Roger McIntyre: Hello, I'm Roger McIntyre, the psychiatrist at the University of Toronto, Professor of Psychiatry and Pharmacology at the University of Toronto. I welcome you to our program entitled Mental Health Prime Time. It certainly is prime time in many, many ways. What we've learned from COVID-19, and it couldn't be a more topical area of conversation over the next hour or so. I'm glad that you have joined us.
I, first of all, want to recognize the support of Sunovion in preparing and helping us put this together and provide this platform for knowledge exchange. In a few moments, I'm going to be also having, I guess, a conversation of sorts with each of my colleagues that are presented here in sequence. Dr. Singh, Manpreet Singh, from Stanford University psychiatrists, Dr. Culpepper from Boston University, a family physician, Dr. Meyer, Jonathan Meyer, from the California Department of State Hospitals, University California, and also Tammy LeBlanc-Russo, a nurse practitioner for the Center for Solutions.
I'm looking forward to inviting them on with me in just a moment, not just for a conversation on COVID-19 but for many different perspectives of this situation. Before I bring them on I just want to really, if I can, cover a couple of areas here that I think really, for me at least provide some of the framework for thinking about COVID-19 from the point of view of mental health. I see the topic of risk, what I call the rule of 1% and resiliency, risk 1%, resiliency is what I would like to speak to.
This truly is a triple threat. It's a public health crisis, but it's also a economic crisis, as well as a mental health crisis. Unlike any event of history, this is a truly global event affecting not just the high-income countries like the United States and Canada, but also some of the low and middle-income countries. Along with this triple threat, and I think what emanates and surrounds this triple threat is malignant uncertainty, malignant uncertainty from a health perspective, both physical and mental from a point of view of information and where to capture accurate information.
The World Health Organization talks about the info demic and the paucity of accurate and reliable information and really certainty as to when we'll get lives back. We know from many lines of research that malignant and persistent uncertainty is certainly negative for all aspects of our health. We're already beginning to see some early indicators now, that what we had projected would happen from mental health perspective are being realized.
Just in the last week, for example, the Robert Wood Johnson Foundation, along with the Chan School of Public Health at Harvard, has reported a survey conducted in America's four largest cities, New York, Chicago, LA, and Houston that 60% of respondents said that they are having very serious financial problems. This leads to not only economic insecurity and food insecurity and also housing insecurity, but also in fact creates a dilemma for people with respect to again, certainty going forward.
You probably all heard that about four weeks ago, the Centers for Disease Control and Prevention, reported that 25% of people between the ages of 18 and 24 report very serious thoughts of suicide. What can be more concerning, especially on the cusp of yesterday, which was the World Health Organization's Suicide Prevention Day globally. Let's move if we can into some survey data, whether it's epidemiologic data captured in general population surveys or clinical data that aims to look at not just measures of distress, but also levels of distress that would be in keeping with a mental disorder.
What we're seeing around the world is an increase in very common conditions like major depression, anxiety disorders, post-traumatic stress, and substance use disorders, to name a few. What we're also seeing are projections of increases in suicide and that segues into something I'll come back to in a moment. Taking together, this is a risk that we just simply have not seen from a global scale the way we are seeing now.
I think for the foreseeable future, we're going to be saying a lot about resiliency. In other words, from an individual perspective, from a societal perspective, how can we augment the resiliency of our population to decrease the risk, of course, of contracting a virus but also contracting mental illness? In other words, to have the unfortunate reality of a declared mental illness and/or an increase in suicidality or to begin to learn a bit about this.
For example, we just completed a survey with the Oxford school, the Blavatnik School in the UK, that looked at 17 variables of government stringency, stringency meaning to what degree did the government shut things down to flatten curves and just stop the spread of the virus that had the unintended consequence of economic disruption not just on the demand, but also the supply chain of the economy.
What we found was interesting, those governments around the world that acted the fastest and shut down their economy with the most aggression, actually had the lowest rates of depression, the lowest rates of anxiety. That's interesting because we've also just observed in a survey we did in Poland and China, that those countries that mandate the use of masks report lower rates of distress in the general population, both from the depression and from anxiety and PTSD perspective.
There's aspects around public health interventions that can in some ways, reframe resiliency. We've also learned from the Great Recession, that when the government provides economic support in the form of wage subsidy, protect the small business, which I call the vaccine of mental health, as well as job retraining, that can reduce rates of distress or pathological levels of distress and perhaps also suicides.
We're learning that not just during this pandemic, but Toronto was the city most affected outside of Asia during the SARS situation back in 2003. These are some of the lessons we learned back then, as well. It's not just about social and government, we're learning about individual resiliency. For example, before this pandemic, we had a very serious epidemic called loneliness right across the lifespan, especially amplified in younger and older populations.
One of the replicated findings in our research, looking at the mental health consequences of COVID, is that those individuals with greater social connectedness appear to be more resilient. In fact, what we have found is that women, people of low economic strata, people who wrote report, high levels of economic disengagement and loneliness, are more prone to experiencing depression, and anxiety.
These are areas that are now emerging around the world, regardless of the GDP of the country. This is a result of a survey that we did, where we looked at the implications of using different types of media. I'll just leave you with the bottom line portion control. We think portion control, we usually think about food and alcohol but portion control also means news media and social media.
