Shirah Vollmer MD

The Musings of Dr. Vollmer

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.

References

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.

References:

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 http://www.nctsn.org and http://www.ptsd.va.gov


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 www.pri-med.com/online-education/podcast/covid-19-mental-health-3

Posted in Musings | 2 Comments »

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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Mental Health During the COVID-19 Pandemic: Healthcare Provider Mental Health and Self-Care (Recorded 3/31/20) | Pri-Med

Posted by Dr. Vollmer on April 2, 2020

In this podcast, Dr. Shirah Vollmer will discuss the mental health challenges that healthcare providers are facing during the COVID-19 epidemic. Clinicians are suffering unexpected stress, and they have had to weigh their personal safety against important work in a dangerous environment. She will provide clear action items for dealing with these difficult decisions and practicing self care.
— Read on www.pri-med.com/online-education/Podcast/covid-19-mental-health-2

Posted in Musings | 6 Comments »

Mental Health During the COVID-19 Pandemic: Social Distancing vs. Social Isolation (Recorded 3/30/20) | Pri-Med

Posted by Dr. Vollmer on April 1, 2020

In this podcast psychiatrist Dr. Shirah Vollmer will discuss the difference between social distancing and social isolation. Dr. Vollmer will provide practical tips for maintaining healthy relationships and maintaining mental health during this unique time when we are physically separated from others.
— Read on www.pri-med.com/online-education/podcast/covid-19-mental-health

Posted in Musings | 4 Comments »

At Home Tools for Mental Health: Cognitive Behavioral Therapy, Mindfulness and Medications.

Posted by Dr. Vollmer on March 31, 2020

Today’s topic is about things you can do from home that will promote mental health.

We have all lost control over our lives. We can no longer gather in person, and we are all forced to have new routines which give us meaning and fulfillment. For many people losing control is the beginning of a downward spiral of mental health issues which include anxiety, depression, and somatization. Feeling helpless can lead to a persistent feeling of lethargy which manifests into a very constricted life with little joy.

Point number one: Even though this is a hard time for everyone, it is still mandatory to feel happiness, joy and fulfillment. If you are not feeling these feelings most of the time, then you need tools to put those feelings back into your life.

Point number two: Telehealth is here which is ideal for mental health issues, as the primary mode of communication needs to be a narrative. Patients should feel free to reach out to their provider online to discuss how they are feeling and how they are coping during this challenging time.

Point number three: Given that anxiety is the most common feeling during this uncertain time, and given that when anxiety persists, depression often follows it is imperative to attend to your anxiety until it resolves.

Point number four: Self-directed cognitive behavioral therapy is a very useful tool for anxiety. Many studies have shown that self-directed CBT can be very effective. In particular, self-directed CBT-i for insomnia has good scientific evidence. https://doi.org/10.1186/1471-244X-12-5. Further, two reviews that each included over 30 studies found that self-help treatment significantly reduced both anxiety and depression, especially when the treatments used CBT techniques. The average amount of benefit were in the moderate range, meaning people did not feel 100% better but were noticeably less anxious and depressed. https://doi.org/10.1016/j.beth.2005.05.002 and Psychol Med. 2007 Sep;37(9):1217-28. Epub 2007 Feb 19.

Please note that self-directed CBT is most appropriate for someone with mild to moderate symptoms who is generally able to function well. A person who is severely depressed and barely able to get out of bed is probably not a good match and will likely need online psychotherapy.

Point number five: There are many books which can be used at home. The Association for Behavioral and Cognitive Therapies maintains a list of books which they endorse. http://www.abct.org/SHBooks/. My personal favorite is “Retrain Your Brain: Cognitive Behavioral Therapy in 7 Weeks” by Seth Gillihan PhD. The workbook presents tools from CBT in a user-friendly way. The cognitive techniques include..

A. Identifying your thought patterns

B. Discovering how your thoughts affect your feelings and behaviors.

The behavioral techniques include..

