Patrice Harris, MD, MA, on prioritizing mental health as we enter the winter months [Podcast]

In today’s COVID-19 update, a discussion about the importance of prioritizing mental health for physicians and patients as we enter the winter months of COVID-19.

Learn more at the AMA COVID-19 resource center.

Speakers

• Patrice A. Harris, MD, MA, psychiatrist and immediate past president, AMA
• Anna Ratzliff, MD, PhD, professor, University of Washington
• Jeffrey Lieberman, MD, chair, Dept. of Psychiatry, Columbia University College of Physicians & Surgeons

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're discussing prioritizing mental health for physicians and patients as we enter the winter months of the pandemic. I'm joined today by Dr. Patrice Harris, AMA's immediate past president, as well as a psychiatrist and former County Health Director in Atlanta, Dr. Jeffrey A. Lieberman, chair, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons in New York and Dr. Anna Ratzliff, director of the UW Psychiatry Residency Training Program, co-director of the AIMS Center and Director of the UW Integrated Care Training Program in Seattle. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Harris, we've been told by public health experts that the next few months could be some of the most challenging of the pandemic, what impact will this have on physicians’ mental health?

Dr. Harris: Well Todd, I think it's important to know that we came into this pandemic seeing increased levels of burnout and issues around mental health and wellness among the physician community. So certainly, this pandemic is just exacerbated those issues. And by the way, certainly for those of our colleagues who are on the front lines, but also those who are treating patients in outpatient settings, I can't tell you the number of emails I've received from my colleagues actually, a couple of those who are treating patients who have substance use disorder, who also talk about these issues. So, it's important that we talk about these issues, but more importantly, talk about how to support our colleagues through this pandemic and actually as we get on the other side of the acute phase of this pandemic.

Unger: I mean, it's been pretty grueling and for some physicians, there really has been little break between the initial pandemic onset and this recent fall surge, is that kind of a double whammy for physicians, Dr. Harris?

Dr. Harris: It is a double whammy. You hear so many of our colleagues talking about the fact that this pandemic has been unrelenting, no opportunity to take a break but also working around these issues with increased financial stress, worry about our own health, right? Remember early on, we were seeing physicians who were updating their wills and also raising the issues around not having adequate equipment, adequate PPE. So, we again are just seeing assault after assault. And by the way, let me also say even being accused of inflating the numbers of COVID-19 for our own personal gain, that was really infuriating, but all of these issues are just adding to feelings of stress among physicians.

Unger: Yeah. That's a very difficult thing to really take. I want to talk a little bit, I'll take a minute, Dr. Harris, about something you mentioned, which is about physicians who aren't necessarily on the front lines, but are still experiencing burnout at record levels. A New York Times article recently reported that doctor's offices are shutting down due to the stress of the pandemic. What are your thoughts on this? And what can we do about it? Dr. Lieberman, do you want to start there?

Dr. Lieberman: Well, I think that the practice of medicine in recent decades has really evolved from something that most people were motivated to sort of go into as a career and it's something that has become much more bureaucratic, much more doing too many things that were not related to patient care and research and the kinds of things that physicians are more inclined towards. And then the COVID pandemic just was close to the worst nightmare scenario that you could expect, because not only were we dealing with the usual process of having to administer health care in a kind of a dysfunctional policy and financial environment, but we had this added burden of a pandemic, which pushed people almost to the breaking point. In fact, unfortunately in my own institution, we had a wonderfully talented and highly respected emergency room physician take her life as a result of the stress that she was under.

And so the combination of the way the profession has evolved as a result of what's happened in the policy and financing arena combined with the added burden has made it very difficult, but then physicians are tough people who are used to discipline deprivation, but at the same time everybody has their breaking point. And the one thing I think we've learned is that the need for support, not just usual human resources, but ongoing national support stress management is really essential and all the more so, because even though we’re psychiatrists—we don't work on the front lines and the ICU or the emergency room—we were deployed into those in various capacities. And I won't take this as an insult, but the first choice of the hospital was to take our trainees who were closer to the medical training, which I'm sure Anna knows something about also.

Unger: I guess, would you like to speak about that in terms of the training and the pressure there as well?

Dr. Ratzfill: Yes. I think it's been really challenging for our trainees as well. I mean, I think I'm in the middle of my career a year where things are really stressful, it's hard, but for someone who is in the middle of their third year of medical school and had to spend five months sitting at home instead of learning those core patients' skills and being out in the clinics where they had been looking forward to that, or our trainees who really had their training disrupted as we were trying to quickly figure out and mobilize how to continue to have that training experiences be available to them. I think that it's really impactful, I think, and it adds extra stress. I think residents and medical students are under a lot of pressure. It's hard to be learning and taking care of patients at the same time.

