Psychiatric Perspectives in an Era of COVID-19

This post discusses topics related to mental health (e.g., depression, suicide) that may be sensitive or triggering for some individuals. Support is available through the resources provided at the bottom of this page.

PLEASE NOTE: The speaker series described in this piece occurred prior to the death of George Floyd and the subsequent nationwide rallies and protests. Therefore, those involved in planning the event did not have the opportunity to engage with any of these topics and explains the absence of such discussions in the material covered below.

Even before the recent events in our country, the mental health toll of the COVID-19 pandemic was significant for many people. A Kaiser Family Foundation Tracking Poll conducted in March found that nearly 50% of adults who were sheltering in place reported their mental health to have suffered due to coronavirus-related worry or stress. Twenty-one percent of surveyed adults said that the pandemic has caused a major negative impact on their mental health. A separate transnational survey administered to over a thousand people uncovered that the top five coronavirus-related mental health concerns among the general public involved anxiety, isolation, becoming mentally unwell, having limited access to mental health support and services, and family and relationships.

Recognizing the personal, societal and institutional challenges presented by COVID-19, the Hopkins Psychiatry Student Interest Group (HOPSY) at the School of Medicine hosted a virtual three-part speaker series, from April to May, titled, “Psychiatric Perspectives in an Era of COVID-19.” The purpose of the series was to shed light on current issues surrounding the delivery of psychiatric care and the pandemic’s ongoing mental health impact. In addition to hearing opening remarks from psychiatrists, students from across the schools of medicine, nursing, and public health were given the opportunity to presubmit or ask any real-time questions they had for the speakers.

The series’ speakers featured the following faculty psychiatrists with diverse practices at Johns Hopkins:

James Potash, director of the Department of Psychiatry and Behavioral Services and psychiatrist-in-chief;
Karen Swartz, associate professor, Mood Disorders and vice chair for faculty, Department of Psychiatry and Behavioral Sciences;
Roma Vasa, associate professor, Child and Adolescent Psychiatry and director of psychiatric services at the Center for Autism and Related Disorders, Kennedy Krieger Institute; and
Christopher Hammond, assistant professor, Child and Adolescent Psychiatry, with a joint appointment at the Behavioral Pharmacology Research Unit.

Informative and engaging discussions between the speakers and student attendees covered a range of pertinent issues.

Topic highlights included the following updates:

The Department of Psychiatry’s response to the pandemic.

Significant changes have been implemented to protect the health of psychiatric inpatients. These include a complete transition to single-occupant rooms, mandatory COVID-19 testing of all incoming psychiatric patients (including those who are asymptomatic); opening of units exclusively for psychiatric patients who test positive; and reduction of inpatient admissions, limited to the most severe psychiatric cases. Research related to COVID-19 is underway, including a project focused on determining whether or not the coronavirus can be detected in the cerebrospinal fluid. Another study aims to understand the mechanism through which the virus affects the sense of smell.

Increasing reliance on and the future of telepsychiatry.

Nearly all outpatient psychiatric care at Johns Hopkins is now done via virtual visits. Approximately 10,000 telepsychiatry visits occurred during the month of April. Because this method is often more convenient for patients than in-person visits, missed appointment rates have declined significantly. Telepsychiatry is particularly beneficial to patients with difficulty accessing in-person health care (i.e., those who live in rural areas) and for patients who have trouble leaving the home (e.g., geriatric or immobilized individuals). Telepsychiatry’s affordance of increased patient access foretells a promising future and may play an important role in addressing disparities in mental health care. Among medical disciplines, psychiatry — which relies primarily on verbal communication and mental status examinations in lieu of labs, medical imaging or physical examinations — may be intrinsically the most amenable to telemedicine. Improvements must still be made to virtual communication, however, to help providers pick up more subtle cues that may indicate high-risk situations requiring inpatient evaluation. Patients seen via telepsychiatry are thus advised to have a family member, caregiver or supportive person nearby, whom the psychiatrist could call on to intervene, should truly emergent situations arise.

Current challenges in telepsychiatry delivery.

Regulations limit the widespread use of telepsychiatry in the present era. Some insurance companies limit pay for telepsychiatry visits to strict circumstances, such as the requirement that consultations occur in clinical environments where the patient is accompanied by a health care provider. Another limitation permits psychiatrists to conduct telepsychiatry visits with patients only in the state in which they are licensed to practice. Nonetheless, the rise in psychiatric needs during the pandemic has prompted temporary lifts on some of these restrictions. For instance, some Medicare provisions allow patients to receive telepsychiatry care in their own home; and some states, such as New York, have allowed in-state residents to receive telepsychiatry care from providers licensed in other states.

Delivery of psychiatric services to the community.

A number of initiatives exist at Johns Hopkins to care for the mental health of people in local communities, which are being adapted to meet the demands of the pandemic. For instance, the Hispanic Clinic provides mental health services to children and adults of Hispanic origin in Maryland. The Adolescent Depression Awareness Program (ADAP), founded in 1999 by psychiatrist Karen Swartz, is a school-based curriculum to educate high school students, teachers and parents about teenage depression. In response to current needs, efforts are underway in the Anne Arundel County Public Schools to transition elements of ADAP into a virtual format, involving asynchronous and synchronous learning components. The program is expected to begin this fall. The Department of Psychiatry Social Work is reinforcing efforts to provide resources to parents and families impacted by the changes occurring in the home, as a result of the pandemic. The Public Mental Health Track in the Psychiatry Residency Program seeks to equip residents with the skills needed to address challenges in delivering psychiatric care to the public, especially disadvantaged communities.