We found in fact, people who spend more time on social media report significantly higher levels of depression, anxiety, probably in part because of overexposure to the so-called info demic, misinformation, and disinformation that both the UN and the World Health Organization has identified as a very, very serious problem. The 1% rule, what is the 1% rule? Well, we've projected out from this current economic crisis, what was also observed during the Great Recession, and to some extent, during the Asian financial crisis of the late '90s.
That is, for every 1% increase in unemployment, there's a commensurate 1% increase in suicide in the adult. What's interesting is that in the United States, within about four weeks after the situation started, almost 15 years of job creation was destroyed. We're certainly very happy to see some of the statistics going in a more favorable direction recently. We certainly hope that it continues to go in that direction.
Durkheim, the father of sociology was the one who, in fact, made it very clear to us in his writings back in the late 1800s, that work serves as a marker of social integration. We know that when people in fact are working, they are on average rating themselves as more socially integrating and having more economic security. These factors, among others, are probably contributing to the distress. This is suicide in the adult.
We also know that children are especially at risk during COVID. We're seeing an increase in some of the domestic calls to law enforcement for violence at home and we know based on systematic reviews of the literature, that one of the precipitants of suicide in children is domestic violence and domestic dispute. That's something, of course, we're especially concerned about in our younger population.
Now, preventing suicide is possible. I think that against this background of incredible trauma around the world. Again, the triple threat as I described it, there's an opportunity and historically access and availability to mental health services has been woeful for as long as anyone can remember. Now, with the virtualization that has really accelerated in the last six months in ways that would've been unthinkable before COVID, that may create an opportunity for not just access and availability, but perhaps more integrated care for people who have serious and persistent mental illness and perhaps we'll say more about that.
This slide is speaking to a result that was published from a pharmacy benefits manager called Express Scripts, wherein we're beginning to see an increase in the prescription of psychiatric medications broadly. This survey looked at medications for depression and anxiety and for sleep, no surprise, they are going up. It's an interesting academic question and clinically relevant whether psychiatric medications work as well, better, or not as well during times of COVID. That'll be a very interesting way to begin thinking about treatments against this incredible background that people are faced with.
One takeaway and final message I'll leave you with before we invite Dr. Manpreet Singh to join me is that I think we have to look at this from the point of view of plurality. Indeed, we know that the full population is dealing with an incredible risk, but the resiliency is not equal across the general population for a variety of social and psychological and economic, and other reasons. For example, we're hearing that people who are indigent or poor are more prone to psychiatric difficulties during this time. Our patients who already have mental illness are more at risk and we've recently reported on that in Asia.
Frontline workers clearly are at greater risk, and we should not forget about the demographic of women in racial groups, Oxfam reporting that women, especially women of minority, are especially at risk during this time. We approach this with a view that we're interested in identifying risk. We want to augment resiliency. We certainly want to prove the 1% rule wrong and towards these aims, we're hoping that the virtualization of what's happening with healthcare broadly and certainly in mental health can provide an opportunity for all of us. With that, I'd like to, in fact, now switch gears to good friend and colleague, Dr. Manpreet Singh. I'm going to invite Manpreet to join me now on the screen. Hello, Manpreet?
Dr. Manpreet Singh: Hello, Roger.
Manpreet: Thank you very much. It's great to be here.
Roger: Manpreet, you bring up a perspective which I think people are going to be very interested in and that's from the early in life perspective, not just because you're still early in life, but you see people who are early in life. You see a lot of children. How's the mental health of kids manifesting during COVID-19?
Manpreet: Well, it's complicated, Roger, and you've done a great job setting the stage for the impact broadly, but let's spend a few minutes talking about kids because at the center of the pandemic is the virus itself. Now, we know that symptoms appear to be relatively mild in most kids but they can still occur. Respiratory difficulties and fever can still predominate and illness and hospitalization can certainly have an impact, not just on health, but on sleep and the quality of interactions that kids are able to have if they do get sick.
Isolation and shielding also result in sedentary behaviors and food consumption, which are likely to impact weight in kids and consequently health and sleep over time. Kids can also experience unnatural increased levels of stress. Given the widespread changes in the family situations, health concerns, and uncertainty, as you mentioned about the future. These two can result in significant difficulties with sleep.
We have to also keep in mind that as schools across the nation close to stop the spread of the 2019 coronavirus disease, millions of kids are obliged to remain at home. During this time, it's never been more important for parents to consider the child's need for structure, education, exercise, social contact, appropriate, leisure time and rest, and calm and rational explanations about the situation. Hard to do if you're a parent and experiencing your own levels of uncertainty, wouldn't you think?
Roger: Well, I think so. You've touched on quite a few things there, Manpreet. Let's talk about the school. What do we know about children in school versus children at home? What are some of the factors to consider? Look, I think just to call a spade a spade, we appreciate that there's a political radioactivity around a lot of this, but we'll put the politics aside. What does the science tell us around this topic of kids being in school versus not in school?
Manpreet: Well, certainly at the root of it is the potential concern for spread and because kids are carefully re-entering schools. The infrastructure, not just to prevent the propagation of COVID among school-age students and teachers, but to also implement strategies to test and screen for contact tracings and things like that have to be put in place. Those infrastructures are still developing in this country. We know from other nations that have done reasonable school entries that those resources and infrastructures are critical to prevent the spread of disease.