A. Scheduling activities that bring you enjoyment and a sense of accomplishment

B. Recognizing how your actions influence your thoughts and emotions.

When doing in-home therapy for anxiety or depression, the key issue is to set aside time, as you would if you were to go to psychotherapy. Create a space which is quiet and solitary. Create a time which is rigidly adhered to. Creating space and time for self directed CBT will reinforce your self-esteem because you are devoting yourself to self-care. In other words, you are making yourself a priority and that is a good first step to feeling better about yourself and those around you.

In this time of high-anxiety and limited access to health care, especially mental health care, self-directed CBT has many advantages. Devoting yourself to CBT can lower your anxiety, improve your mood and provide you with life-skills which will give you resilience to both our current challenging situation as well as future challenges.

Part 2: Mindfulness

Mindfulness is also an evidence-based treatment for anxiety and depression. https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=29080597

Mindfulness is the process of observing what is in your mental interior without using judgment. Applications such as Headspace are tools you can use at home to help with experiencing and accepting the current moment. There is scientific evidence to support mindfulness.
Blanck P, Perleth S, Heidenreich T. Kroeger P, Ditzen B, Bents H, Mander J. (2018). “Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic review and meta-analysis”. Behaviour Research and Therapy. 102: 25–35. doi:10.1007/s12671-014-0379-y.

Studies also indicate that rumination and worry contribute to the onset of a variety of mental disorders, and that mindfulness-based interventions significantly reduce both rumination and worry. Further, the practice of mindfulness may be a preventative strategy to halt the development of mental health problems. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220915

Mindfulness can be seen as a strategy that stands in contrast to a strategy of avoidance of emotion on the one hand and to the strategy of emotional over-engagement on the other hand. Mindfulness can also be viewed as a means to develop self-knowledge and wisdom.

This current era of uncertainty and fear is a great time to begin a mindfulness practice. Crisis presents new opportunities, and so this current crisis allows us time and space to look inwards. Mindfulness is a good tool to use for inward reflection.

People who incorporate mindfulness into their lives often report heightened levels of happiness, patience, acceptance, and compassion, as well as lower levels of stress, frustration and sadness.

Practice mindfulness meditation can be a great way to cope with today’s landscape. Using an application such as Headspace gives you education about how the mind behaves during meditation, leads you through a particular meditation technique, and suggests how to integrate this technique into your everyday life. The major goals of these techniques is to create calmness and clarity of thought.

Let’s move on to part 3 of this discussion about home tools for mental health.

If your depression or anxiety is inhibiting you from functioning, and by that I mean you are not taking care of your responsibility as a parent, a friend, an employee, or a spouse, then along with self-directed CBT, and mindfulness, I would suggest you seek an online consultation for medication.

To begin, if you are experiencing uncontrollable palpitations associated with anxiety, then consult your clinician about Propranolol. Those folks with asthma may not be candidates, but in general, this is a very useful medication to help with the peripheral symptoms of anxiety. This can be taken as needed or multiple times a day, depending on the severity of anxiety.

Second, if you are feeling listless, apathetic, with very little motivation to start or complete projects, and/or to initiate contact with friends or family, then consider asking your doctor about Prozac. Yes, this is old school at this point, but you might be thinking that your behavior is consistent with the current state of the world, but that would be a false assumption. Even in this uncertain time, you should have energy and excitement for new experiences and deepening relationships. If you do not have that enthusiasm then there is something wrong and you need to attend to your feelings so that there is a shift in your mental state. Medications are appropriate to consider in that they can jump-start you into a more energetic position and thereby enable you to connect with pleasurable activities. Prozac, in particular, can be helpful because it tends to activate folks who have become couch potatoes.

