Category: COVID-19

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COVID-19 Education Public health psychiatry

Reactions and Behavioral Health Symptoms in Disasters.

The Washington State Department of Health started posting Behavioral Health Monthly Forecasts in April 2020. Two disaster psychologists, along with other staff, compile and share useful information such as the anticipated course of psychiatric symptoms across the population, how different populations might manifest their distress (e.g., children), and data related to changes in substance use and firearm purchases. It makes for interesting reading, though it’s frequently a bummer.

One chart that appears every month is “Reactions and Behavioral Health Symptoms in Disasters”. In the inaugural issue in April 2020, the forecast oriented readers to general model from SAMHSA[1. SAMHSA is the Substance Abuse and Mental Health Services Administration. What a shame that it is a distinct department from the Centers of Disease Control and Prevention (CDC). The mind remains split from the body in our administrative and health care systems, which is why there is no formal framework for public health psychiatry.] of reactions in disasters:

Note that there is no indicator here about where Washingtonians were at that time. The Y axis uses color to depict emotional states and the X axis, so optimistic, has only a notation to mark one year.

In May 2020, the forecast made a proclamation about where Washingtonians were. It was a warning: We were on the precipice of disillusionment:

We braced ourselves for this. Yes, we had witnessed heroism from so many, whether health care workers or first responders or neighbors dropping off food for those who were medically vulnerable or distilleries producing hand sanitizer or seamsters and seamstresses joining brigades to make cloth masks. Of course this level of concern and anxiety was unsustainable. How bad could it get?

Well.

By December 2020, we were in a trough of disillusionment and it felt like it:

Thousands of people were dying a day in the US and other countries around the world. Hospitals were overrun with sick people. People were starting to leave their jobs due to overwhelm. When would the vaccines become available? I remember looking at this graph and thinking, “I thought the graph last month had us in the nadir of disillusionment.” But there was a branching of lines! Maybe we, as a state, would follow the yellow line and things would improve for us all, regardless of station in life.

Well.

A terrible winter passed. The days got longer, there were more opportunities to be outside, many people got vaccinated… but the yellow line never manifested for those in my professional and personal communities. By June 2021, we were still in a trough:

In retrospect, that “secondary honeymoon” was accurate. All the numbers we hoped would drop, did: Reproductive number, cases, hospitalizations, and deaths. People in the Seattle-King County area were getting vaccinated. But so many of the people under our care were dying from overdoses, suicide, and chronic medical diseases.

Then came Delta, Omicron, more cases, hospitalizations, and deaths. Health care workers and others left their jobs out of frustration and demoralization. A contingent of people continued to decline vaccinations, despite knowing the possible outcomes… including chronic disease and impairment that still has no effective treatment.

When the December 2021 graph came out, someone observed, “The trough just keeps getting longer.” I wondered who on Earth was experiencing the benefits of “reconstruction”.

I have never had so many people under my care die during a comparable period of time. At least 10 of my patients have died since the beginning of the pandemic; the first death occurred in July 2020. The most recent death (that I am aware of) happened in November 2021. None of these people died from Covid. They either died by suicide, overdose, or their chronic illness collided with an acute, fatal event.

We know from history that pandemics do not last forever. The 1918 flu pandemic lasted just over two years. The 2002 SARS outbreak was declared over in less than two years. The 2013 Ebola epidemic persisted for less than three years. All things change, all things end.

I, like so many others, hope that we all will exit this trough sooner than we anticipate. I worry about the psychological consequences of this pandemic in the years to come. We continue to focus on the viral pandemic; the psychological pandemic has already arrived. We have yet to see an organized response to that.

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COVID-19 Education Nonfiction

The Pandemic and DBT Skills.

If you look at my archives, you can tell when the burden of the pandemic (whether due to the pandemic itself or the consequences of it) became great: Weeks or months went by without a post. This doesn’t mean I stopped writing; I just stopped posting. Though it is true that some writing (i.e., ranting, rambling) is better kept private, my lack of posting was chiefly due to fatigue. One must think about something to write about something and, you know, I, along with everyone else, am tired and cognitively impaired.

While walking along the still waters of Lake Washington with a friend recently, we reflected on the endless opportunities to practice dialectical behavior therapy (DBT) skills throughout the pandemic. I had the good fortune to learn about and practice DBT for a full year of my psychiatry residency training; I also led the DBT skills training group. As such, I taught the skills to myself over and over again (as that, for me, is the only way I feel comfortable teaching these skills to other people). To the group I often said, “I use these skills all the time.” They may have thought I was telling a white lie, though I was not: I used them all the time and continue to use them now.

