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Roger: Hello. Welcome to today in Mental Health: Caring From a Distance. I'm Roger McIntyre, psychiatrist at the University of Toronto. My pleasure to be moderating today's session. I want to start off by first of all thanking Sunovion for a grant support to make this event happen. I also want to thank NEI for the management and the organization behind this particular program. I want to encourage all of you to keep a hand on your mouse. In other words, we're going to be asking for you to submit any questions you'd like throughout the program. We've got three presenters today. I think the topic could not be any more timely.

We're going to be speaking to two interrelated topics that is the impact of COVID-19 on mental health and more specifically, the impact on COVID-19 on our practice as healthcare providers, attempting to provide timely quality care to people who are affected by a mental disorder. Before I introduce my colleagues, a few introductory remarks just to set the stage of sorts. I've referred to the last six months as the triple threat. In other words, this is not just a public health crisis. This is an economic crisis and a mental health crisis. It is affecting not just the high-income countries, but also the low and middle-income countries. This is truly a global event.

There's now, in fact, been reports that we've contributed to and other groups as well of rising rates of mental disorders in many parts of the world including but not limited to depression and post-traumatic stress as well as anxiety disorders. We also, in fact, have concerns about rising rates of suicide. In fact, it's been reported during the Great Recession as well as previous shocks of an economic nature that rising unemployment is highly associated with increases in suicide. For example, we've recently reported in North America that for each 1% increase in unemployment, we could project out a commensurate increase of 1% in suicide. These are very, very significant times.

Now, the event that we're in now is clearly unprecedented. I think unprecedented is the right word. It's not hyperbole. It truly is. These events were prefaced. I always say that the pandemic was prefaced by an epidemic, an epidemic of loneliness. This has been described across the age band right across the world. The loneliness epidemic known to predispose and portend chronic diseases like obesity and heart disease, but also known to predispose to suicide, especially in younger people. It's not younger people that I wanted to pick up on. They're not the only group that we're interested in, but we're really, in fact, seeing select subgroups, especially at risk, including young people.

For example, the Centers for Disease Control, in the last month, has reported that around 25% of people, 18 to 24, seriously thought about suicide in the last 30 days. This is an incredible statistic. These statistics, again, come on the tails of other lines of research. For example, from NORC at the University of Chicago, that only about 15% to 20% of Americans would report themselves as being content in feeling happy in their life. Taken together, this is an event like no other. The hazards that are posed on mental health are difficult to, in fact, describe.

As we speak, there's efforts going on around the world to not only identify groups at risk and to identify which types of mental disorders are especially more likely to be encountered during this time but also on a more promising note what we can do as public health officials, as advocates for people who have mental illness or who are at risk of mental illness, what we can do to mitigate the risk. I say that flattening the curve is not the objective. It's flattening the curve and preventing the curve. In other words, flattening the curve of the virus, but preventing the curve of suicide as well as mental disorders that are associated with suicide.

I, in fact, just got off a call earlier today where I was speaking with colleagues of mine. We're doing a study in China looking at among other things some of the moderating factors of risk for mental illness in people in China exposed to this trifecta, again, the public health crisis, the economic crisis, and the mental health crisis. What was so interesting about that is we are finding that there's many factors that we can moderate. One of the factors that we found which I thought was very interesting was the issue of portion control.

Now, when we talk about portion control, I usually think about how much food I'm taking in or how much alcohol I'm drinking and that includes that, but what I'm referring to is also social media consumption. I thought you'd find it very interesting that in young people, those over the under the age of 25, those that consume more social media are also persons more likely to report nuanced that depression and anxiety disorders in the context of COVID-19. That's an association, that's not causation. It gets us thinking about factors that we can begin thinking about how we can intervene and how we can intervene in the general population, but also how we can intervene in our clinics.

That's my segue now. It's my own experience. Six months ago, like everybody else, we were faced with this virtualized world. I, in fact, did have a hybrid practice before this began in about February, March of this year. In other words, I had a brick-and-mortar clinic at the university and I did do some telepsychiatry maybe about 10% to 20% of my practice. Now, like many, turn into 100%. I suspect that once COVID is behind us, we look forward to that, that my practice will look more and more hybrid in the sense it'll be probably a much higher allocation of my time will be spent with respect to the virtual interaction with patients and families.