And this added stress of often having extra family obligations or being worried about your family has definitely been something that I've seen take its toll. And we've really had to think about how to come together as a community and support each other and find ways of staying connected, even when we're supposed to stay socially distance. It's a real tension between those two things because I do think peer support is such an important part of resiliency, which I think we all need to build capacity for right now. I mean, resiliency is something that we can build capacity for and thinking about how do we do that has been something I've thought about a lot as a program director, of course accurate to this.

Dr. Lieberman: As difficult and as really challenging as it's been, the health care profession has risen to the occasion incredibly well. And it's really something to be proud of and to really marvel at. I think one of the things that many of us, particularly those of us who are in administrative roles that have to make budgets and so forth is that we don't see in addition to having to deal with the stresses of patient care and the vicissitudes of the infection rates in the pandemic, we also know that there's going to be a financial second shift at some point, and we haven't seen a rescue package for the hospitals or for the medical schools.

And then we also have a public that isn't necessarily doing their part because of the fact that there is this confusion that's being sown as to what the reality is of the virus and what needs to be done to prevent the contagion and really wait until the vaccines arrive to be able to really wrestle this thing to the ground.

Unger: Well, we know the pandemic is also affecting patients. In fact, a lot of in the news is pretty heartbreaking stories about what kind of stress people are under right now. Dr. Lieberman, should physicians expect to see an increase in mental health issues over the next few months and what are the factors, obviously I think some of them are evident, that they should be watching for?

Dr. Lieberman: Unquestionably that the aftermath of the pandemic, which with the vaccines in the offing can be sort of foreseen the sequelae that will be predominant will be those of a mental health psychiatric nature. And we can predict this with some degree of quantitative accuracy based on data from disaster psychiatry studies of past events. But the past events have largely been geographically or temporally limited, Hurricane Sandy, an earthquake, a tsunami, 911 but this is global and this is sustained. And this produces not just physical hardship, but also economic and social disruption.

So, we can predict what disorders are going to have a significant increase. And they're in the order of mood disorders, anxiety disorders, phobic disorders, obsessional disorders, substance abuse, complications of these things like suicide, domestic violence, criminal violence and with the loss of jobs and things. There may be an increase in homelessness also. And so, I think there's a recognition of that, but I haven't heard about any real steps that are being taken to try and pursue any public mental health initiatives to preempt it.

Dr. Harris: Yeah. And I think that's an opportunity for us as leaders to think about the next steps regarding advocacy. As Dr. Lieberman noted or hinted at, we come into the pandemic on decades of underfunding mental health in this country. And so, it will be all the more critical for us as leaders, as institutions, as associations to make sure that we are advocating for the need for more resources and supports. And as we are talking about patients, I do want Jeff at some point to talk about the work they did at Columbia regarding peer-to peer-support regarding colleagues but clearly it's our physician colleagues, our other health professional colleagues but at the end of the day, it is also about our patients.

Unger: Dr. Lieberman, do you want to comment on that?

Dr. Lieberman: When the pandemic hit, it hit New York. Washington State was actually the first state, but it didn't have the magnitude of the effect that New York did. Our first patient in the hospital was on March 2nd, the first in New York. And by the middle of March, we had 200 patients in the hospital. By middle of April, we had 2000 patients in the hospital. So, it was literally like having battlefield casualties coming in. And apart from psychiatrists having to deal with this our patient populations in terms of suicidal people or psychotic individuals or drug overdoses and toxic, we also realized that there was a huge need to support our ICU ED medical step-down unit colleagues, nurses, technicians, respiratory therapists and doctors. And we rolled out a very rapidly developed what we called COPE Columbia Program, which held virtual town halls, individual forums by employee groups and then a 24/7 hotline. And I think that this was a real lifesaver in terms of bolstering people and also maybe preventing somewhat might've been life-threatening outcomes.

Unger: Dr. Ratzliff, you're a national expert on collaborative care, can you talk about what this is and how it might help in the treatment of mental health issues and particularly on the patient side over the next few months?

Dr.  Ratzfill: Great. Yes. So collaborative care is an evidence-based model that really allows us to enhance the capacity to deliver effective mental health treatment in primary care settings. So, this is a really important evidence-based model that has been around actually in the... Evidence-based has developed over the last 20 years, but there's been a real opportunity in the last few years with new funding models through payment available to actually fund this model to actually disseminate it. So, the basic model is that you take primary care and that's actually a place where most people currently are getting the treatment for their common mental health disorders, like anxiety and depression, even substance use disorders. A lot of times that's the first place that a patient will really present.

