Reading of the Week: Our Pandemic Reality – How It Affected Our Patients, How It Changed Our Practice, How It Changed Us

From the Editor

A year ago this week, provinces across the country ordered the first lockdown. In the days that followed, I remember driving to the hospital and noting the eerie quiet of the streets with almost no cars or trucks on the morning commute.

Now, a year later, we can ask some questions. How has the pandemic affected our patients? How did it change our practice? How has it changed us?

This week, we have four selections that explore our pandemic reality.

We begin by focusing on patients. In the first selection, we look at a paper from Annals of Internal Medicine. Dr. Jonathan S. Zipursky (of the University of Toronto) and his co-authors consider alcohol sales and ED visits. They find that there was an increase in alcohol sales of 38% at the start of the pandemic. They write: “Higher alcohol sales during the lockdown are worrisome because alcohol consumption can cause poor judgment, medical complications, and immune suppression.”

In the second selection, we consider an editorial from BMJ. Though some have predicated a significant increase in suicide completions, there is little evidence. Still, the authors write: “We must remain vigilant and responsive, sharing evidence early and internationally… in these evolving uncertain times.”

Then we pivot and look at providers. In the third selection, Dr. Daniel Guinart (of Hofstra/Northwell) and his co-authors report on the findings of a survey on telepsychiatry. “In this study, we report highly favorable attitudes toward telepsychiatry in its diverse forms, across a large and wide array of mental health care professionals.”

In the fourth selection, Andrea Frolic (of McMaster University) talks about the pain of the past year. After breaking a toe, she notes about the psychological injuries of our pandemic life. “As a health care leader, I am supposed to be a cheerleader, a silver-lining finder, an opportunity-seeker – a hero, not a human.”

DG

Selection 1: “Alcohol Sales and Alcohol-Related Emergencies During the COVID-19 Pandemic”

Jonathan S. Zipursky, Nathan M. Stall, William K. Silverstein, et al.

Annals of Internal Medicine, 2 March 2021

During the coronavirus disease 2019 (COVID-19) pandemic, many regions across the world recommended stay-at-home orders, closure of public spaces, and physical distancing to reduce community transmission. These measures contributed to isolation and anxiety, with recent surveys indicating increased subsequent consumption of alcohol. Although drinking can lead to temporary relief of stress, alcohol misuse is a leading cause of mortality worldwide, contributing to about 3 million deaths annually.

So begins this a brief report by Zipursky et al.

Here’s what they did:

• “We examined alcohol sales and alcohol-related emergencies in Ontario, Canada (population, 14.7 million), from 1 July 2018 to 30 June 2020.”
• “We obtained alcohol sales data in Canadian dollars (weekly, then aggregated to monthly) from the Liquor Control Board of Ontario, the government agency overseeing retail sales in the province for more than 99% of spirits, 83% of wine, and 31% of beer.”
• “We obtained data on monthly alcohol-related emergency visits from the Ontario Ministry of Health. Alcohol-related emergencies were grouped into 4 diagnostic subcategories: psychiatric, gastrointestinal, intoxication, and miscellaneous.”

Here’s what they found:

• “Alcohol sales totaled $5.537 billion from 1 July 2019 to 30 June 2020, of which $1.885 billion was from March to June 2020. In contrast, sales totaled $5.156 billion from 1 July 2018 to 30 June 2019, of which $1.617 billion was from March to June 2019.” See graph below.
• “Year-to-year monthly increases in alcohol sales were highest at the onset of the pandemic, with $462 million in sales in March 2020 versus $335 million in March 2019 – equal to a 38% relative increase…”
• “Accounting for the 32% decline in overall emergency visits from March to June 2020 compared with March to June 2019, the rate of alcohol-related emergency visits was 15.2 per 1000 visits in March to June 2020 compared with 13.4 per 1000 visits in March to June 2019, equal to a 13% relative increase. ”

A few thoughts:

1. This is a good study.

2. The results aren’t particularly surprising – with so much stress, many turned to substance.

3. As noted in past Readings, there is strong evidence that alcohol use patterns have changed with the pandemic. For example, in the last CAMH-Delvinia survey, more than one in four Canadians reported binge drinking in the last week.

4. Should the pandemic response include more robust substance programs?

5. Should we be asking more about alcohol and substance when patients mention the stress of the pandemic? Should motivational interviewing techniques be part of our basic interview?

