Pandemic and Practice

How the Pandemic Has Changed Psychiatric Practice—1

Register NOW for CLP 2020 on November 12-13

A COVID-19 key session highlighting learning from the pandemic and its implications for health care will be held on day two of CLP 2020.

Speakers are:

Anthony Fauci, MD, director of the US National Institute of Allergy and Infectious Diseases, and a member of the White House Coronavirus Task Force.

Brent James, MD, clinical research professor at Stanford, and an international leader in quality improvement and patient safety.

Peter Shapiro, MD, FACLP, director of the C-L Psychiatry Service at New York Presbyterian/Columbia University Irving Medical Center, who leads the Academy’s Learning from COVID-19 Presidential Task Force established by Michael Sharpe, MD, FACLP.

CLP 2020 is being held virtually on November 12-13 with the theme: Delivering Our Vision of Integrated Care.

Registration includes six live-streamed plenary sessions, 56 workshops, 58 brief oral presentations, and 200 posters, together with access to an extensive library of pre-recorded sessions that will remain available for viewing for six months until mid-May. Skills and Essentials courses are also available at a modest extra cost.

The full program for CLP 2020 on November 12-13 is here.

See a welcome video here from ACLP president Michael Sharpe, MD, FACLP.

How the Pandemic Has Changed Psychiatric Practice—2

C-L psychiatrists 'face monumental task' to provide evidence of outcomes

 

The rapid and widespread adoption of telepsychiatry has been the most appreciable change in psychiatric practice during the pandemic—a change predicted to have lasting implications on the accessibility and quality of mental health care long after the COVID-19 crisis.

Telepsychiatry is being used not only between physicians and patients, but also between C-L psychiatrists and primary teams.

But the expansion of telepsychiatry has not been accompanied by rigorous evaluations of quality nor outcomes for patients who have been unexpectedly transitioned to this modality, say colleagues (pictured below) at the University of Colorado School of Medicine Department of Psychiatry and the Psychiatric Emergency Services at Denver Health.

They studied scientific literature on coronavirus since its emergence and its relationship to psychiatric practice—and hypothesized that evidence may show at least some negative impacts: causing psychiatric symptoms, exacerbating extant mental illness, and complicating the delivery of psychiatric care. But [at the time of their research] they found no evidence.

“Protocols provide specific guidance to enhance infection control in inpatient behavioral health units,” say the researchers.“No outcome data support the efficacy of these interventions, nor describe potential adverse impacts for delivering psychiatric care in this manner.”

In their review, published in the November/December edition of Psychosomatics, they describe telepsychiatry’s limits. For example, electroconvulsive therapy cannot be performed remotely, and it places practitioners at high risk of contracting coronavirus. Some opioid-assisted therapies, particularly with methadone, require in-person treatment, and patients who cannot remain in treatment are at risk of relapse.

In addition, telepsychiatry may not be accessible for all patients, including those who are homeless, severely cognitively impaired, technologically uncomfortable, or young children. “There were no descriptions of adapting telepsychiatry to these at-risk populations,” say the researchers. “Impacts on clinical outcomes were not studied.”

That said, they acknowledge psychiatrists’ workloads during the crisis and compare their contributions to “fighting a war against the pandemic.” The psychiatrists’ role, they say, has often been to direct clinical care. So much so, in fact, that they may have been required to refresh their medical knowledge to support their patients, collaborate with primary providers, and direct patients to appropriate treatment. “C-L psychiatrists are accustomed to this role and can support efforts to integrate treatment by providing training to staff and sharing relevant operational processes.”

The pandemic has also had implications for psychiatric prescribing. Several psychiatric drugs impact the efficacy and tolerability of antiviral therapy through P450 metabolism interactions; agents with fewer drug-drug interactions should be used preferentially (e.g., citalopram, olanzapine, or valproic acid). New guidelines have been published for assessing patients treated with clozapine who presented with ‘flu-like illness or suspected COVID-19 given those patients’ risk for neutropenia.

“It is unknown whether coronavirus itself may impact the efficacy or tolerability of psychiatric medications,” say the researchers. “These systemic changes emphasize the advantages of building adaptable health care delivery models and strong community support for mental health service before a crisis.