On the other hand, if you are feeling like the energizer bunny who just cannot sit still because you are internally disrupted, then consider asking your doctor about Celexa. Celexa can serve as a calming medication which allows you to settle down and reflect on the triggers to your mental state. The current situation is not only difficult by itself, it is also triggering past traumatic experiences, and as a result, it is important to try to connect the past to the present so that you can have a more coherent narrative about your internal process.

Now, let’s suppose you have tried SSRIs..such as Prozac or Celexa and they have not helped you in the past. At this point I would suggest you consider Gabapentin for anxiety. This can cause weight gain, which is undesirable for most people, but at the same time, it can take the edge off, which like I stated for Celexa, is important so that you can reflect on your internal experience.

In summary, there are a lot of tools at home that can promote mental health. The shelter at home mandate gives us an opportunity to explore our internal worlds such that we can find happiness, enthusiasm and vitality in the midst of a very uncertain and scary time.

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Healthcare Provider Mental Health and Self Care

Posted by Dr. Vollmer on March 30, 2020

Welcome to my second post/podcast brought to you to share with you different aspects of how Covid-19 is contributing to mental health challenges.

Today’s topic will be the health care provider, those on the frontlines of this scary and all too often, fatal disease.

The first point I want to make is that no heath care provider signed up to risk their life and the lives of their loved ones. For all of us, including our medical teams, this viral explosion came to us with little warning, and thereby little psychological preparation. This little time for psychological preparation is a major contributing factor in the stress to the health care provider. They are caught between doing their job, risking their life, the lives of their loved ones, vs. taking time off and feeling cowardly and not truly devoted to their field. This dilemma right there is often an enormous moral dilemma/stress for the clinician. They are faced with a lose/lose proposition. They can go to work and risk their health and the health of their loved ones, or they can take a leave of absence and be plagued with guilt. For some, there is simply no good answer and so they are left with symptoms of stress which include exhaustion, stomach aches, poor sleep, poor eating habits, and poor concentration.

The second point I want to make is not every health care provider has support from their family. Prior to Covid-19, most health care providers were the pride and joy of their support system. After Covid-19, the health care provider became an object of fear and avoidance. This rapid transformation in how others are viewing clinicians reflects the fact that the loved ones are now faced with protecting themselves from a healthcare provider who is now a potential super-spreader.

The third point I want to make is health care providers are feeling very let down by a system which does not provide enough PPE-personal protective equipment. The system, the government, the leadership, however hard they are trying are not able to provide the basics of viral protection. As such, there is stress from feeling unsupported from the higher ranks. This can feel very disappointing and contribute to stress symptoms.

Now, I want to move on to three action items that can help the stress of the health care provider.

1. Talk about what you are going through to one trusted supportive person in your life. Ask this person to be your confidant, because you need to share your experience, your perspective, and your mental and physical reactions to all of this stress.

2. Discuss and even write down the pros and cons of going to work every day. Talk about what it would feel like to take a leave of absence. Talk about what it would feel like to not take a leave of absence. Talk about how your loved ones feel about you working. Talk about how your loved ones would feel if you took a break. Begin an on-going narrative about life in the “trenches” and give yourself permission to do a thought experiment about having another life where you put your profession on pause.

3. Eat well, sleep well, exercise, and know your limits. By this I mean, the first priority is your day to day health. Create a routine of meals that work for you and nourish your body. Make sleep a priority because without sleep you will diminish your functioning capacity. Exercise daily to manage stress. Punch a bag, go for a run, walk uphill. Get your heartbeat up so that the blood flows throughout your body, waking up your brain so you can think more clearly. Finally, know your limits. You may be able to work, but perhaps not as much as what is demanded of you. Negotiate your time so that your schedule works for you.

In summary, history will write that the healthcare providers during this pandemic were heroes and they are. Still, it is a personal decision to be a hero, and there should be no shame, no feeling of weakness, if your job does not suit you during this time. Stress means it is hard to prioritize, and so during this period, stress is high because healthcare providers have to make very difficult personal decisions. Accepting this difficulty and appreciating that each person makes a decision that works for them is the first step. In this challenging time there is no room to be judgmental, and there is no room to be around judgmental others. There is only room for love, acceptance, and understanding.