The full Annals paper can be found here:

https://www.acpjournals.org/doi/10.7326/M20-7466

Selection 2: “Trends in suicide during the covid-19 pandemic”

BMJ, 20 November 2020

As many countries face new stay-at-home restrictions to curb the spread of covid-19, there are concerns that rates of suicide may increase – or have already increased. Several factors underpin these concerns, including a deterioration in population mental health, a higher prevalence of reported thoughts and behaviours of self-harm among people with covid-19, problems accessing mental health services, and evidence suggesting that previous epidemics such as SARS (2003) were associated with a rise in deaths by suicide.

Widely reported studies modelling the effect of the covid-19 pandemic on suicide rates predicted increases ranging from 1% to 145%, largely reflecting variation in underlying assumptions. Particular emphasis has been given to the effect of the pandemic on children and young people. Numerous surveys have highlighted that their mental health has been disproportionately affected, relative to older adults, and some suggest an increase in suicidal thoughts and self-harm.

So begins a BMJ editorial.

The authors review the evidence:

• “Timely data on rates of suicide are vital, and for some months we have been tracking and reviewing relevant studies for a living systematic review.The first version in June found no robust epidemiological studies with suicide as an outcome…”
• “A reasonably consistent picture is beginning to emerge from high income countries. Reports suggest either no rise in suicide rates (Massachusetts, USA; Victoria, Australia; England) or a fall (Japan, Norway) in the early months of the pandemic.”
• “The picture is much less clear in low income countries, where the safety nets available in better resourced settings may be lacking. News reports of police data from Nepal suggest a rise in suicides, whereas an analysis of data from Peru suggests the opposite.”

They go on to call for vigilance and action. “Tackling known risk factors that are likely to be exacerbated by the pandemic is crucial. These include depression, post-traumatic stress disorder, hopelessness, feelings of entrapment and burdensomeness, substance misuse, loneliness, domestic violence, child neglect or abuse, unemployment, and other financial insecurity.”

A few thoughts:

1. This is a well written editorial.

2. Regardless of the stats on suicide, vigilance and prevention are important.

3. Suicide is complicated. At times of war, completion rates tend to decline (national purpose); at times of economic strife, they tend to rise (national distress). How to interpret the pandemic? In the first year, suicide rates didn’t seem to change. What about the second year and beyond?

The full BMJ editorial can be found here:

https://www.bmj.com/content/371/bmj.m4352

Selection 3: “Mental Health Care Providers’ Attitudes Toward Telepsychiatry: A Systemwide, Multisite Survey During the COVID-19 Pandemic”

Daniel Guinart, Patricia Marcy, Marta Hauser, et al.

Psychiatric Services, 17 February 2021  Online First

Telehealth refers to providing health care remotely and is not a new concept. As early as 1878, the use of the newly invented telephone was suggested to reduce unnecessary office visits. Since then, a substantial body of scientific literature supports the notion that reliability, effectiveness, and outcomes of telehealth applied to psychiatry, that is, telepsychiatry, are comparable overall to in-person care across multiple disorders, treatment modalities, and patient populations, and telepsychiatry is also cost-effective. Despite this, however, telepsychiatry implementation was previously limited and restricted to a subset of unevenly distributed clinics and clinicians, although previous studies have reported generally positive clinician and patient attitudes.

This dissociation may have been driven partially by implementation or technical difficulties, organizational culture limitations, and reimbursement problems…

Because of the COVID-19 pandemic, many health care systems around the world were forced to massively and rapidly transition all or almost all visits to telepsychiatry, a shift that was accompanied by a significant regulatory relaxation. This unprecedented scenario provided a unique opportunity to qualitatively assess the attitudes and opinions of mental health care professionals in diverse clinical settings.

So begins a paper by Guinart et al.