For most folks and school systems that are struggling to build those infrastructures, distance learning has become the norm rather than the exception, and that in it itself has some implications because social distancing advice to stay indoors can reduce exposure to sunlight which is also so central to establishing a consistent sleep routine. You also end up having exposure to blue light, extended periods of time of exposure to blue light with more time using technology, which can especially be problematic in the pre-sleep period and disrupt melatonin production.
We're in a really important catch-22 when it comes to the science and the evolving science of this issue and the impact of it on brain development, on learning, on all potential issues that are, I think, at the root of what we need to address and systematically study. Kids sleep, I think can't be underscored enough because it's a biological imperative. Yet, a lot of kids who are in the distance learning mode aren't getting the sleep that they would normally get if they went to school and so because of that disruption in sleep, wake cycles, some of the kids that come into my clinic say, "I used to have a commute to school for a half-hour, an hour. I had a pre-preparation period before I actually had to get to school and start learning. Now, I roll out of bed five minutes before class and get on a screen."
You can imagine there are a number of factors that contribute to what might be evolving understanding of not just vulnerabilities to sleep disruption, but broader concerns about how that impacts vulnerabilities and risk to depression and anxiety and other psychiatric conditions. Those risk factors say, for example, if they're already present for youth, they're simply exacerbated by this situation. An appreciation of the fundamentals of how we keep kids regulated from the perspective of sleep and routines is critical for our resilience and for our children's resilience, which I hope we have an opportunity to also touch on.
Roger: Well, sage advice. Manpreet, let's keep going with this issue about sleep. I know you have expertise in bipolar disorder, and I'm already starting to think about the implications of what that has for our patients with not just bipolar disorder, but that jumps to mind right away given what you and I do for a living. How has the telepsychiatry, how has it affected your practice with respect to seeing kids and seeing families?
Manpreet: You know, Roger, at the first outset of the pandemic, there seemed to be a honeymoon period. It was like kids were super happy that they were out of school, party time. There was a relaxation a little bit from the normal stresses that occur from being in a school setting, and so probably for the first month or so in my practice in child and adolescent psychiatry and the specialty practice in pediatric-onset mood disorders, a lot of the kids that I saw were doing just fine. My check-ins with them seem to suggest a relative stability and a reduction in symptoms.
Even the anxiety around the uncertainty of this had seemed to come. Maybe there were more connections with family members that were very positive and encouraged the prosociality that kids didn't get, the connections that they didn't get with their parents who were at work and they were at school. Something happened during that first month that seemed like a honeymoon period and then after that, when the pandemic continued, there seemed to be a gradual increase in stress, anxiety, exacerbation of mood symptoms, suicide risk increased.
It seemed like more kids were contemplating and also engaging in self-injury. I had to hospitalize several kids over the summer as a result of these exacerbations and also be thoughtful about how to provide pharmacological management through a telehealth environment where I can't monitor, for example, those things that are fundamental to our practice like weight and height and vital signs. That's been a shift for my practice, certainly.
My hope is that as we get our legs under us to be able to do this well, we can continue to practice the things that we know work for kids and reinforce some of those principles in our practice but also leverage the home environment more. Now we have an opportunity where we didn't before, where kids and parents are at home, to reevaluate that honeymoon period and see if there are ways to build adaptive family connections.
In our own work, we've demonstrated that in fact, when you reduce family conflict, you reduce suicide rates, you reduce mood recurrence, particularly depression relapse. These are things that are intuitive but now we have a science to back them up.
Roger: Very nice points [unintelligible 00:22:06]. Manpreet, don't go too far. We're going to come back to you in just a few moments but just one short snapper before you go and, of course, it's an easy short snapper and that is we're hearing about the epidemic of loneliness so amplified in young people during this time. Do you have any quick, easy tips that you offer your children? How do they deal with this issue?
Manpreet: It's a great question. To me, one of the key principles of resilience in my work in working with children of parents with bipolar disorder and depression is the element of pro-show sociality and the idea of social connectedness. Of course, the way you battle social isolation is to try to get connected. It's a hard gig to imagine kids and parents getting connected and miraculously interacting with each other if they don't really necessarily want to.
We've got to arm children and families with skills, communication skills, problem-solving skills, to be effective at communicating with each other where they haven't had to before and encourage that prosociality in ways that are adaptive. Because it turns out that establishing and nurturing a supportive social network is a key principle that makes humans resilient. If we can continue to encourage that in our families, nothing like it.
Roger: Great point, and don't go too far, Manpreet. Thank you for that. I think we're all especially interested in our younger populations, among others, but certainly our younger populations. I want to now segue if I can, and invite Dr. Larry Culpepper to join in. Larry is a professor of family medicine at Boston University. Larry, welcome.
Dr. Larry Culpepper: Thanks. Glad to be here.
Roger: Larry, I think we all like to be where you are right now given that background. Larry, from your perspective in primary care, what are you seeing?
Larry: I think it's important to understand primary care in some ways is the front door to psychiatry. We see a lot of the patients early that eventually get to specialty level care. What we're seeing a lot of times it's going to end up in your offices with a delay. We're seeing a number of things. Our practices tend to be in urban Boston, so we see a lot of lower-income patients, but we also have a middle and upper-income patients. The middle and upper-income groups seem to be doing well. They've transitioned to online work. Their incomes have often not been affected greatly, and it's really the blue-collar and the low income that have had the double whammy of effects of COVID.
