Acute-Care Psychiatry During the Pandemic

in the early days of this century, I spent a lot of time in Avian Influenza Task Force meetings. I was on two separate task forces and at the same time working on an acute care inpatient psychiatric unit. One of the meetings took up four hours in the afternoon and I would have to go back to my unit and make up those four hours. I made the mistake of that not saving all the documentation from those meetings. There were hundreds of pages. The main focus of one task force was on “surge suppression” or helping with crowd control to prevent emergency departments from being overwhelmed by people who did not really have the viral infection. The other meeting was more about the actual response to the viral infection. I was always skeptical of what I heard. We kept hearing that if there was an epicenter of infection, large pallets of Tamiflu would be on the way. We saw presentations with pictures of those pallets under plastic wrap. At the same time there was discussion about morgues and refrigerated trucks that have become part of the current crisis.

I was more concerned about what would happen to inpatient psychiatry units. I kept hearing that the medical and surgical beds would be overwhelmed. When I suggested that we increase the capacity of negative airflow rooms and rooms vented directly to outside air, I was told that was impossible. One expert gave the opinion that if there is an airborne virus in the hospital: “The minute you walk into the hospital you should be wearing an N95 mask”.

That was about 2005 and I had never heard of an N95 mask before that. I had certainly worn masks for painting, dust protection, and various chemical and biological experiments that I did in the course of education and research. I went out and bought a small package of N95 masks. I fitted them per the instructions and noticed a couple of things. The fit was extremely snug due to upper and lower elastic bands (that have a much smaller circumference than a human head or neck), the circular contour of the mask providing a suction fit to some extent, and a flexible metal band that bends over the bridge of the nose to effectively seal that area. When you are wearing an N95 mask your voice is muted and you are breathing against resistance. If you wear it long enough, it becomes soaked with exhaled droplets. I rapidly concluded that it would be nearly impossible to conduct a psychiatric interview wearing this mask.

I never really learned at the time whether there was a plan to shut down inpatient psychiatry and use all the beds for avian influenza patients. Thankfully it never got to that point. Flashing forward 15 years a real pandemic is upon us and the problems remain unsolved. Inpatient psychiatric units and residential drug and alcohol treatment units are considered necessary services in most states and they remain open. Very recent information from the authorities now suggest that SARS-CoV-2, the virus causing COVID-19 is airborne and that there are a significant number of asymptomatic carriers.

I have been using telepsychiatry at this point for two weeks and it seems to be going well. There are definite constraints compared with face-to-face interviews. I have noticed more constraints since my original post on this topic. I put a couple of questions out there on social media today to see how my colleagues who are still actively engaged in acute care are adapting to the changing parameters of this pandemic. Before putting those questions out, I had the thought that telepsychiatry could be used over the short distances in inpatient settings. As a resident I had the experience of observing psychotherapy firsthand and being observed from adjacent rooms that also had microphones for communication between those rooms. I was interested in seeing whether or not anyone had implemented those solutions.  I was pleased with the feedback that I have so far.

One of the first responses was that psychiatric staff were using surgical facemasks and face shields in some settings. In other settings, adjacent rooms and telepsychiatry both on-site and off-site were being used for acute-care units. The most unique solution I heard of was a consultation liaison team using iPads to interview medical and surgical patients remotely where possible. That reminded me that some people have joined my telepsychiatry sessions using smart phone apps. It was generally very suboptimal if the phone was not completely stabilized.  I also had the experience this week of getting a link sent to me from a colleague who worked for a large healthcare system. It was an invitation to open up a video session with him even though I am not registered in his clinic.  It was very similar to a Zoom session that I did for a podcast. All this information shows that there are technologies available right now that are effective and actively being used. They have also been very rapidly deployed or are in the process of being deployed. There is some potential that this sudden change in the delivery of psychiatric services may be a more permanent one.

I asked the question about whether or not the services were saving personal protective equipment (PPE). The response to that question was somewhat mixed. I am not clear on what it means but speculate that some of the staff still need to have direct patient contact at some point during the day. Most acute-care staff at this point have been assigned PPE. The PPE specifics seem to vary from place to place but it is clearly rationed. If I was designing a survey of acute-care psychiatric facilities I would like to see the specifics of how many people had N95 masks and other kinds of protective gear.

Preadmission screening remains a question mark.  There is general agreement that there is an asymptomatic carrier state for SARS-CoV-2 (1,2).  Carriers may have a lower viral load and be partially symptomatic. Most people admitted to inpatient psychiatric units these days require intensive nursing care for their own safety. If there were environments where patients with COVID-19 could be safely segregated and treated that would be ideal, but I doubt those kinds of environments exist on inpatient psychiatric units. Even then the asymptomatic carriers would require the same psychosocial interventions as non-carriers.  The general screening done is to ask about contact with known cases and daily temperatures. I am not aware of any screening procedures that involve trying to identify the virus and carrier state.