Mindfulness. In DBT, this refers to paying attention, without judgment, to what’s happening right now. (See “Right now, it’s like this.”) When we give our attention to what is happening right now, we can witness the events that are (or are not) happening, our reactions to those events, and other “things” we might be adding to the situation. (Our minds are miraculous thought-generating machines, just as our hearts are amazing pumpers of blood. That’s just what they do.) We cannot take next steps if we don’t know what’s happening right now. For example, if a friend is trying to give you directions, but you have no idea where you are, you and your friend will have a hard time finding each other.

The underlying dialectic in DBT is acceptance versus change. If you don’t accept that you don’t know where you are, you cannot change. If I insist that I’m in Los Angeles, even though I’m actually in Seattle, then I am in for a lot of suffering as I try to get to Diddy Riese Cookies by public transport. It is only when I accept that I’m in Seattle that I change and, instead, go to Hello Robin Cookies.

Yes, it’s hard to give our attention to the pandemic and the illness and deaths it has caused, American politics and the ensuing vitriol, and the suffering that both (and other events) have wrought. Acceptance doesn’t mean agreement. Without acceptance, we cannot take next steps.

Distress tolerance. The acceptance described above is a form of distress tolerance (and, in DBT parlance, is called “radical acceptance”). Distress is difficult to tolerate; who among us wants to feel distressed? Wouldn’t you rather feel serene or joyful? Sometimes we worry that the distress will overwhelm us, that the shame or anger will consume us and never go away. Distress tolerance involves mindfulness to attend to what is happening right now, accepting that right now, it’s like this, and then choosing how to cope with the current reality. (See Viktor Frankl’s comment about the space between stimulus and response.) We can’t evade distress. We can choose how we respond to it.

Last winter, one strategy I used to manage my distress was eating a lot of carbohydrates: Pizza, burgers, noodles, dumplings, and my beloved cookies. I understand why I chose that strategy (and it’s one I still fall into on occasion), but it’s not one I want to repeat this year (largely because it didn’t actually reduce my distress much). Oddly enough, the distress feels less acute and piercing this year, perhaps because it is impossible to maintain those physiological and psychological levels of stress for a prolonged period of time. It may also be that I have come to embrace that yes, we all can die at any moment and, thus, we must enjoy all the little things that are lovely while they are happening.

Interpersonal effectiveness. When we don’t feel at our best, our communication and interactions with other people can sour. Not even because we want to come across as aloof or jerky; it just takes energy and mindfulness to assert ourselves and maintain harmonious relationships. Often interpersonal effectiveness skills focus on asking for what you want, managing perceived (and sometimes real) conflict, and boundaries.

If I am alone when I learn of new Covid cases at work, it is not uncommon for me to groan and mumble words that may or may not be profane. Sharing such sentiments with colleagues, though, isn’t helpful and doesn’t increase my effectiveness. Crabbiness generally isn’t charming. Assertiveness scripts or nonviolent communication templates may seem unnatural, though, with practice and personal tailoring, help all of us get along when we’re all feeling tired and cranky.

Emotion regulation. Though internal and external voices may tell you otherwise, your emotions, regardless of what they are, are valid. You feel what you feel. There are, however, things we all can do to increase the likelihood that we will feel certain emotions. In 12-step groups, people often refer to “HALT”: Hungry, Angry, Lonely, and Tired. If we are already experiencing one of those four things, we are more likely to feel worse if another stressor comes our way. (Hence the value of eating and sleeping regularly, as well as building and sustaining community—whatever that may mean to you.) Naming emotions (with the help of mindfulness) is also a skill, as that helps us recognize that we are feeling an emotion, we are not actually the emotion. Emotions give us vital information, though sometimes we realize that there are no logical reasons that underlie how we feel. If I feel anxious because I believe I’m in the way, but I’m not actually in anyone’s way, then the task is to do the thing that will make me feel more anxious… so I eventually stop feeling anxiety due to thoughts about being in the way.

The duration of the pandemic and its consequences makes emotion regulation hard. We can try to reduce our vulnerabilities by eating, sleeping, and connecting with others as well as we can, though ongoing news of illness, death, conflict, and violence reduce our resilience. There are real problems in the systems we live in and under in the US. It is unfair and inaccurate to ask individuals to keep their chins up and “just be happy” when our current context is so abnormal. We, however, can still make choices in that space between stimulus and response.

I often quip (with decreasing levels of energy) that the pandemic is developing my character, though I’m ready to be done with personal growth. Right now, though, it is like this. We also know that everything changes. The pandemic will end (just not when we want it to), things will change (though perhaps not in the way that we anticipate), and many of us enjoy blessings right now that we take for granted (e.g., you are able to read these words! you have access to the internet! most, if not all, of you know where you will sleep tonight! you haven’t died from Covid!).

If you’d like to learn more about dialectical behavior therapy and the four skills above, this website is pretty good and covers the four core skills with plenty of examples.

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COVID-19 Nonfiction Reading Reflection

Pictures in Time.