As you vehemently described, there are a lot of increase in the stressors that our patients are under, financial uncertainty, and so forth. The other thing, though, is that we're seeing a broad range of difficulties. Certainly, we talk about stress and depression and anxiety, but we're also beginning now to see COVID-recovered patients coming. With them we may have PTSD, we may have flashbacks to their hospital experience.
We also have families that are undergoing grief reactions from the loss of a loved one. If you reflect, right now we don't have the rituals that go with death. Oftentimes families know their loved one died in the hospital. They may have had a glimpse on a screen before the death, but they don't have the rituals that we usually have, they don't have funerals the way we used to. We can expect, I think, a significant increase in grief.
We are also seeing in the post-COVID patients unusual symptoms. I think one of the things that we're going to be turning to psychiatry and neurology for is to help us unpack what is actually going on with patients? What's going on in their brains? Is this a neurological insult? Is this psychiatric stress? We have a lot in the future. You've mentioned the income issue greatly. I've looked back at the 2009 depression and fear of losing jobs. Just the fear of losing a job increased the risk of depression twofold.
If you did lose your job, your risk went up three or fourfold. If you went without heat, I mean, we're moving into the winter when people and all of the supports are collapsing in the United States because government supports are running out. Being unable to heat your home, five to sixfold increase in depression. We can see a significant increase. Catherine Ettman is a researcher at Boston University School of Public Health. She's in the doctoral program there.
She recently did a survey using the PHQ-9 nationally representative survey, compared it to pre-COVID similar nationally representative surveys. What she found was, I think, significant. Certainly, it replicated that the more stressors increased the risk by up to threefold. What was astonishing, the most astonishing figure to me, was whereas pre-COVID community survey showed about 0.7% of patients reporting severe levels of depression. Now it's 5.1%.
Mark increase not just in depression, but in severe depression. This is going to be long-term. If you look back at the 72 depression, what we find is that losing job, being in poverty, increased rates of high depression symptoms four to five-fold up to 10, 12 years later. It's a big issue that is going to be with us for a long, long time.
Roger: Oh, I think that's well taken, Larry. I think we're all hoping-- people talk about V-shaped recoveries, W's and U's and L's and all kinds of other letters, but absolutely this yoking, this linking economy to mental health is one of the most replicated social observations, social determinants. Let me ask you a more practical question, Larry.
Roger: Once you put on your futuristic glasses, where do you see telemedicine three to five years from now?
Larry: I really think it's going to settle in and be a permanent part. A lot of it depends on what we do in terms of reimbursement. The United States, each state may have very different reimbursement rules. We're moving to, hopefully, permanent adoption of equal pay for telehealth and in-person. I think we need to think through some of the more subtle possibilities. Telehealth gives us a chance to outreach.
We know that prior patients that have had episodes of depression in the past are at much more risk now, so we need to be outreaching. They may be disappearing into their homes and be isolated. Outreach may be very useful. We need to think about telehealth involving staff. Social support is useful. We can have drop-in sessions that are educational, particularly around community health centers, community mental health centers. We know that behavioral activation by telehealth is affected and lay telehealth behavioral activation is effective, but even more effective than that is telehealth problem-solving counsel. Helping patients think through, and come up with practical approaches to problem-solving.
Screening is going to be critical. We need to screen, not just for depression, but as appropriate mania, substance abuse, PTSD. There are a lot of conditions that we can outreach to find. Patients that are depressed tend to deactivate. Behavioral activation is effective and exercise, getting off the couch, getting out of in front of the TV may be useful. Thinking about community resources. We often know about community resources that our patients don't know about. Reaching out to them, understanding referral options for patients with various problems can be very helpful to our patients. Mobilizing community resources can be key. A couple of other things is--
Roger: Just maybe-- just the issue of time, because we're running out of time here. I was brought on this program for one reason only to give us a stick to stay on time. I'm trying to do my job here. [unintelligible 00:31:43] just one more factor around this area that you pick, you were top of screen. I couldn't agree more, but maybe one more takeaway message on that.
Larry: Think about guns in the home. We're moving into suicidality in the United States, depending on your state. Guns may be one of the most highest risks for particularly adolescents and young adults. Think about guns and do appropriate screening and counseling.
Roger: Beautiful. Don't go too far, Larry. We're going to come back just wanting to make sure we have enough time for everyone else. We're going to come back and have a group discussion. Thanks for that. I want to invite now Tammy LeBlanc. Tammy, nurse practitioner. Welcome, Tammy.
Tammy LeBlanc-Russo: Hi, Roger. Thanks for having me.
Roger: Hi there. Glad you could join us, Larry. Just pick up for Larry left off Tammy. That is from your perspective, what are some of the aspects that you're seeing in your patients during this COVID-19 time?
Tammy: What I've been seeing is definitely the shift to telepsychiatry. My practice is about 95% telepsychiatry now, and it consists of telephone calls using doxy.me, FaceTime, Zoom, all of the things that you can think of. I'm trying to use that to my advantage and being able to see inside somebody's home when I'm on a call with them and we're working on things that Manpreet and Larry spoke about earlier, nutritional status, trying to get people to move around more.