Perhaps the change for me was one more of quantity than quality. In other words, I spend more time on telepsychiatry, but my overall activities didn't change a whole lot because I spent a lot of time doing telepsychiatry to begin with. One of the aspects about this that really came into very cold clarity for me that I had, perhaps not marinated as much as I should have, is how to handle situations that are commonplace in my practice. I run a mood disorders program. I see people who are very suicidal, who are very at risk of self-harm and trying to manage aspects of the psychiatric emergency.

For example, people at risk of suicide in the context of virtual healthcare, something I've had to do more in the last six months I've had my entire career. Other aspects as well with respect to integrating care. This has been one of the more positive externalities, one of the more positive unintended consequences of this COVID-19 is, in fact, the opportunity to integrate care with other care providers as part of the care team including not just social workers and physician assistants but also employers and other family members as part of the team to name a few others.

I think, in fact, we are going to be talking about COVID-19 for many, many years from now. This is a threat to mental health I can't really find in the history books, but it's also an opportunity. It's an opportunity for us to rethink the way we're providing care for people, not just in those who have a declared mental illness, but also from a more societal level, some of the public health initiatives that we can begin to think about that simultaneously mitigate risk, but also augment the resiliency of our population because we're going to be hearing a lot more about risk and resiliency in the general population public health sphere.

With that, I want to, in fact, pivot and I want to now invite our first speaker for today's event. It's Dr. Doug Ikelheimer. Doug is a psychiatrist. He is in Colorado. Doug would certainly receive anyone's vote as an early adopter. Doug has been working as a full-time on-demand telepsychiatrist. Full-time for the last eight years. In fact, telepsychiatry going back to 2005. Doug clearly has the ability to see the future in ways that I've not seen before. Doug and I have been discussing his practice and I was intrigued to hear that he is not simply saying outpatients in a general psychiatry practice. He's seeing people with substance use disorders and also in the emergency to name a few other ecosystems and populations.

Doug, welcome to today's program.

Dr. Doug Ikelheimer: Yes, thank you, Dr. McIntyre. It's a pleasure to be here. Yes, I identified telepsychiatry in my early days as a psychiatrist working for Denver Health, the county hospital in Denver. It was approximately 2004 and I was working full-time in the psychiatric emergency service. I also was working in a suboxone clinic at Denver Health treating patients who came in from all over Colorado, in some cases driving many hours to see me for a brief 15-minute med check in order to receive their Suboxone prescription for the management of their opioid dependence.

It was around that same time that I was doing my first Skype meetings with various family members and I put two and two together and realized that I could entirely meet the standard of care of traditional outpatient psychiatry while seeing patients by video. It was in approximately 2005 that I opened what may have been the first home-based telepsychiatry clinic. For the next 10 years, approximately, I treated patients from all over Colorado for mood disorders, anxiety disorders, and opioid maintenance using Suboxone.

The key, of course, is that I was meeting the standard of care, traditional outpatient psychiatry in all other ways, including things like physical examination, laboratory investigations by the primary care doctor, vital signs, random urine toxicology screening, traditional outpatient support groups, et cetera. Patients really enjoyed the convenience and the access that they were afforded through my home-based telepsychiatry clinic.

Roger: That's a great story, Doug. With respect to the access and that's something certainly my patients have described as well, the efficiencies built-in, what would you say are some of the dos and don'ts that you've learned over the years with telepsychiatry?

Dr. Ikelheimer: Yes, that's an excellent question. I would say first of all that the number one thing to realize is that telepsychiatry is not a new form of practice. Rather it's just the harnessing of technology to provide services you're already providing to a wider population. The number one do is, do see the same patients you're already seeing in your practice and don't change your practice in any other way, other than to harness the secure video technology to perform the interview and mental status examination that you would otherwise be performing in-person. Other dos and don’ts. Do practice within your own state licensure. Of course, this is defined by the location of the patient.