And what we do in collaborative care is really take that relationship between that primary care provider and the patient, and give some support to it so that effective mental health care can be delivered. And that's usually the help of a behavioral health provider that can provide, for example, evidence-based brief behavioral psychotherapies right there in primary care or, and support from a psychiatric consultant. This is often a psychiatrist who actually doesn't see most of the patients. There aren't enough psychiatrists to see every patient that needs help, but they really leverage their expertise to support that primary care team.

And they leverage their expertise by providing assessment and recommendations indirectly. So, a single psychiatrist in a couple hours of time, a week can actually support up to 100 patients. So, it really takes limited time of that psychiatrist and really helps them actually support good care for a lot of patients. And so, this is a really exciting model. I think there was already a lot of momentum with some new payment options to support the delivery of care this way that was happening even before the pandemic, but now I feel like it's essential that we really look at alternative models like this to be thinking about how do we build capacity across the whole spectrum of behavioral health treatment opportunity.

So, building more capacity in primary care and that hopefully it will be helpful to keep more capacity available in specialty mental health settings, where people with more serious disease and burden really need to be treated. So, I think this is a really exciting opportunity and I hope as we are looking for solutions to this coming mental health really pandemic that we imagine will happen, that we are actually thinking about strategies like this to actually create more capacity in our system.

Unger: Well, final topic, Dr. Lieberman, I'd like you to talk a little bit about the issue of stigma, which is really, can we really prevent people from seeking the mental health resources that they need, both patients and physicians? Can you talk a little bit more about stigma and why it's really important to address that right now during the pandemic?

Dr. Lieberman: Well, stigma is something that has really afflicted mental illness and psychiatric care historically previously, because there was very limited scientific understanding or effective treatment for it. But ever since the latter part of the 20th century, when the Foundation for Psychiatric Medicine was developed and expanded in a very substantial way and treatments were provided for that were very effective for the majority of disorders, there is no excuse for people not availing themselves when they need it. The problem is that the old attitudes and skepticism and prejudices continue. And it's like, if imagine you didn't take advantage of the polio vaccine and you were susceptible to polio, imagine if you have a lump in your breast and you needed to have a lumpectomy and then chemotherapy, but you only got a lumpectomy and didn't know that there were other things available for you, or you didn't know how to access the care.

People don't know...if you have chest pain, people immediately think heart attack or heartburn or something. If you have some kind of psychological difficulties, people begin to wonder, and you don't know do I go see my clergyman, do I go see a new age therapist? Do I engage in yoga? Do I see a social worker or do I go to a psychiatrist? So, stigma is really a barrier to care at a care that does exist. And the only way to try and overcome it is by enhancing people's awareness and their access to care.

And the fact of the matter is when you do the math on the epidemiology of not just being the worried well and having problems in living, but severe mental disorders, only a fraction of the people that have them are getting care. And that's something that really is costing the country a great deal in terms of human suffering and also economics. And so it makes good sense to try and address it but the stigma that you're referring to, Todd, is not just stigma that the average person on the street has, it's the policymakers and the legislators that also suffer from it, which is why psychiatric research and mental health care is underfunded.

Unger: Dr. Harris, do you want to close by talking about resources that AMA has made available to help physicians with these efforts?

Dr. Harris: I do Todd. And first, I just want to say how excited I am really about all of the policy that AMA has regarding access to mental health care. Just at our recent policy meeting, we even passed policy advocating that we look at providing methadone treatment and primary care. And so, I really want to highlight the importance of the work at AMA and our recent Behavioral Health Integration Project. So, we are here and ready to lead on ensuring improved access to care for those who have mental disorders. And as far as addressing some acute issues right now regarding COVID, we have a wonderful resource page. We've developed a couple of resources. I'll highlight a couple here, Managing mental health during COVID and Caring for our caregivers and so many other resources on that resource page. So just wanted to highlight those. And we will continue at the AMA to partner with other medical associations and institutions to do all that we can to reduce stigma and improve access to care.

Unger: And through our continuing work on physician wellness, we are working with organizations to monitor the impact of COVID-19 on their workforce. Dr. Harris, Dr. Lieberman and Dr. Ratzliff, thank you so much for being here today and sharing your perspectives. That's it for today's COVID-19 Update. We'll be back soon with another segment. For updated resources on COVID-19 visit ama-assn.org/COVID-19. Thanks for joining us, please take care.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

With an increased number of people reporting worsening mental health in recent years, it is imperative that people are aware of the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) telephone program.

People experiencing a suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress can call, chat or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, 7 days a week.

The previous National Suicide Prevention Lifeline phone number (1-800-273-8255) will continue to be operational and route calls to 988 indefinitely.