recedes, tele-mental health, for some, will be a supplement to in-person treatment or it may replace in-person treatment. As with all aspects of the pandemic, we will need to wait and see which changes in our world will stick, which will revert to our old ways of doing things, and which will become a hybrid of both.

Let’s start with a little history. Although it seems like tele-mental health is a new concept, the timeline begins in 1959.

In 1959, the Nebraska Psychiatric Institute used videoconferencing to provide group therapy, long-term therapy, consultation-liaison psychiatry and medical student training. This goes back a long way but it was not mainstream at that point.

Tele-psychiatry was slow to be adopted because one of the major concerns is privacy. Even with privacy protections, there is still a large concern that the conversation can be hacked, and can be used for unwanted purposes. As such, there can be tension in the patient about what they can and cannot say. Privacy is the bedrock of mental health services, and as such, video-conferencing tools, even with protection, are still quite vulnerable to hacking, and so the patient and the provider must understand the risk of losing privacy and what that might mean to the trust in the dyad. In addition, there are significant limitations when it comes to aggressive patients. In an office setting, long-acting injectable and/or restraints can be used to treat aggression, and when the patient is at home, our only option is to call for emergency services, which are in short-supply in some areas of the country. Further, we are only just beginning to learn the appropriate scope of practice with tele-psychiatry and the limits with regards to both diagnosis and treatment.

In the past, all tele-psychiatry guidelines have strongly suggested that there also needs to be boots on the ground, and that means that there is an in-person available if the therapist/psychiatrist feels that the person is unstable and needs to be evaluated in person. This may not mean that the patient needs to go to urgent care or an emergency room, but only that online treatment may not be appropriate for all patients. With more limited resources, and the fear of going to a physician’s office, an urgent care or an emergency room, the options for “boots on the ground” are limited. In this case, the provider is encouraged to learn better assessment tools online. It may also be important to get consent to talk to loved ones who can help us evaluate what is going on with the patient. Online therapy may have to expand to family support therapy, with patient consent, as the family has eyeballs on the patient, whereas the therapist only sees the patient from the neck up.

The other major limitation to tele-psychiatry is that although there is a history of tele-psychiatry which precedes this pandemic, the studies are very limited as to what are the potential pitfalls. With the absence of studies, we can anticipate that the screen might disguise or cover up information that would have been apparent with an in-office visit. For example, if the patient does not shower for ten days, there is no way an online provider would suspect that, unless the patient confessed. Not being able to smell the patient is an example of how tele-psychiatry is not the same as in-person treatment. Future studies will illuminate other examples of the limitations, but for now, both patient and practitioner need to be mindful of the differences between in-person and on-line assessment and treatment.

Clinical experience tells us that switching a patient from the office to video therapy is fairly straight-forward. The challenge is in working with new patients. With new patients, a rapport must be developed and this is usually facilitated by sharing physical space together. In the absence of sharing physical space, the patient and the provider are left to a verbal interchange, which, when building a relationship online may seem superficial or mechanical. This is a bad outcome which providers need to learn how to avoid. Transmitting warmth and concern to a new patient is one of the challenges of online treatment. In other words, seeking online treatment is convenient, and necessary during this pandemic, but the downside might be retention. Will patients stay in treatment while doing online therapy? Does the ease to “connect” to a therapist make it also easy to disconnect? With time, we need to monitor the strength of the provider/patient relationship for those who started treatment online. Further, we need to develop new relationship building tools to apply to online treatment.

Perhaps these new tools come in the form of having patients text message between sessions, or having them share essays that they have written or songs they have written and/or sung during this period. Adding on exchanges outside of the therapy hour may be critical to developing deeper and hence more trusting relationships online.

In the past, all tele-psychiatry guidelines have strongly suggested that there also needs to be boots on the ground, and that means that there is an in-person available if the therapist/psychiatrist feels that the person is unstable and needs to be evaluated in person. This may not mean that the patient needs to go to urgent care or an emergency room, but only that online treatment may not be appropriate for all patients. With more limited resources, and the fear of going to a physician’s office, an urgent care or an emergency room, then once again, the online provider is encouraged to learn better online assessment tools. In this situation, it may also be important to get consent to talk to loved ones who can help us evaluate what is going on with the patient. Online therapy may have to expand to family support therapy, with consent, as the family has eyeballs on the patient, whereas the therapist only sees the patient from the neck up.