The clinical contact, by definition, occurs at the location of the patient. You must be licensed within that jurisdiction within that state. Now some of these issues are changing with regard to the arrival on the scene of the interstate medical licensure compact, which is a process of several states, and in some cases, and going to be many states cooperatively sharing licensure for the purposes of practicing telemedicine.

That's an ever-evolving story, the interstate medical licensure compact, but be sure that you are practicing in your own licensure as defined by the location of the patient. Do use a private setting with a neutral backup of a backdrop. Always use front lighting, never any bright lights behind you, otherwise, your patients will only see a silhouette. Maintain HIPAA compliance for all aspects of your practice, including the video platform, scheduling, and billing. Do occasionally look into the camera so the patient has the experience of eye contact. Even if for the clinician is somewhat artificial momentarily to be looking into the camera. Those are really some of the main dos and don'ts.

Roger: That's very helpful. You were very clear in highlighting the residents of the person you're speaking to as de facto where that clinical contact took place. Would you see a patient who was, for example, from Colorado who took a trip to Mexico on holiday, and they want to contact you from Mexico? Would you have seen them from Mexico out of country?

Dr. Ikelheimer: Ah, yes. Excellent question. Well, let's see. If the de novo doctor-patient relationship is established under appropriate licensure within the USA then yes, it would be appropriate to see a patient when he or she is out of the country for a brief visit a support or questions that the, that the patient may have while they are outside of the country but of course, I would avoid attempts or avoid prescribing for this patient when they're outside of the United States. The main thing is as long as you establish relationship inside the United States and in under your own licensure, it'd be okay to visit a patient with a one-off visit by phone or video for some kind of urgent meeting, that would be okay.

Roger: Doug, a more basic question, but one that I've encountered more in the last six months than I ever have is that many of my patients cannot afford broadband and Wi-Fi. In fact, Canada, the United States pay some of the highest rates in the world for broadband and Wi-Fi. I've had many patients over the years who've contacted me from their local McDonald's or their local Starbucks, or what have you, they get a public Wi-Fi. What's your view on public Wi-Fi? You mentioned HIPAA compliance earlier.

Dr. Ikelheimer: Yes, that's another fascinating question. In my private practice, I have had some patients who would try to conduct video sessions from their car outside of a fast-food restaurant, trying to use the restaurant's Wi-Fi. Historically, I would allow that as a one-off or on a single occasion while at the same time encouraging the patient that they really need to be accessing me from a private setting in order to continue accessing my services. I have had occasions where I needed to discharge patients from my clinic because they were not able to routinely access me from a traditional private setting.

The other thing I would mention is that my own personal-- one bugaboo that I have is that I really need the camera on the patient side to be situated on a hard surface like a table or other hard surface because that helps us avoid the sensation of an informal chat session. Yes, that's the other thing I really do like to have the camera on a hard surface on the patient side.

Roger: COVID-19 as I described earlier, I think we all agree as a, well, it certainly is unique and unique as an understatement. COVID-19, how has that affected your professional endeavors with respect to telepsychiatry, if in any way?

Dr. Ikelheimer: Well yes, first of all, what we saw with the arrival of the pandemic and quarantine was an instant conversion around the country of most behavioral health clinicians to offering remote services overnight. This occurred to such a degree to where the word telepsychiatry almost now has become so commonplace as to be virtually synonymous with the word psychiatry.

In my full-time position now as an on-demand telepsychiatry telepsychiatrist, I offer emergency services to emergency departments around the country, as well as constant liaison services to hospitals in multiple states around the country. What we saw with the onset of the pandemic was an early drop in volume. My personal opinion is that this occurred, of course, because patients were for a short time there for a couple of months, were avoiding hospitals avoiding coming into the emergency department to access behavioral health services.

Also, hospitalists on the various floors of the hospitals were initially less inclined to consult psychiatry. I think probably because they were overwhelmed in their conversion to practicing COVID medicine. Yes, we did see an early drop in volume. However, that has after the first couple of months that has now returned to full pre-COVID volume. If anything, we're busier now than ever.