I'm spending some time doing education with my adolescence and my adults about proper nutrition. I find that, for me, if I'm able to get some labs, to have a starting point, review the labs on nutritional things like B12, vitamin D, things like that, and I have something on paper and we say, look, here's where you are and you have some deficiencies and how can we change your diet to make you feel better? Now we have a goal that we can measure again. I'm taking the telepsychiatry to my advantage and having them pull things out of their cabinet and say, "All right, let's look at what kind of nutritional status does that food item have?" I find that it's been really helpful and it's definitely a shift, that's for sure.
Roger: Yes, absolutely. On that topic of weight and management of weight, we heard this also from Larry and Manpreet, people, their behaviors change. They're not sleeping the way they once did. Their schedule is disrupted. People are talking about putting on weight across different age groups. With respect to the patients you see who are taking psychiatric medication, has that had any impact on what you're doing with respect to greater prioritization of medications with less weight gain, things of that nature?
Tammy: Yes, of course. I tend to try to treat my patients the way I would treat my family and I'm using meds that have a kinder metabolic profile. Not only am I doing that, but I am measuring and for the folks that do not have scales at home, at the very least, I'm asking them how do their clothes fit? Are they tighter or looser about the same? You can measure some things on the back end, I'm doing homocysteine and C-reactive protein. Not only am I mindful of the medications, I'm trying really hard to motivate them, to make some changes at home for their weight.
I think part of that, like Larry and Manpreet were speaking of, is getting your patient moving. When people get home and they're stuck in their house and they're afraid to leave, they're not moving as much, the gyms are closed. I'm trying to get patients to do something that I call tiny habits. Know if you've heard of that, it's by BJ Fogg. You get somebody to commit to 30 seconds of some movement, one minute of some movement and you build on it from there. I've been having really good luck, so I'm not seeing huge weight gain with my patients but it's motivation, right?
Roger: Oh, absolutely. Tiny habits, that's a nice pearl. I would agree with that. On that note how do you then, in fact, with your patients, how do you measure their weight and how do you measure other physical aspects? Are you actually still seeing patients in person? Is it a hybrid model you have?
Tammy: It's hybrid. Most of the patients are virtual. I have a handful that are coming in. The folks who are home that have scales, I am documenting every time. They know the drill, we log on and they either give me their weight or they hurry up, and go get it and come back. They are doing that and for the folks who do not have scales just simply trying to ask them how their clothing is fitting, because that's difficult. If you don't [unintelligible 00:36:31] how are you measuring?
Roger: Right. I suspect a lot of people putting on their dress pants for the first time in six months are probably having a bit of distress at the current time. Keep going with that. I was asking Larry about telepsychiatry and you're using it obviously. Are there any disadvantages to telepsychiatry from your perspective? It can't just be all good.
Tammy: There are. I have some folks that really don't have the ability to connect virtually so I'm doing phone calls. When you have a phone session, you're missing that piece of seeing the person, seeing what their mannerism is, do they seem fidgety? Do they seem lackadaisical? What's that perspective? That does make it more difficult or you have the folks who are able to connect and their connectivity is poor. I've seen the roofs of cars, people put their phone down and now you're seeing the top of their car, you're not seeing their face.
I'm asking them to reposition. Sometimes their background noise is loud so I'm asking them to please shut your door or please turn down the TV or turn it off. There is a lot of adjusting. I feel like after the first visit or so, it's been smoother. However, I do miss seeing people physically in person and people are missing that. They're asking when they can come back in and we're just trying to play it safe. We're following the guidelines and I'm in upstate New York and when we feel like it's easy to have people come in and manage them that way, I certainly will be eager to get that moving.
Roger: For you, where you're located, in your jurisdiction, are there any incentives or disincentives or both, in fact, to continue with telepsychiatry?
Tammy: Well, yes, there are. With a lot of our payers, we're able to have 10% reimbursement and the copays are being covered by the insurance companies. Not having patients canceled because they can't afford their copay that's being covered. That's beneficial for myself and the patient. It's not causing a burden in that way.
Roger: Right. Tammy, thanks for your perspectives. That's fantastic. Really appreciate it. Don't go too far. We're going to bring us all together for a more round table virtual conversation. Thank you. This is an opportunity for me now to introduce friend and colleague, Jonathan Meyer. Jonathan, welcome.
Dr. Jonathan Meyer: Hey, Roger.
Roger: Hi there. Glad you could join us and nice to see you. Jonathan, you see a variety of patients, but certainly, we're very familiar through expertise in people with serious mental illness. How has this time affected people with serious mental illness such as schizophrenia?
Jonathan: Well, there are some things which are unique to that population and some things which are common to the entire discussion we've had. I think the part which is in common is that this is a population which already has a very high rate of persistent depressive symptoms. If you look at longitudinal studies of schizophrenia, patients followed over 12 years in Germany, 40% had persistent, moderate, or severe depression. That's only going to be exacerbated by the current situation, partly because also they are suffering from isolation. I think it's very important that you try to screen very carefully to see how people are doing using the best methods you can. We think phone is better than nothing. Obviously, tele is better than phone and then maybe at some point, if we're very lucky, you'll see people face to face, but try to do the best you can and also maybe alter your model. The traditional model of seeing a schizophrenia patient has been, we'll see in four weeks, six weeks, eight weeks, but perhaps now during this period of crisis and uncertainty, brief and more frequent visits may be a better way to go and we strongly encourage providers to do this as much as possible, maybe 15 minutes every two weeks is a much better way to go than that 30 minute med check in a month.