Here’s what they did:

• “A survey was locally distributed to all clinicians at 18 hospitals and community centers affiliated with the Vanguard Research Group, a research consortium specializing in behavioral health research, in 11 different U.S. states.”
• “Psychiatrists, psychologists, nurses and nurse practitioners, social workers, therapists, mental health counselors, residents, and fellows were invited to complete the survey anonymously.”
• “The surveys were distributed in April and May 2020 and could be completed electronically.”
• “The survey included 12 questions about satisfaction with telepsychiatry in its different modalities and used a 5-point Likert scale, as well as questions about potential challenges and positive experiences”

Here’s what they found:

• “The survey was distributed to approximately 2,000 mental health care professionals, of whom 837 completed the survey (response rate=42%).”
• Demographics. “39% (N=318) of the sample being >45 years old.”
• Practice. “The respondents worked mostly in adult outpatient clinics (N=458, 56%) and child and adolescent clinics (N=148, 18%). They used mostly a combination of two-way video and telephone (N=500, 61%).”
• Experience. “The overall experience was excellent or good for 73% (N=397) of the respondents who were asked about their experience with two-way videoconferencing and for 66% (N=523) asked about telephone only…”
• Challenges. “Some of the challenges health care providers reported with telepsychiatry included inability of the patient to properly use the conferencing devices (N=422, 52%), lack of sense of closeness or connection (N=379, 46%), and technical problems (N=323, 39%)…”
• Advantages. “As an advantage of telepsychiatry, health care providers reported flexible scheduling or rescheduling (N=633, 77%), followed by timely appointment start (N=568, 69%) and lack or reduction of no-shows (N=427, 52%…”
• Diagnoses. “Psychotic disorders were considered the least appropriate diagnosis to conduct telehealth (N=438, 67%), whereas anxiety disorders were considered the most adequate (N=683, 96%)…”

A few thoughts:

1. This is a good study.

2. The survey was done in the spring of 2020. Would the results be different today?

3. We read much of “Zoom fatigue” but mental health providers reported a high satisfaction rate.
4. How many will continue with telepsychiatry? “In total, 34% (N=275) of the respondents indicated that after the COVID-19 pandemic has resolved, they would want to continue using telepsychiatry in ≥50% of their caseload, and an additional 30% (N=242) would like to keep using telepsychiatry in 25%−50% of their caseload.” Wow.

5. This paper captures well the transformation of clinical work. Picking up on the last point: after the pandemic, telepsychiatry is likely to be a major part of practice.

The full paper can be found here:

https://ps.psychiatryonline.org/doi/10.1176/appi.ps.202000441

Selection 4: “As a health care leader, I am supposed to be a hero, not a human”

Andrea Frolic

The Globe and Mail, 10 March 2021

Recently, I stumbled into the door frame of my bathroom as I rushed to get ready for work. First, I swore. Loudly. Then I hopped around on the other foot. While cursing my foot for its insistent throbbing, I was late for my 7 a.m. pandemic-response meeting.

For the past year, pandemic response has been my life – 7 a.m. to 7 p.m., most weekdays and often weekends, too. Assuming it was just a stubbed toe, I pushed through meetings about allocating vaccines, potential surging hospitalizations and the spiritual needs of patients and staff. Once or twice I noticed that my foot had developed its own heartbeat, but I was busy responding to another round of COVID-19 challenges, so I ignored it.

So begins an essay by Frolic.

She realizes something is amiss with her toe. And more than her toe: “someplace deep within me whispered to that toe of mine, ‘I get it, I am bruised and broken, too.’”

My new brokenness has revealed an accumulation of breaks acquired over time, like the thin lines of bone scarring revealed by an X-ray. Looking into the eyes of my colleagues on a hospital ward or the faces that appear in my Zoom squares, I can see how our outward resolve is masking our collective brokenness. The long, slow grinding of this pandemic against the soft flesh and brittle bones of our health care system has led to so many losses. We lost our delusions of infallibility when our careful plans were shredded by the virus and we couldn’t protect the people we swore to keep safe. We lost our ability to experience joy or hope or excitement, so numbed are we by constant exhaustion, worry and unattainable expectations. We lost our sense of belonging, so isolated are we from our friends who can’t understand our experience of working in a state of constant vigilance for 12 consecutive months.

She goes on to urge us to acknowledge our situation:

We have to acknowledge what is broken and make space to grieve our losses – the losses of lives for sure, but also the loss of a way of life. We need to stop expecting each other to bury our pain in order to grind through our tasks. Delayed treatment of a broken foot can lead to lifelong pain and disability. Delayed support for psychological trauma and unresolved grief can lead to relationship breakdown, maladaptive coping and worse.

A couple of thoughts:

1. This is a moving essay.

2. The psychological wounds of COVID-19 are likely to linger long after the last patient is discharged from an ICU at the end of the pandemic.

The essay can be found here:

https://www.theglobeandmail.com/life/first-person/article-as-a-health-care-leader-i-am-supposed-to-be-a-hero-not-a-human/

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.