Roger: Some of the colleagues who are joining us, Doug, for this program might be thinking to themselves, are there implications from a remuneration perspective, in other words, from a reimbursement of service perspective are there any disincentives, are there any incentives that you see now, or you see in the near future that is after COVID is behind us with respect to transitioning to telepsychiatry?

Dr. Ikelheimer: Well, as you're probably are aware, there was already a gradual transition underway whereby third-party payers and insurance companies were increasingly reimbursing for telepsychiatry. Since COVID, this transition has accelerated dramatically. Now most, if not all third-party payers and insurance companies, including Medicaid, Medicare, BlueCross, Cigna, United healthcare, all of these third-party payers are now reimbursing for telepsychiatry. Even in the home-based setting.

Roger: Reimbursement at par or is there a reimbursement less than par?

Dr. Ikelheimer: In many cases is very close to par if not on par. Each insurance company will have its own policies on how close they come to the amount that they reimburse for an in-person visit. The gap is certainly closing rapidly.

Roger: Which is good news. That's obviously a very relevant issue to one's practice. Doug, one of the reactions I've had to the literature on, for example, psychosocial interventions, well, maybe cognitive behavioral therapy as a manual-based therapy in depression, for example. The evidence shows that when that type of therapy is delivered through a computer, computer-assisted, computer-facilitated, the outcomes in depression are as good as seeing a therapist in person which is important for access and scale of the treatments and a variety of other advantages.

My question to you is, with respect to telepsychiatry, you have probably more experienced than anyone I've ever met, frankly, people might be wondering, well, how do you in fact liaise with the primary care provider? In other words, how do you liaise with the circle of care given what you do?

Dr. Ikelheimer: In telepsychiatry, we practice exactly the same way we practice traditional in-person psychiatry. None of those factors change at all really. I guess that is really the biggest take-home message of all with regard to telepsychiatry. I will liaison with family members, primary care providers, and I still reach out to all the relevant players in a given patient's care, just as we do in traditional outpatient psychiatry. Remember, telepsychiatry is not a new form of practice. Rather, it's just a new way of harnessing technology to deliver the same care you're already providing to a wider population.

Roger: Yes, well put. I've noticed here in Ontario, for example, we've been increasingly embracing a virtual medical home. In other words, we have co-localization of various members of the care team, all within the same virtual space. The patient, of course, provides permission for this and so on. I have been especially excited about the opportunity that this interface has to, as you talked about earlier, Doug, really deal with the access and availability issues. It's often said that if we had the cure for schizophrenia, or mood disorders, today, it would make a little dent on the impact of the illnesses because people don't get access to the care.

The point being is that this is a major deficiency. Perhaps this may be one of the externalities, one of the unintended consequences of COVID-19. Not just greater adoption of digital, but perhaps also an opportunity to have a more integrated and a more accessible, really. framework from the public health perspective. Doug, given your foresight, I don't have any reasonably that you might not receive some emails from people saying that they want some stock market advice from you because you clearly can see the future.

We're going to, in fact, now shift directions. It's really my pleasure, in fact, at this point, to invite Mr. John Braggiotti, to join me here on this virtual platform and share his experience. John Braggiotti, he is a care provider for his brother, his brother has a diagnosis of schizophrenia. John has graciously joined us here today to tell his story. John, I want to, first of all, give you a warm welcome, and very interested in your story. People would want to hear about that and especially how things have been affected by COVID-19. Welcome.

John Braggiotti: Sure. Well, Dr. McIntyre, thank you for this opportunity to share our family story. We have a brother as you alluded to that suffers from schizophrenia. He's had schizophrenia since he was a child and I have been taking care of him for quite some time, intensely, since both my parents passed away. Actually, that's a story that I want to bring up because it intensified with COVID-19.

As many people in the audience know, the best care is to provide to date in person, especially with drastic situations like a family member passing away. When my father passed away, I wasn't physically with my brother and the psychiatrist and we had some support around him because we felt that he was going to relapse significantly. That was incredibly helpful. I wanted to follow up a little bit also on what Dr. Aiko Heimer Ikelheimer mentioned because I think it doesn't change from what I see as a brother and as a caregiver, it doesn't really change, telepsychiatry adds provides a tremendous amount of support, but it doesn't really change the way you provide the support.