“C-L psychiatrists’ training positions them to advocate at an individual, institutional, and systems levels for integrating psychiatric surveillance and care into health systems. The global nature of the pandemic has prompted international collaboration and opportunities for such advocacy to happen on an international scale.”

The long-term sequelae of coronavirus on psychiatric symptoms, however, remain uncertain, and compound concern about poor-quality data on the virus’ impact on psychiatric care. Concerns have arisen over the risk of post-traumatic stress, cognitive impairment, and suicide risk among survivors, “but whether these risks are conferred by SARS-CoV-2 or concurrent medical illness and psychosocial stressors are uncertain.”

The pandemic has induced widespread psychological unease, they say, but no epidemiological studies applied diagnostic or functional impairment criteria to populations of interest. Mental health sequelae observed at a population level are confounded by concurrent changes in psychiatric care delivery, economic stressors, and public health interventions. “Indeed, the ubiquity of distress calls into question whether an individualized psychiatric treatment approach is preferable to broader public health and political initiatives.”

The researchers state: “C-L Psychiatry can play an invaluable role in expanding our understanding of coronavirus implications for psychiatric care and addressing gaps in the scientific literature.”

Psychiatrists should not only seek to better understand the psychiatric consequences of the pandemic, but also interpret and apply those findings in developing population-level interventions. Examples of such interventions may be how to best triage patients with non-specific anxiety related to the pandemic, or how to maintain access to psychiatric services for vulnerable populations.

Measuring and reporting outcomes related to quality and access to care would represent an important contribution, as these data are lacking in literature to date. If specialized mental health services prove inaccessible, psychiatrists should consider how patients may be identified and best treated through extant medical systems.

 

 

C-L psychiatrists should be mindful that studies of COVID-19 among hospitalized patients represent a select subgroup of medically ill patients who may differ from a larger population of mildly symptomatic patients with coronavirus infection, say the researchers. “The impact of coronavirus on immediate family members and survivors is an area of concern that requires attention. C-L psychiatrists have access to these populations through work in integrated care settings (where milder COVID-19 presentations are treated) or with families of hospitalized patients.”

The researchers conclude: “As COVID-19 and its related public health responses transform life around the globe, the psychiatric sequelae of the pandemic among individuals and societies are uncertain. Original research remains scarce and of poor quality. High levels of distress and potentially revolutionary changes in psychiatric practice are being described, but there is a poor understanding of the pandemic’s impact on the incidence, prevalence, and prognosis of psychiatric disease and implications for access to and quality of care.

“Coronavirus’ potential psychiatric symptoms have not been described, although there is a reason to suspect the virus may cause direct neuronal injury. Several small interventions on reducing psychological symptoms among at-risk populations suggest the potential for Psychiatry to adopt an assertive and positive response equal to a monumental task.”

How the Pandemic Has Changed Psychiatric Practice—3

SIG members encounter heightened patient anxiety from treatment delays and fear of contagion

Postponed or delayed care due to COVID-19 is high on the list of concerns for members of the Academy’s Palliative Medicine and Psycho-Oncology SIG.

Also faced with ‘no visitor’ policies, and anxiety among cancer patients over contagion and resilience, the SIG’s members have continued to make effective use of their listserv to elicit opinions about cases, learn about institutional protocols, and propose scholarly projects.

Topics have included management of psychiatric symptoms and barriers to communication in patients with head and neck cancers; approaches to co-management of care by psycho-oncology and palliative medicine; and strategies to support caregivers of patients facing terminal illness living together during “shelter in place” policies.

Among many SIGs presenting at CLP 2020, the Palliative Medicine and Psycho-Oncology SIG aims is to describe innovative models of psychosocial oncology care delivery that promote integration and adoption of scientific, evidence-based findings into clinical practice, training programs, and policy.

Their library workshop, Confronting Ethical Challenges for the Psycho-oncologist: Caring for Patients with Psychiatric Illness and Cancer, will focus on how they confront ethical dilemmas when caring for patients with prior psychiatric illness.

“Challenges can occur at the time of cancer diagnosis, when consenting to treatment or clinical trials, and at the end of life,” says SIG chair Sheila Lahijani, MD.

Major barriers to oncology care for patients with psychiatric illness, including stigmatization, delays in screening, and a lack of access to oncology treatments, will be highlighted, as well as challenges related to capacity, clinical trials, and cover strategies for maintaining engagement in cancer care.