It allows you to keep tabs on what's going on and most importantly, if you started to act that they have depressive symptoms, treat them. Antidepressants are very safe in patients with schizophrenia obviously be mindful of drug drug interactions I have to put on my little psychopharmacology hat there. Be mindful of drug drug interactions, I often will go to sertraline as my default. It's generic, readily available, minimal drug drug interactions, I can give you as much as I want. There's some concerns with citalopram, and escitalopram about QT prolongation. Why worry about that? Well, I have to send somebody someplace to take EKG, they don't want to leave their house anyhow.
If you have somebody with a bipolar diathesis, that's a different story. People with schizoaffective bipolar type that may need a different type of consideration because they may not tolerate or respond to traditional antidepressants, you may then have to consider, do I want to switch these individuals antipsychotic to one which may also have an indication for bipolar depression and there are a couple of options out there. Those are some things which are both the same and somewhat unique. I think the more unique aspect is how the issue of disconnectedness plays out. As much as I like psycho pharm. It's just the foundation for treating schizophrenia patients.
They need rehabilitative services and there's a wonderful article, it's only two pages in the September issue of Psychiatric Services from Judith Cook is at University of Illinois, Chicago, just talking about, you have to reintegrate these people back into their groups, back into their peer support, back into all those things which they used to do when they went out and came to the clinic, came to the clubhouse, or whatever. It has been challenging.
As we know, for a lot of people with severe mental illness, they have difficulties negotiating technology, a lot of people do, it's not just them but even more so, they may not have access readily to a laptop. Hopefully over the last six months, a lot of us have been able to troubleshoot some of those issues and get them access, either through a provider, family member or whatnot to set up and initiate this connection but it's important to try to reestablish these rehabilitative services so that people can do the psychosocial rehab, they can do the CBT for psychosis, all the other things that are going to be added on to medications and again, it's not just the rehabilitative benefit of that.
It's a benefit, as we've been talking to throughout this hour of reconnecting people with those social contacts that have been so important that they're used to, they will go into that same symptom management group for three years, and now they lose it. That's very, very hard and it's important, though, I think we recognize that yes, well, I want to make sure you're getting your medications, I want to keep tabs on your psychiatric symptoms, psychosis, mood, whatever, but also the other parts of what we do in order to treat people with schizophrenia, to give them really the best chance of riding this out, knowing that it may be prolonged in many parts of the country and we may just not be able to have groups the way we used to, at least for the for the time being.
Dr. Roger: You mentioned Sertraline John, with respect to depression, I wasn't sure were you referring to schizophrenia and/or is that your treatment of choice for bipolar disorder as well for the depression? Is that what you're getting at?
Dr. Jonathan: I was speaking more for schizophrenia patients, because they're often on a number of medications. I'm worried about drug drug interaction. I go to that as my default choice for the schizophrenic patient who does not have a history of mania. Just schizophrenia, not schizoaffective bipolar, as I alluded to, and you and I have had this discussion extensively. Even when bipolar spectrum patients are mood stabilized, bipolar one, or Schizoaffective, bipolar in particular, they often either do not achieve a robust or sustained response to traditional antidepressants, or we destabilize them and the idea that well, because they're on lithium or Divalproex, I can definitely give them a traditional SSRI, SNRI it's something to really think twice about, because there is a risk of destabilization.
With the world were different and this was January, I'd say, well, in some instances, we could maybe accept that risk, but that's not acceptable these days. The idea that I could destabilize somebody and maybe send them to the hospital. You'd have to think twice and I think it's really important when you have the bipolar spectrum patient, again, the bipolar one and schizoaffective in particular, you think of traditional antidepressants really as the drugs of last resort, we just don't have the ability to manage people the way we did previously and the folks have exacerbations, it's gone to a really different situation and presents a whole different types of stresses not only for the individual themselves, but also all those around them.
If you're trying to manage this, maybe get the person to the hospital, can be really, really a very difficult situation for all involved.
Dr. Roger: Agreed very much, Jonathan. In August of our American Journal of Psychiatry, a report came out that really, I think, caught a lot of people's attention. One being that looks like antipsychotics are the most frequently prescribed drugs in bipolar disorder, a significant change over the last two decades and with that observation, of course, there are Cardinal treatments is you just have this foundation and schizophrenia, how do you assess for movement disorders or TD in this virtual world?
Dr. Jonathan: Yes, it's somewhat challenging, but not as difficult as you think. I think Tammy really mentioned that you want to have people have a stable platform for their video. When you're trying to assess them for TD, you're actually seeing their mouth and not their top of their forehead or their ceiling. I can't assess the ceiling very well, it doesn't seem to move. Maybe there's a tremor but that's really important. You can actually do a lot of movement disorder assessment via tele, obviously, I cannot check you for rigidity, I can certainly look at the type of tremor you have, is this an intention tremor from your Lithium, or is it a little bit more pill rolling, because you're Parkinsonian, I can get them to get very close to the camera, open their mouth, do some distracting maneuvers.