Having outlined some concerns, the advantages, especially in the days of COVID 19 are numerous. The accessibility is great, not only because all that is necessary is two computers capable of video chat, treatment can be done when the patient wants to take a break during their work-day, thereby minimizing the time taken away from their demanding job and also providing immediate on the job relief.

Since the major tool in a psychiatric visit is listening, tele-psychiatry lends itself to this modality since listening is intensified, given that other senses, such as smell and touch are out of the question. This forces both the patient and the provider to focus on a narrative, which is a key component to working through the stresses and strains trauma in general and this pandemic in particular. In other words, on the positive side, tele-psychiatry is an exciting option for those verbally-inclined individuals who are overwhelmed or internally disrupted in general, and/or specifically internally disrupted by this pandemic.

As a psychiatrist myself, I am living through an era of great transition in medical practice. This pandemic has forced us to rapidly shift our practices from office work to online evaluation and treatment. We had little time to prepare for this transition, and as such, we are learning as we go. We know we will make mistakes. We know we will make both diagnostic and therapeutic errors. We know that these errors can cause human suffering to our patients and their families. And yet, we have no choice. We must adapt to a new delivery method of care. We must be humble and learn new skills which suit our new technology. We must be mindful that although we have trained for many years, some of our old skills might not transfer over to our new demands. Knowing all of the above, and knowing that our patients need our services, however clumsy we may feel, we need to learn as we go, and be open and curious to how we are both succeeding and failing with online communication tools.

Psychiatry brings to medicine a deep humility. We must listen to our patients because only they know their experience. This pandemic must deepen our humility further, because patients want to be heard and we want to listen, but now we must rely on machines, with internet connections, which can be unreliable and thereby limit our understanding of the patient and their concerns.

In summary, tele-mental health is the major option today for obtaining behavioral health care during COVID-19. This is a new frontier for both providers and patients. With new frontiers brings a steep learning curve to providers, mandating that we stay curious and humble in the face of many unknowns. Patients are given easier access which might decrease stigma and increase demand, but might also decrease retention if a bond is not formed. History is yet to be written. I will be particularly curious about the history of psychiatry during COVID 19.


Learning Objectives:

1. The practitioner will learn the advantages and disadvantages of telepsychiatry

2. The practitioner will learn the concern about privacy and aggression with online mental health evaluation and treatment.

3. The practitioner will learn the ease of setting up online therapy, if there are enough providers available.

Summary: This podcast reviews how a referral to online psychiatry is not the same as a referral to in-person psychiatric assessment. There is a discussion of the potential advantages and disadvantages of mental health moving to an online platform.

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Coping with Death and Loss During COVID-19

Posted by Dr. Vollmer on April 7, 2020

Many providers are reckoning with losing their patients. As is often said, healthcare now resembles war-time efforts, and as such, post-traumatic stress disorder in health care workers can be anticipated.

Today, I am going to focus on how a healthcare provider can deal with the gravity of losing so many patients in such a short period of time. Although for some COVID-19 patients death is inevitable, healthcare workers often feel a tremendous sense of inadequacy when a patient dies. The rational part of their brain knows that this virus, for some unfortunate folks and their families, overwhelms lung capacity and there is very little to do, even with a ventilator. The feeling/emotional part of their brain feels that physicians are there to save people, and so each patient loss is a personal failure. Even though family members may be understanding, many physicians are vulnerable to large feelings of inadequacy in the midst of doing heroic, and life-threatening work. In other words, lay people see health care workers as heroes, and they are, but the health care worker might see themselves as horrible failures because the death rate at those reaching a hospital is higher than they have ever seen before. These feelings of inadequacy can cause mental health problems down the line. These mental health problems can take the form of PTSD, anxiety disorders, depression and/or substance abuse.

Let us first focus on the unique aspects of loss for the healthcare provider during Covid-19. First, most health care providers are not used to mass casualties. This is a new challenge which can be overwhelming and may require psychological unpacking for many years to come.

Second, because of the requirement for isolation, the healthcare provider does not get the opportunity to spend time with patients, or their families to learn about the human being they are treating. Likewise, the patient does not see a human face, but rather a masked, and gowned provider who does not look familiar. This emotionally distant relationship can make the loss more difficult to deal with.