In the past, we would have sessions with the psychiatrists, my brother and myself there, and perhaps even a staff member at the facility that he lives. He lives in a group home. His levels of schizophrenia is pretty high. He's on very significant medications. In this situation with COVID-19, my mother passed away during this COVID-19. It added a significant amount of pressure because obviously, I couldn't go and visit him, I couldn't tell him this in person.

Knowing that he reacted heavily in the previous situation when my father passed away, I spoke with a psychiatrist, and I said, why don't we just do this through telepsychiatry, and let's try to create the same support infrastructure that we had done before, in person, through telepsychiatry. We did that and at first, we felt that it was going to be very challenging. Moving forward, what I can say, in summary, is that it was a session that we had, that probably lasted about an hour and a half, which I wasn't expecting it to last that long, frankly, I thought he was going to shut off. He was very conversant.

The first few minutes, he was a little bit shy. As he saw me, as his brother on there, he became more friendly to the camera. We were able to communicate and go through this process.

Roger: Wonderful, John, thanks for that. With respect to the ability to make appointments and coordinate appointments, how's that-- in terms of just user-friendliness of the platforms, how's that been?

John: That's a great question. In the past, I've actually shown him capabilities of looking at a screen or so forth. He's become a little bit more friendly to that environment. What I've done is with his support infrastructure, I've said, "Look, a phone call, we felt that was not as effective." We have moved forward in making appointments with him. We felt that even though we had a good session with him, and I was able to discuss that his mother had passed away, but his world was not going to change in a negative way, as much as sharing that support infrastructure with him, and then finding a continuance to that, with making those appointments with the psychiatrist and also some local support.

I know that some of you listening know that some of these patients are not at home in our homes, and sometimes they're in group homes. I think it's incredibly important, at least I found it incredibly important to have some support infrastructure, also, that is aware of that situation, number one, number two, that you create a continuous situation where they can follow up with that patient with that person suffering of schizophrenia, and be there for them because there's going to be a relapse, we know that.

We did have a bit of a relapse. That's one of the reasons why I worked closely with a psychiatrist to make sure that if we had to make some adjustments to his drugs, that he was aware of his reactions on the spot so that we were preventive, rather than reactive.

Roger: That's very helpful, John. I was thinking as you were mentioning that, the phone. I've had a number of occasions now, in the last six months with some of my patients and families that I see they don't have Wi-Fi. I have had some challenges speaking over the phone. I can speak over the phone just fine. I'm talking about having a medical assessment over the phone. Look, we have to work with what we have. I've had some challenges with that. We've made it work. What do you see as a limitation of phone-based versus having the video? In other words, what are some of the advantages of video [unintelligible 00:29:59] limitation of the phone? You alluded to that.

John: It's a great question. I have been using the phone with him and we've been using the phone. Our situation was that we were away from him as a family. He was in a different state, in different location. He was in group homes because as many of you know, I think one of the tragedies is that you have people with schizophrenia living at home sometimes and that causes-- Being with a family is not always a sensitive issue and that we can make a full session of that, but it's not always the best scenario for them. The family may feel comfortable because they have their loved one there, but it's not the best situation for them.

Having him far away meant that I, for years, used the phone as a support mechanism. I have to say initially because of his up and down, he was very up and down with his schizophrenia level. When he was able to make outbound calls, he would call us at all times of the day. You could get a call at 2:00 AM or 3:00 AM, so we had to work with that as well. We reduced, in other words, we took away his ability to make outbound calls for a while, but we kept it regular where he had a phone call that he knew he would get every so often from either myself, a loved one, a relative, or as well as help or it could be a caregiver.