I think the idea is you do your best you can, I do want to reiterate to people that about a third of patients with TD don't have manifestations above the neck, so be mindful of that, have them sit back a little bit, see if you can see what's going on with their torso. Ask them of course, if they've noticed anything movements in their extremities. Again, you can only do what you can do. I think we all wish we could do it the way we used to but it may not be possible but I think you make the good faith effort and I think that's what we've all been talking about. You just do the best you can to say, "Look, I'm trying to screen for these things and monitor for these things, given the limitations of what we're dealing with."
Dr. Roger: One other aspect you talked about, in referring to the article you cited was the importance of being integrated. Thinking about family and thinking about caregivers and so on. How do you engage caregivers and other people as part of the circle of care for people with schizophrenia in the virtual world?
Dr. Jonathan: I think part of it is knowing that for one thing, there are support services availed for them specifically and you talked about DBSA, [inaudible 00:47:58], make sure they're getting what they need, because they're under stress too, economic mood, everything they're under stress too. I think many of them to be honest, often recognize the fact that their loved one is suffering from the lack of the surfaces they used to have but I think the idea is get them to advocate and if that clubhouse was really shut down in March, maybe it has resurfaced, and they just haven't heard about it. Try to make some calls, try to find what is out there, that they can reconnect their loved one with services and I think the idea is, as Manpreet, I think really eloquently talked about, try to explain to this individual who may have some cognitive limitations in a calm and reassuring manner, that we're going to be safe.
This is what's going on, this is how we're going to try to manage the situation and most importantly, as that sort of third pair of eyes and ears, let the clinician know and let them know as your provider I'm available for you. If you start to see your loved one is not doing well, psychiatrically let me know. Maybe it's just depression. On the other hand, maybe they're starting to have some exacerbation of a primary disorder for a number of reasons and we may need to consider readjusting their their primary psychiatric medications but don't wait till it gets to the point where you're calling the psychiatric emergency response team that's really something you want to avoid of having somebody go to a hospital right now.
Try to let me know as soon as possible. Mary doesn't seem right. Can we schedule a brief appointment with the idea that I'm going to be as flexible as I can be as a provider knowing again that maybe frequent contacts is good for all parties involved in trying to manage the situation.
Dr. Roger: Very well put. John, I know that you're a proponent of measurement-based care are you doing things differently or much the same with respect to measurement-based care tracking patient's symptoms, side effects and so on.
Dr. Jonathan: It can be challenging for individuals with schizophrenia. I think you do want to have a sense of what their baseline is. For every person I deal with who has, for example, schizophrenia, they usually have some target symptoms, which will get worse when they are not doing well. For some people, it could just be very subtle to say, "If I'm not sleeping three nights in a row, I know that things are going well," Certainly for the bipolar patient that may be, but often it's a very specific symptom this voice becomes more prominent, I start to have this particular thought which may relate to a delusion. I try to keep tabs on what is important to that person based on my history with them, so that if they notice, again, these subtle things we can get on top of it, as soon as possible.
As much as I like rating scale, I would say, in general, my clinical global impression of severity, there's a mouthful, but this is something that everybody does every time you see a patient in your mind, you just say to yourself, "How sick is this person? How have they changed since I saw them last?" If you actually, look at the literature on industry and other double-blind placebo-controlled studies in schizophrenia, these changes in your clinical global impression match perfectly to changes in the gold standard rating scales used for research, like the pans, and certainly for mood disorders for the modulus. I think the idea is to trust your gut if the patient doesn't look the same, if they look worse than they are, and they really need to be attended to, and try to figure out as best you can, what is going on?
Dr. Roger: Beautiful, John, thanks so much. I'm going to ask our technology folks helping us out to bring everyone else back to our virtual roundtable here today. Welcome, everybody back. We've got a few moments now before we wrap up, this time goes by very, very quickly. With respect to one of the questions that's come up here, one of the questions is we're now involved in the Telepsychiatry, and one of our colleagues is asking the Ryan Height Act, is it preventing CS prescribing without first seeing a patient or person? Anyone want to take that one?
Dr. Larry: Well, certainly hasn't been a real barrier, I think we have seen new patients, we're coming up to the start of school. With the start of school, we get a fresh pair of eyes on kids and patients, adolescents, and even their parents at times. We're going to be seeing an influx of patients that do need meds. I'm not sure the legalities for practically it has not been a barrier.
Dr. Roger: Others.
Dr. Jonathan: Last week, we had a conference, and there's an individual who does a lot of opiate treatment. He also referred to this and said, "You know you are seeing the person face to face, it's just not in the same room." His feeling is that this should not be a barrier in any real sense of the word, although there may be a need, over time, for some subtle changes to the wording, I think the idea of these are not people who are being treated unseen, they're simply not being seen within the physical proximity of your office. I think the idea is that with a lot of things which have gone on during COVID, including Clozapine monitoring, for CBC is that there's been some reinterpretation of what seems safe and reasonable in order to make sure people get, in this case they're controlled substances.
Dr. Roger: Question relates to [unintelligible 00:53:54] which has been a major, major focus of concern for just about everybody Manpreet you also spoke, I think everyone made reference either directly or indirectly to that. A question came in about a specific medication, we won't go into the details of specific medications. I'll start with Manpreet since you're the one that touched on it first, any practical approaches to sleep and sleep efficiency and trying to make sure our chronal biology cooperates?