The rocks of the mountain beneath your feet broke apart before you were born. Glaciers carved the valley before your eyes before your grandparents were alive. Trees towering overhead on this west coast sprouted before the ships from far away landed on the east coast. All of this was here long before you arrived and will persist long after you are gone.

History precedes you and the future remains unknown while you live in the present, where a pandemic persists. This tiny county that holds giant mountains reported two new deaths from Covid-19 this past week, leading to a total of 13 deaths over the course of this cursed pandemic. This number seems paltry compared to the 1,812 deaths in the county you live in, but for each death, many mourn.

Someone offered this idea to me a few years ago: You know those days when you feel sad, though there are no obvious, logical reasons as to why you feel sad? Maybe someone, somewhere, has died and there is no one left to grieve that death. Your sadness is a mourning of that death.

Maybe that, in part, is what we’re all experiencing now.

(I also did not realize that newspaper boxes are mirrors. Exhausted health care workers don’t expect to see exhausted health care workers on the front page of the local paper.)

Though we are exhausted—in varying degrees—and may wonder why we “spend” “our” time doing this work, perhaps this is how time is choosing to use us. Oliver Burkeman’s book Four Thousand Weeks is a gentle yet firm reminder that our time is finite, that only planning for the future logically means that we should only plan for death. That is what awaits all of us in our futures, right?

I highly recommend this book. (Bonus reason, beyond the content of the book: Mr. Burkeman sent a personal reply when I sent him a thank you note!) This choice did not diminish me; it enlarged me.

Sometimes reading about the past brings clarity to the present. The model Wilkerson puts forth in Caste about the relative status of Americans resonates with me (i.e., the actual issue is a caste system, where “race” is often the indicator). Her model better explains the interpersonal and inter-group dynamics of the US compared to solely race-based models. I also highly recommend this book.

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COVID-19 Homelessness Medicine Seattle

Surge.

When I was younger, my intention was to become an infectious disease doctor. Forces, seen and unseen, pulled me into psychiatry.

My undergraduate studies were in microbiology, virology, and immunology. Had someone told me twenty years ago that I would someday use that knowledge on a daily basis, I would have shrugged and said, “Well, that makes sense. That’s the plan, right?”

Had someone told me ten years ago that I would use knowledge from my undergraduate studies during a pandemic, I would have snorted: “But now I work as a psychiatrist. And a pandemic? What are you talking about?”

Had someone told me two years ago that I, as a psychiatrist, would be leading a public health response for a homelessness services agency during a global pandemic, I would have furrowed my brow: “What are you talking about?”

And here we are.

We’ve never had so many people—staff and patients—test positive for Covid at one time during the pandemic as we have in the past three days. Thankfully, most have had only mild symptoms and none, thus far, have needed hospital-level care.

The work we’re doing for Covid isn’t as intense or heartbreaking as the work my colleagues are doing in emergency departments and hospitals. Never before had I thought that a homelessness services agency could play a vital role in prevention and early intervention.

And here we are.

Throughout the pandemic, our team has framed our efforts as one way to keep people out of emergency departments and hospitals. These could be our humble contribution to our colleagues working in inpatient settings. We have been largely successful, though I worry that our luck is running out.

We continue to witness the indirect effects of the pandemic. Some have been lethal: Suicides and overdoses, whether intentional or not. Some are worrisome: More irritability and increasing intolerance for the challenges and annoyances of life, regardless of one’s station. I wince when I consider what might come next as we witness this surge of cases.

God have mercy on us all.

Categories
COVID-19 Nonfiction Public health psychiatry Seattle

God Help Us All.

It’s like watching something happen in slow motion, but there is somehow not enough time to stop what is happening.

I don’t know either emergency department medical director well, though we are friendly enough to send greetings a few times a year. We all already knew that hospitals across the state are over capacity. One wrote about the “brutal impacts” across the state due to the additional number of patients. And this precedes the anticipated “all time highs for Covid in about two weeks”. The other, more economical with his words, noted that his team is “maintaining”, but “that the recent surge is further stressing the teams”, adding to “moral injury”.

A friend who works for a third hospital system shared with me that an emergency department had to close down because there weren’t enough staff to operate the place. This emergency department is in a suburb, not a rural town.

It’s not just emergency departments. My colleagues in primary care are reporting that they have had more people under their care die in the past year. They’re not dying from Covid. They’re dying from chronic medical problems.

I myself have never had so many people under my care die in such a short amount of time. They, too, did not die from Covid. Instead, they died from suicide, overdoses, and chronic medical problems.

Like others, I’m watching the number of Covid cases soar. There was a time when daily deaths from Covid were only a few dozen. Now we’re somehow back in the hundreds.

During the late winter, when thousands of people were dying each day in the US from Covid, the grief would overcome me without warning. These days, I feel the mass of dread growing in my body. My chest caves in from the misshapen weight; my jaws are tight, as if they are holding back anguish that transcends words.

God help us all.