Third, the healthcare provider carries the anxiety of contracting the disease, and transmitting the virus to loved ones, making the baseline anxiety higher than would otherwise be. Adding to this baseline anxiety is the anxiety that they are not doing their job well because patients are dying, however irrational that may be, can permeate the inner life of a health care provider.

Fourth, the health care provider is expected to be selfless at this time, and so many providers do not feel at liberty to express their needs and fears. A strong service-orientation, a lack of time, difficulties in acknowledging their own needs, stigma at being removed from their duties during a crisis may prevent staff from requesting support if they are experiencing grief and loss and a sense of inadequacy.

Knowing that health care workers on the front lines are vulnerable to these mental health problems, let us discuss managing stress and loss in the healthcare provider.

Both institutional supports and self-care strategies are important. In terms of institutional support, employers should be proactive in encouraging supportive care in an atmosphere free of stigma, coercion, and fear of negative consequences.

Self-care strategies include recognizing and embracing grief. Grief is about turning inward and recalibration, so there needs to be time to reflect, if not immediately then health care workers need to understand that a “grief” period may be in their future, and they need to be prepared for that. Moving through grief is a journey that requires time, energy and support from loved ones. Avoiding grief leads to psychopathology, and in particular, substance abuse. Narrating this journey to a loved one and/or a mental health professional is critical to the grief journey.

Research from the bereavement literature shows that the nature of the person’s attachments has an effect on their grief reactions. For many health care providers, the attachment is to their profession, where they feel powerful to help people, and losing this feeling of power can be quite disturbing. The pandemic forces health care professionals to confront the frailty of such attachments and the loss of an identity as a healer.

Further, health care professionals are grieving a living loss-one that keeps going and going. Each work day involves more loss so it can be overwhelming to talk about grief in the face of massive deaths, and yet talking is what is needed for healing. Healthcare providers often feel they have wordless suffering and yet, mental health providers online can help give words to what seems like wordless suffering.

Writing about the experience is another positive outlet to improve mental health. The task is to write about what you are losing and how you are trying to cope. Since most of healthcare workers have not experienced a pandemic before, writing is a way of sharing experiences, opening a conversation, allowing professionals to learn coping skills from one another. At the same time, although the experience is unique, the basics of mental health are the same. When we experience loss, either to our identity, or the loss of a loved one, or the loss of a patient, we must allow ourselves time to recover, time to grieve, time to express ourselves, time to feel loved and supported.

The journey of grief is a timeless journey. Like the virus, the timeline is unknown and so the healthcare provider must be patient with themselves. Each timeline is unique and unpredictable. Having said that, all loss stimulates previous losses and so the provider needs to be prepared not just for grieving over this pandemic and what it has meant to them, but also re-living past losses and what those have meant to them. It is as if the brain has a file cabinet, which this pandemic has now opened, in which all the files under the category of loss, have been revealed for current review. In general, the larger that file cabinet is, the longer the grief process will be. At the same time, the larger the file cabinet, the more the person knows that each loss, which may seem unbearable at the time, is survivable, and ultimately results in a deeper sense of humanity along with remembering the loving feelings associated with that loss. In other words, each loss generates more compassion, and that compassion serves the health care provider well for many years to come.

The action item is quite straight forward. Ongoing social support is critical to move on from grief, rather than get stuck in it. Phone calls, text messages, and video chat are all important ways to stay connected. The key is the word ONGOING. Our literature tells us that healthcare providers will need their loved ones to check in on them, long after the lockdown ends. For many healthcare providers, the stress, the sense of loss and grief will continue LONG after quarantine ends.

Returning to institutional support, there will be a need for increasing supervision, consultation and collegial support, long after this crisis ends. Healthcare workers should be given paid leave when this crisis ends so that they can take the time to re-integrate into their personal life. Warning signs are the usual warning signs for mental health issues which include, use of alcohol or prescription drugs, suddenly making big life changes, negatively assessing their work contributions, keeping too busy, viewing helping others as more important than self-care and not wanting to talk about work experiences with others.

Healthcare workers not only face enormous physical and emotional demands right now, they are also facing a unique human tragedy and watching this first-hand might create a major change in their world view. Loved ones and health care institutions should be prepared for that.