Recommendations will be made for managing disruptive behavior, and examining decision-making about involuntary psychiatric hospitalization for patients with a terminal cancer diagnosis.

Dr. Lahijani herself will present the ethics of end-of-life decisions and physician-assisted suicide in patients with a high burden of psychological and physical distress.

Some of the SIG’s members have also convened to liaise more closely with the American Psychosocial Oncology Society (APOS). Several ACLP members are APOS committee and psychiatric oncology SIG members who have submitted abstracts to the APOS virtual conference next March.

How the Pandemic Has Changed Psychiatric Practice—4

Where to Find Purpose and Meaning... When You Most Need It

Ashwini Nadkarni, MD, director of faculty well-being at the department of psychiatry, Brigham and Women’s Hospital, values the support of peer groups in sustaining personal resilience.

My sister is 41 years old. She was just diagnosed with a brain tumor.

I was in a meeting when I missed her four phone calls, each of which was an urgent plea for me to pick up so I could reassure her that the incidental finding on her MRI was nothing; merely a cyst at most.

The next 24 hours were a blur. Her neuro-oncologist calmly discussed the likelihood of the tumor being a low-grade glioma. She would need a maximal resection. A week later, my sister was prepping for a craniotomy. Now, as I write this, she has started on the slow road to recovery through extensive physical therapy.

Bearing witness to the suffering of one’s family is a shock that will never wane. But this is life as a C-L psychiatrist—even as we help our patients come to a place of acceptance about their pain, so is suffering inevitable for the one providing treatment. 

Personal resilience is one of the three major components of the Stanford framework for understanding physician burnout. It is defined as the “individual skills, behavior, and attitude that contribute to emotional, physical, and professional well-being.”

As the director of faculty well-being in the department of psychiatry at an academic hospital, my prevailing goal in developing programs for personal resilience is to focus on what the system can do to help the individual. This means shifting the burden away from what the individual must do to help themselves. In my experience researching the merits of well-being interventions, peer support programs not only provide the framework to achieve this, they also convey the essential mission of any effective burnout intervention: “Let’s take care of each other.”

What does a peer support program look like in practice in the hospital setting as a burnout intervention? It can be as simple as a group of like-minded C-L psychiatrists coming together on a regular basis to discuss the problems they’re currently facing, the solutions they’ve adopted, and their insights on the way forward.  

One peer support program that I’ve helped to found is a group for mothers in Psychiatry. Our meetings generate lively conversations about the challenges posed to physician parents during Covid-19 and ways to advance professional equity within our hospital. The group has become a powerful impetus for change. My peers have given me a far better understanding of what types of programs would truly advance professional fulfillment for female faculty more than any survey would.

The merits of a peer support program may seem clear but how does one successfully implement such a program and ensure it makes its mark? It’s not enough to merely convene a group of C-L psychiatrists within the hospital setting. Dialogue must be authentic and participation has to come from the heart. Identifying a common purpose or goal enhances the meaningfulness of the experience. My experience has shown me that great ideas for burnout interventions really do come from a conversation with a peer in which both of you are lamenting the need for “X.”

A moderator who will do the work of sending meeting invites and focusing the group’s discussion may emerge organically or may need to be appointed. An important barrier for many is time—how does a C-L psychiatrist carve out time for such a commitment with all of one’s other myriad responsibilities?

Although I have witnessed consistent participation for the multiple peer support programs within our own hospital, I am mindful of the need to balance the benefits of a potential program with the burden of attending meetings. I will say, it helps to offer virtual attendance as an option but also to gain a better understanding of the personal barriers to participation within the group. A key, often overlooked step, is to get the word out. Although many of us often turn to email, my research on outcomes for burnout interventions has demonstrated that word-of-mouth travels farther and much more powerfully.

The final step that can truly create momentum for such a program is to seek funding to offer shared meals or implement follow-up interventions. Within the hospital setting, grant funds may be available. I have found that a conversation or a “pitch” to a mentor or sponsor can also go a long way.

Suffering brings everything in one’s life into question. I am fortunate that during a truly challenging time in my own life I have had peers to cover my clinical responsibilities when I have had to take time off. But the true value for me of peer support structures has been their role in helping me to recognize that in spite of my recent pain, my work, which enables me to collaborate with such a dedicated peer group, continues to bring me purpose and meaning.