Posted in Musings | 2 Comments »

Social Distancing vs. Social Isolation

Posted by Dr. Vollmer on March 27, 2020

Welcome to my first post in the Corona virus era. These posts will be the basis for my upcoming podcast series about staying mentally healthy in an unstable and scary world. These podcasts will be available through Pri-Med and I will have more details in the coming weeks.

Today’s topic is social distancing vs. social isolation or in other words, how to maintain relationships in an era that generates the fear that other people can unwittingly infect you and thereby your loved ones. Although not rational, many folks assume that social isolation will protect them, as this disease is transmitted from human to human, but with a gentle reminder, such as this post, social connection will help and is in fact essential during this vulnerable time.

So, let’s talk about social connection. We need to re-establish relationships with our loved ones, our close and long-term friendships, and we need a sense of community, of “meeting” people who have similar interests who we know as acquaintances now but who might become friends in the future. Maybe some of us have exercise buddies, people we see in yoga class or at the gym. We need to regain those relationships too.

The challenge is on. Maintaining strong and weak bonds in an era where hugging, eating together, and going to the movies is strictly out of the question. But wait, we need to re-define being together. We need to broaden our understanding of that concept. Being together means listening to one another, so perhaps during this time of quarantine we will need to sharpen our listening skills, an unintended benefit of these challenging time. We can listen on the telephone and we can listen through video conferencing. We can do most of our activities over video chat which allows us to tell our stories, share our worries and talk about common interests. We can have dinner parties, happy hour, walking groups and movie time, all by phone or video. We can change our language from “virtual happy hour” to “happy hour”. The trick is that we have to feel committed to showing up for “happy hour” in the same way we feel committed when we promise to meet a friend for a drink. In other words, we need to prioritize our virtual activities as we used to prioritize our in-person activities.

Isolation is bad for our mental health. There is no question about that. Isolation is vital for our physical health. There is also no question about that. And so, we need a new language. A language which says physical isolation is mandatory, and social connection is also mandatory.

What are the action items that I want you to take from this post?

1. Fill up your calendar with social commitments, be they dinners, happy hour, shared movie watching, or walking friends, where each friend goes on their solitary walk but that the two of you are talking on the phone while walking.

2. Restore your calendar. If you had a book group, set it up virtually, for the same time, with the same host. If you were going to church or synagogue, join a virtual group so that religion can return to your life.

3. Go outside and maintain social distance. Even seeing new and old faces from a distance will remind you that we are all in this together and we are all trying to cope with the fear and uncertainty that surrounds us.

4. Meal times should still be social. Make coffee, lunch and dinner dates with your friends and share meals over phone or video. Talk about what you are eating and how it is tasting. Talk about how these dates may be in person one day, but for now this is how you want to catch up with their lives.

5. Look at your calendar and take everything that was canceled, including cultural events, sporting events, family events, work meetings and ask yourself how you can modify those activities by using technology?

To conclude, the natural response to being told to stay safe at home, is to think of home as a place to hibernate until spring comes or the danger passes. Don’t do that. Stay safe and active at home. Use technology to replace in-person experiences. Prioritize that so that your mind, your body, and your soul stay healthy.

Posted in Musings | 2 Comments »

Should I have a podcast?

Posted by Dr. Vollmer on February 8, 2020

That is my question. How does this work? What will I call it? What is the content?

 

1. Ask Dr. Shirah?

2. Medication questions?

3. Psychiatry…good news and bad news

4. Mental health care disparities…what to do?

I have a lot to say. Maybe it is about time I say it?

Shirah speaks! I like that!

Something to think about.

Thank you Shelly…for being the first person to suggest this.

wow….love being challenged!

stay tuned!

 

 

Posted in Musings | 2 Comments »

 
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