Now I have to say in the past, we've seldomly used some help from psychiatry through the phone, but what worked the best, and I have to comment on what Dr. Ikelheimer mentioned, is that we replicated a very successful model. The successful model that we had with a psychiatrist, especially when we had a very low-- They go through highs and lows, so he had a very low situation. We were in person, I was there with a psychiatrist, he was combative, but with a psychiatrist, I would leverage that help for him and that was very successful. We took that same model and leveraged it to the telepsychiatry which has worked very well.

Roger: Wow, that's amazing. John, you obviously play a very significant role in supporting your brother. Are there other members of the team and either part in the family or professionally that are part of this team helping your brother?

John: Absolutely. I have to say that, especially during this moment of aggravated, as you mentioned, it's not just an economic but it's a trifecta, right?

Roger: Yes.

John: It's these three things coming in. What I found is that because he hasn't been able to see, I think in many ways, my brother is privileged in the sense that we are able to physically see him. I've also encountered families we've helped each other. I've talked to families that haven't been able to see their loved ones, either they haven't been able to afford to travel, or because of the current situation with COVID-19. Getting local support has been incredibly important. We've done that with a variety of staff. We've had them in different locations throughout the years, some have worked better than others.

In some situations, it's been more difficult to have support infrastructure, but when there's a will, there's a way. I think that you can always find people, social workers, that even if they don't have the high level of psychiatry needed, but they need to have someone. I think loneliness, you alluded to that, the loneliness, especially with someone that already suffers from schizophrenia bipolar-- My brother's got schizophrenia bipolar and OCD. High levels of that can cause them to really go off the rails, even having some support infrastructure really helps.

Roger: That's very well put, John. I feel it's a topic we don't speak as much too, that being loneliness. I think when I started today's program, I spoke to resiliency and I think we're going to be looking at this from different perspectives for many years to come. As individuals, as groups, and as a population, we really need to think about how we can become more resilient. One of the ways to boost resiliency is to have a strong social network. Your brother is certainly in a position where he's got obviously a loving and caring brother taking very good care of him and keeping a very watchful eye over things.

Your insights and comments are greatly appreciated, John. I'm going to pivot now and I'm going to introduce a very good friend and colleague psychiatrist, Dr. Jonathan Meyer. Dr. Meyer is the clinical professor of psychiatry at the University of California at San Diego site. Dr. Meyer is also at the California Department of State Hospitals and has a very, very extensive history of managing people with persistent mental illness. First of all, Jon, welcome. Great to have you with us.

Dr. Jonathan Meyer: Thank you for having me, Roger. It's nice to be here.

Roger: Jon, let's get right down to it. This has clearly been an event like no others this last six months or so. COVID-19, how would you say COVID-19 is affecting people with a diagnosis of schizophrenia or bipolar? In a two-part question, which you're never supposed to ask two-part questions, but here's a two-part question. What are the coping strategies that you might recommend for people?

Dr. Meyer: I think it's fair to say COVID-19 is a societal source of distress. People are suffering from economic distress, people are suffering from isolation. We know that patients with severe mental disorders are vulnerable to stress so that in and of itself is something that has to be recognized. I think you allude to this in the second part of your question about the coping strategies. As a big part of what has happened during COVID is people have now become isolated. There was a great survey study which was published in the September issue of psychiatric services from a group at Yale.

The respondents were predominantly more so mood disorders than psychotic disorders, but 98% of people who responded to the survey said they had at least one significant concern related to their care as it was impinged by the COVID epidemic. The biggest issues were either service disruption or loss of access to their medications, having difficulties getting refills. I think it's really incumbent on us as clinicians to do what we can to help support individuals so they can have access to all of their coping strategies in the forms of a support system.

I thought it was very touching to hear what John has been able to do for his brother, and for one thing, I just want to express my sadness for the loss of his mother. Not only is this a sad event in any individual's lifetime, but certainly during this period of COVID where there's a lot of loss already. I think what we need to do as clinicians is what I say is follow the three Rs, which is reconnect, reassess and respond.

By reconnect, it's not just me reconnecting with my patients, but also helping them reconnect with all of their support structures. Maybe the clubhouse has moved online, help your schizophrenia patient connect with that. Maybe there now is access to certain psychosocial rehab groups, cog rehab groups. Let's find them and let's reconnect you with them. Most importantly, do what you can to help them negotiate the difficulties of technology.