Current and upcoming mental health impact of COVID-19.

At present, we are thought to be in what Johns Hopkins disaster psychologist George Everly calls the “disillusionment” phase of disaster, with the worst perhaps to come. Anxiety, depressive, obsessive-compulsive and substance use disorders are particularly vulnerable to pandemic-related issues. These include stay-at-home orders, excessive media consumption, collective fear and social isolation. Health care workers can be trained during this time to deliver psychological first aid through a free course offered by Dr. Everly at the Bloomberg School of Public Health. Consistent with prior literature on the health-related aftermath of disasters, the sobering reality is to expect an even greater uptick in mental health issues some three to 12 months from now, or whenever the pandemic subsides. Special attention must be given to individuals at increased risk for suicidality, particularly those who may be impacted by the economic fallout of the pandemic.

Caring for frontline health care workers.

Heroes need help, too. Dr. Swartz is leading hospital efforts to deliver mental and emotional support to staff as they care for patients during the pandemic. This includes staff support groups and individual treatment for those working on COVID-19 and other inpatient units. Daily mindfulness meditation sessions are currently being led by Neda Gould, psychologist and director of the Mindfulness Program. Additionally, Resilience in Stressful Events (RISE) initiative establishes infrastructure to enhance peer support at Johns Hopkins and other medical institutions. Johns Hopkins staff can access mental and emotional support resources through the Office of Well-Being.

Caring for children and adolescents.

Young people are also susceptible to emotional distress during this time, due to a number of unique stressors, including educational transitions, loss of normal routines, separation from friends, and potentially unstable home environments. Reactions can vary by age. Young children may exhibit confusion and throw tantrums; school-age children may be become bored, frustrated and anxious; and adolescents may struggle with thwarted independence and concerns about their future plans like college and jobs. Special attention should be given to those with neurodevelopmental disorders, such as autism spectrum disorder, intellectual disabilities, ADHD, and learning and language disabilities. The Kennedy Krieger Institute, an affiliate of Johns Hopkins, offers behavioral therapies through their Behavior Management Clinic, Pediatric Development Disorders Clinic, and Child and Family Therapy Clinic. Treatment at Kennedy Krieger is now being delivered via telehealth.

Caring for parents.

Many parents are struggling with the need to fulfill new and unfamiliar extra-parental roles, such as teacher and therapist for their children. The challenge of meeting their children’s academic needs may be compounded for parents who are working from home. Dr. Vasa advises parents to take time to recharge. “Pace yourselves, incorporating relaxing activities in your routine,” she says. “Set realistic expectations for yourself and your children. Watch your alcohol intake, and consume news in moderation. This is a unique opportunity to offer mindful and sensitive-responsive parenting to your children, which will benefit them in the long run.”

Caring for ourselves.

In their respective sessions, all speakers offered tips for staying well during this time. These included:

Staying connected with others regularly (via phone, video call, etc.)
Practicing gratitude
Practicing mindfulness meditation
Taking one day at a time
Attending to basic self-care (nutrition, exercise, sleep).
Limiting the news
Doing something for others
Learning something new
Finding creative ways to celebrate milestones

In a recent COVID-19 webcast, Dr. Swartz offered additional strategies for coping with stress and social isolation. According to Dr. Vasa, current challenges are an opportunity for us to cultivate resilience, defined by Merriam-Webster as “an ability to recover from or adjust easily to misfortune or change.” Ways to do this include all of the previously mentioned tips.

Caring for each other.

It is more important now than ever to be kind. Many people are experiencing unspoken trials, and kindness can go a long way for someone who is struggling. Keep a close eye out for your elderly relatives and neighbors, especially those who find using technology-based communications (e.g., zoom) challenging. Check in with them regularly. Consider sending handwritten letters and cards. As Rogers says, “There are three ways to ultimate success: The first way is to be kind. The second way is to be kind. The third way is to be kind.”

To contact the Hopkins Psychiatry Student Interest Group (HOPSY) with questions or ideas for upcoming events, please email one of the 2020-2021 medical student co-leaders: Leigh Alon (lalon2@jhmi.edu); Isabella Pan (ipan3@jhmi.edu); or Howard Chang (hchang68@jhmi.edu).

Resources

If you are a medical/graduate student, trainee or health care professional at Johns Hopkins, and are struggling with mental or emotional health, consider reaching out to one of the following confidential institutional resources:

For students, house staff, fellows and trainees:

University Health Services Mental Health
410-955-1892
hopkinsmedicine.org/us/university_mental_health.html

For students only:

Johns Hopkins Student Assistance Program (JHSAP)
443-287-7000
jhsap.org

For anyone feeling hopeless or having thoughts of self-harm:

Baltimore Crisis Response: 410-433-5255

National Suicide Prevention Lifeline: 1-800-273-8255

Crisis Text Line: Text HOME to 741741