Loss is always hard, especially when there are so many at one time. In this essay I have focused on the healthcare professional who must cope with mass casualties along with the loss of a feeling of effectiveness. People who are not on the front lines cannot really understand what they are going through, but we can be curious and interested to hear them explain it to us. Mental health treatment should be sought out when social supports fail. We may never have lived through a pandemic before, the our old tools of active listening can still be very helpful.


Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., … & Watson, P. (2006). Psychological first
aid: Field operations guide. National Child Traumatic Stress Network and National Center for
PTSD. Retrieved from and

Gonzales, G. (2003). Deep survival. Who lives, who dies, and why. True stories of miraculous endurance and sudden death. W.W. Norton & Company. New York.

Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283-315.

Reissman, D. B., Watson, P. J., Klomp, R. W., Tanielian, T. L., & Prior, S. D. (2006). Pandemic influenza
preparedness: adaptive responses to an evolving challenge. Journal of Homeland Security and
Emergency Management, 3(2).

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Mental Health During the COVID-19 Pandemic: At Home Tools for Providers and Patients (Recorded 4/3/20) | Pri-Med

Posted by Dr. Vollmer on April 7, 2020

In this podcast, psychiatrist Dr. Shirah Vollmer will discuss at-home tools for managing mental health during COVID-19. She will discuss cognitive behavioral therapy, mindfulness strategies, and medication options. Clinicians can use these tools to help their own mental health as well as provide recommendations for their patients.
— Read on

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Mental Health During COVID-19 Pandemic: Mentally Healthy Media Diet

Posted by Dr. Vollmer on April 2, 2020

News media needs to sell news. News media sell news by stimulating the amygdala, meaning the broadcast/publishing companies work hard to create the feeling of shock and awe so that when your amygdala, or the fear part of your brain fires, you then feel compelled to watch more news to gain mastery, some sense of control over your amygdala which is now telling you the world is very scary and you are out of control. Knowing this, the individual needs to dose the news intake according to how much their amygdala can handle at any one time. In other words, like any other consumption, each individual has to find out the kind and the amount which suits their brain, which suits their ability to handle distressing and shocking news.

The action items are simple: Limit the amount of time you spend reading or watching things which cause you distress. Decide on a specific time to check in with the news.

There is a lot of misinformation around. Stay informed to trusted sources of information such as government and scientific websites. Limit social media engagement around the corona virus as the information there is often not scientifically verified.

Why is this a complicated subject? Fear is good to get people engaged with social distancing. Some amount of media consumption is vital to understanding why we need to accept a new normal and avoid physical gatherings. However, too much fear leads to paralysis and constriction such that anxiety is now inhibiting people from finding new activities and deepening relationships by using technology. The optimal amount of anxiety is that which focuses attention on the problem without resulting in a panic attack, somatization or lethargy.

Media consumption is also complicated because at its worst, mass hysteria ensues, resulting most clearly with the recent run on toilet paper. The old rules apply to explain this phenomena. People are afraid and feel out of control: the amygdala is firing rapidly. People try to quiet the amygdala by finding some sort of control, and if not control over the virus, then something they can control, even if it is unrelated, or marginally related to the virus. Some people get anxious that they could run out of toilet paper so they begin to hoard toilet paper to manage their anxiety, which manifests around toilet paper but it is actually around the virus. Others, go to the store and see there is no toilet paper, and since we are herd animals, we immediately think that we too have to stock up on toilet paper, even if we did not think that before we went to the market. Suddenly, there is not enough toilet paper and anxiety rises, again focused on toilet paper, but more deeply, and perhaps unconsciously about the virus. This phenomena is now called mass hysteria because the hysteria originated from the anxiety of others, and not from a source that needed to be feared.

Separating mass hysteria from the appropriate anxiety over a world-wide threat to life and to the economy is enormously difficult. What we do know is that a certain number of people will get sick, and very sadly, a percentage of those folks will pass away. Far more people will have long and deep economic hardship. Far more people still, will have anxiety that permeates their life for many years to come.

As the story of the pandemic is just unfolding, and there are so many uncertainties, there are also some certainties. It is certain that anxiety disorders will outnumber the amount of Corona virus cases throughout the world. As such, anxiety prevention is an important topic. Limiting media consumption to a few trusted sources of media, along with limiting the time of media consumption to one to two specific times of day, will go a long way to preventing an anxiety disorder.

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