There's a lot of people who struggle with this and some people simply don't have access. The schizophrenia patient doesn't have a smartphone, perhaps, doesn't have a laptop, but perhaps somebody at the group home does, perhaps there's a caregiver who does, who can help facilitate the appointment. Often we're dealing with older individuals sometimes who just simply have difficulties with the technology. Again, maybe there's a loved one, a friend who can help facilitate that connection.

As we say, a phone appointment is better than no appointment, but we would much rather have video. We get all of that nonverbal information which is so important. Most importantly, don't dismiss depressive symptoms as simply expected. Oh, this is a stress reaction, we'll call this an adjustment disorder. If the person meets a criteria for a major depressive disorder, we have to treat it as such. Yes, a stress can underlie a major depressive episode, but if you're meeting those symptom criteria and severity for two weeks or more, it should be addressed.

I think we all understand that bipolar disorder is a mood disorder, but I'm not sure everyone does understand that having schizophrenia means that you have a high rate of moderate or severe depressive symptoms. This is part of the disorder. There's a very famous 12-year study which came out of Germany, followed a group of first-episode patients for a dozen years. 40% met criteria for moderate or severe depressive symptoms. If your patient is now leading criteria for a major depressive episode, you need to reassess them. If they just have a mood disorder, go ahead and treat that bipolar depression with the agents that we now have available.

If you have a schizophrenia patient, there's a couple of thoughts. Number one is think about symptom exacerbation presenting as depression. The voices are worse. Maybe the delusions are worse and that gets manifested as depressive symptoms. We know that when schizophrenia patients are admitted to an inpatient unit, about 80% will actually meet criteria for a major depressive episode.

Now, a lot of that gets better with antipsychotic treatment, but I think the point is that don't assume it's just mood. Also, understand that the underlying symptoms may be transiently worse and need to be addressed. If you feel like that's not the case, antidepressant therapy is very important for patients with schizophrenia, assuming that they have no prior history of mania.

That's a part of the response as well. What we're doing here is to try to treat people the best way we can under a period of extreme stress. It's not surprising you will see a lot of depression, but again, if the criteria are met for a major depressive episode, we need to respond and we need to initiate the appropriate treatment for these patients.

Roger: Very helpful, Jon. One of the observations I've had, and I'm certainly not alone in this observation, seeing many of my patients with depression and bipolar disorder, which is the population that I provide care for, people are really feeling despondent. They're feeling isolated. We talked about that. There's almost a pervasive anhedonia about life. They feel very disconnected. Then the question is, are these treatable symptoms of an underlying mental illness, and/or are these reactions, or is this a COVID 19 adjustment disorder? What are your reflections on that?

Dr. Meyer: Well, again, Roger, this really addresses what I just discussed. We would say that adjustment disorder is a reaction to a stressor and it encompasses a certain level of distress. However, once it now meets criteria for a major depressive episode, I think we have to look at it differently. I'm going to bifurcate this statement based upon whether you have schizophrenia or a bipolar spectrum disorder.

If you just have schizophrenia, there's a couple of reasons why you can be depressed. One of them is you just have major depression. We know this is very common. As I said, about 40% of schizophrenia patients have persistent, moderate, or severe depressive symptoms. It's actually part of the disorder and it's very common. However, we also know that individuals who are suffering a relapse of their schizophrenia and exacerbation will have even higher levels of depression. If you look on an inpatient unit about 80% at the time of remitted for an exacerbation of schizophrenia will actually meet criteria for major depression.

Now, a lot of that improves as we adequately treat those psychotic disorder. I think the most important thing is not just say, "Well, I'd be depressed too if I was isolated and under economic stress." That's not acceptable. You have to provide them the treatment that they need understanding that if they've now met the criteria for major depression, they deserve to be treated as such.

As far as the isolation aspect of the question, we really need to do the best we can to reconnect with our patients. We would say a phone appointment is better than no appointment, even better is going to be video because we get that nonverbal information that we don't get just by telephone. The challenge for a lot of individuals is negotiating technology. This really has nothing to do with whether or not you have a mental disorder.