Dr. Manpreet: Alludes to the point you made earlier Roger that we need to set some boundaries around our exposure to screens and try to simulate the best we can the routine natural cycles that our bodies are used to and accustomed to and that might mean cutting off-screen time and exposure at a certain time, a fixed time every day and every evening, and avoiding caffeine and doing the basics of good sleep hygiene. Getting up in the morning at a consistent time and getting ready as if you were to leave the home even if you're not just to provide yourself with that, again, day-to-day routine, I think you can't underscore the biological benefits of a stable routine, particularly in times of uncertainty.
I would reiterate those preventive strategies at the very outset before moving into more aggressive strategies, which often are necessary when folks are already experiencing pretty significant depression and anxiety, those illnesses in and of themselves disrupt sleep. Compound that with the pandemic, and you've got a major sleep problem on your hands. Thinking about adjunctive aids to help again, facilitate regulation could be something to consider and discuss with patients.
Dr. Roger: Beautiful. Well, we have a few minutes left, and I want to make sure we at least have an opportunity to speak on this topic about health care provider well-being maybe Tammy, I'll start with you. I'll just consistently chime in, what are some recommendations for health care providers so they can, in fact, reduce their risk and boost their resiliency? They can be there not just for their patients and their families, but also be there for themselves? Any thoughts or comments about that?
Tammy: Absolutely. I think, one, definitely having a good sleep-wake cycle, like Manpreet was mentioning, but two, providers, I don't know, we're afraid to ask for help. When we have meetings like-- I know, we're still having Nurse Practitioner Association meetings virtually, there needs to be a time to chat without having a specific topic and say, "No, hey, how are you guys doing in your area? What's going on?" Just provide that person-to-person support for each other, keeping your hours restricted to a certain timeframe. I know, I have colleagues that are leaving their office, and they're still continuing to do work well into the evening. They're not having downtime. Part of their excuse for doing that as well, is what else are we going to do? Like, there's enjoyable things to do? There's spend time with your family, like, sometimes you have to remind people of it's okay to shut off and it's okay not to be there for 15 hours a day for somebody else, you have to have time to take care of yourself mentally and physically, and discuss what that could look like.
Dr. Roger: Absolutely. Very, very good thoughts. Any other thoughts my colleagues have on that very important issue?
Dr. Larry: I think it's a place where family discussions also is really important to monitor and promote.
Dr. Jonathan: I'll add two cents. We were supposed to talk about treatments. I apologize, I did leak about an antidepressant, although it's been generic for decades, but one of the greatest drugs out there for mental health is exercise, find a way to do what you can, the gyms are closed, I have a set up here, the bike on a Bluetooth controlled trainer, whatever you can do, but boy exercise, for all the reasons we talked about you feel better, you fit your clothes better. There's something you get, the neuroprotective aspects and neurodegenerative aspects you get from exercise you don't get from anything else. It's important to encourage your colleagues to find a way to get that done. It's good for you.
Dr. Roger: It's good for that. I agree, John, it's a very nice point to end on. I often ask for a pop quiz. What's the vaccine for mental health problems? It is one that it's called exercise and I couldn't agree more. We published a paper just last month in the American Journal, we surveyed health care providers in China, frontline nurses, physicians, also people who weren't frontline, with very high rates of what we would expect we've already discussed of depression and anxiety. 60% said that they really, really wanted to speak to somebody to receive some guidance on this very topic as to how they can boost their resiliency.
That's why I wanted to end on this topic, which is a, I think, an extremely important topic and as a general comment, it's my impression that beyond psychiatry, but from a population health perspective, we're going to be hearing a lot more about this framework of risk and resiliency. As is always the case when we have programs like this, the time goes by very very, very quickly. We hope that all of the participants at the congress, were first of all able to have no technology hiccups, that's something we don't take for granted anymore. We also hope that this topic was not just timely but also relevant to what you're doing in clinical practice. I hope that to some degree, what we've told you is what you already knew, perhaps a little different version of what you knew, and maybe something entirely new altogether that you can actually take away.
For me, as I start off today's session I really do see this not only as a viral crisis and public health crisis, I truly believe this is an unbelievable economic crisis and mental health crisis. I'm very, very pleased to see that a very large organizations like the World Health and UN and Oxfarm and many others, there's really an effort to really try to address the mental health, not just of wealthy countries, but of some of the low and middle income countries from a very population-based perspective.
We don't need to convince ourselves these are difficult times, we agree on that. My hope is, is that the externality, the unintended consequence of this event, is that there'll be a shift in the thinking around mental illness, not just declared, but the protection and the prevention of mental illness. Hopefully that's followed up with what we desperately need in psychiatry, and that is a coherent, comprehensive, accessible high quality healthcare systems. Maybe virtual would be more of our friend going forward.
I want to thank my colleagues for joining me on this virtual platform today and providing their insights and perspectives. Thanks to all of you. We thank Sunovion for sponsoring, and obviously, we thank all the folks behind this infrastructure that make it all look very seamless and all very easy. We thank the US psyche congress folks who provided obviously the larger framework for this meeting. With that, I'm going to bring this meeting to a close and I thank you all very much.
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