Some individuals are either older and struggle with the technology. Some people simply don't have the economics to be able to afford a smartphone or have access to a computer with a camera. I think what we want to do as much as possible is for those who do have some limitations in dealing with technology is try to help connect them with caregivers, friends, or providers who can help them either set up their laptop so they can use Zoom, show them how to use a smartphone, or perhaps invite them over for a session. Say, "Here, let's set you up, we'll put you in the room so you'll have privacy and you can go ahead and do the session."

I think John spoke very, very eloquently about what he's been able to do in order to reconnect his brother with the various services he needs. In particular, for patients with more severe mental disorders like a schizophrenia spectrum disorder, they simply just may not have the wherewithal to figure out that, "Hey, this group, which I used to belong to is now meeting online, and here's the way I can get to it. These people who I used to see at the clubhouse are now meeting virtually, and this is how I can reconnect." It's important to try to help these individuals as much as possible so they can get back all of their support sources and really do the best they can during this period of isolation.

Roger: Jon, as you know, the reports have been very clear that people with preexisting conditions specifically morbid obesity, type 2 diabetes, and hypertension are especially at higher risk of not only being infected by COVID-19 but also having complications like hospitalization and mortality. We know that people with bipolar disorder and schizophrenia have a much higher rate of all of these disorders and you've contributed to this literature in a very significant way when compared to the general population.

This is something that we're all concerned about with our patients, but here's my question point-blank. Do we in fact know if antipsychotics, anti-depressants, lithium, anticonvulsive mood stabilized, I can keep going, do psychotropic drugs have any type of effects on the immune system that increase or decrease a person's risk to COVID-19?

Dr. Meyer: Well, this is a very interesting question. I think to the best that we can say is that psychotropics, in general, do not have a direct effect on immune response. I think as a psychiatrist, my bigger source of concern among my patients is their underlying cardiometabolic comorbidities. I used to do metabolic research in patients with schizophrenia. These are individuals who have twice the population rate for metabolic syndrome, twice the population rate for type 2 diabetes and to compound that very high rates of smoking. All of these present significant sources of comorbidity, which we know makes individuals more vulnerable to the severe sequelae of COVID infection.

I think it's not appropriate to focus on changing the psychotropics, but more importantly, counseling individuals who you know have these comorbidities to be as safe as possible. Obviously, it's a great opportunity these days if you have patients who are smoking to really let them know, "This is a great opportunity to consider trying to quit." For one thing, cigarettes are very expensive. In many states, they've raised the taxes significantly to discourage teenagers from starting smoking.

Now that the news is out there, that smoking is one of the big risk factors for having a more severe outcome from a COVID-19 infection, we can perhaps get those people who may be on the fence about stopping smoking and say, "Hey, what can we do to put you in a smoking cessation program today." Guess what? These are available virtually. They can get the support they need, not just the patches and the gum or the lozenges, but people who stop smoking who have severe mental disorders are five times as likely to fail as the general public and the general public doesn't have great success either.

Put people with all the resources they need in order to have their success and as I say, this is maybe a great time to talk about smoking cessation, if you haven't already, because you might find a receptive audience.

Roger: Look, this has gone by very quickly. I think we're only scratching the surface. First of all, my professional colleagues, Doug and Jonathan, thank you for your words of wisdom here today. John Bragiodi, thank you so much for being with us and first of all, providing your perspective. It's certainly what it's all about, it's why we're all here, to help patients and families.

I also, in fact, would just summarize by saying, this is, like I said, a very unique time. I refer to this as the trifecta of risk, but my hope, which I think is a hope based in reality is that the externality of this is that we will have a rethink of how we provide care from a health systems perspective, which has really been the elephant in the room with respect to people who suffer from persistent mental illness. My hope is we'll have a better system for people so they can access the services that they need and they deserve.

We thank Sunovian for the grant to make this possible, NEI for all their engineering and architectural skills behind the scenes and I thank all of you for participating today, and I wish everyone a very good day. Thank you all. Take care.

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