My overriding concern is that medical and psychiatric staff everywhere have adequate protection. We have known since my days on the avian influenza task forces that airborne viruses are difficult to contain. They can infect through surface contamination, droplet contamination, and traveling on air currents. Working to cancel all those routes of infection is a tall order especially on an inpatient psychiatric unit.

The only practical way to maintain the level of communication necessary and minimize risk of infection is through some type of electronic communication. Some of the early methods have been listed in this post. Having worked in these settings for a large part of my adult life I am very concerned about the staff with daily direct patient contact including nursing, nursing assistants, and occupational therapy.  Housekeeping staff also have a vital role and are directly exposed to most contaminated surfaces. I have seen large numbers of inpatient staff come down with seasonal respiratory viruses and I know that vulnerability is there. They all need PPE. We need additional innovation in these settings to protect all staff and patients.  

And we have needed that innovation for a long time.

George Dawson, MD, DFAPA




References:


1: Lai CC, Liu YH, Wang CY, Wang YH, Hsueh SC, Yen MY, Ko WC, Hsueh PR. Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths. J Microbiol Immunol Infect. 2020 Mar 4. pii: S1684-1182(20)30040-2. doi: 10.1016/j.jmii.2020.02.012. [Epub ahead of print] Review. PubMed PMID: 32173241.

2: 1: Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, Ma H, Chen W, Lin Y, Zheng Y, Wang J,Hu Z, Yi Y, Shen H. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020 Mar 4. doi: 10.1007/s11427-020-1661-4. [Epub ahead of print] PubMed PMID: 32146694.

Supplementary 1:

I am very interested in what you are doing at your facility to contain this virus while continuing to go to work every day and treat patients.  I am also very interested in whether you have enough PPE.  I am interested in hearing from everybody staff psychiatrists, residents, social workers, occupational therapists, nurses, nursing assistants, and housekeeping staff.  Please post in the comments section below and feel free to remain anonymous. 


Graphic Credit:

Shutterstock per their standard agreement.

When To Not Prescribe An Antidepressant?

I encountered that interesting question just last week.  Antidepressant medications have been around for a long time at this point and they have an increasing number of indications.  Everywhere around the Internet there are algorithms that make prescribing these drugs seem easy and automatic.  Qualify for the vague diagnosis and follow the line to the correct antidepressant. At the same time there is plenty of evidence that their use is becoming less discriminate than in the past, largely due to the use of checklists rather than more thoughtful diagnostic processes.  It is common for me to encounter people who have been put on an antidepressant based on a "test".  When I ask them what that test was it is almost always the PHQ-9 or GAD-7, checklist adaptations of DSM criteria for depression and anxiety that can be completed in a couple of minutes.  There is a significant difference between the checklists and the diagnostic process as I pointed out in a previous post about the sleep question on the checklist compared with more detailed questions about sleep.  The list that follows contains a number of scenarios that will not be accessible by a checklist.  In those cases a more thorough diagnostic assessment may be indicated.

1.  Intolerance of antidepressants - Every FDA package insert for medications includes this warning, usually referring to an allergy or a medical complication from previous use.  In addition to allergic reactions (which are generally rare with antidepressants), there a number of significant problems that preclude their use.  Serotonin syndrome can occur with low doses and initial doses in sensitive individuals.  In the case of the more potent classes of serotonergic medications - the SSRIs as many as 20% of patients will experience agitation, nausea, headaches, and other GI symptoms.  By the time that I see them, they will tell me the list of antidepressants that made them ill and that they cannot take.  It is an easy decision to avoid medications that are known to make the patient ill.

2.  Behavioral intolerance of antidepressants - SSRIs in particular can have the effect of restricting a person's emotional range to a narrow margin.  They will typically say: ""I don't get low anymore but I also don't get as happy as I used to get."  A person who is affected in that way finds that to be a very uncomfortable existence.  Many have been told that they will "get used to it" - a frequently used statement about these medication related side effects.  I have never seen anyone get used to a restricted range of emotion and I tell them to stop it an not resume it.  I avoid prescribing antidepressants form that class and that class is typically SSRIs.

While I am on the topic, I frequently use the following vignette when discussing the concept of "getting used to" side effects:

"Many years ago I treated a man who came to me who had been taking a standard antidepressant for about 7 years.  He was not sure that he was depressed anymore.  He was sure that he had frequent headaches and very low energy.  I recommended that we taper him off the antidepressant and see how he felt.  He came back two weeks later and said: 'Doc - I feel great.  For about the last 6 years I felt like I had the flu every day and that feeling is gone.'  That is my concern about 'getting used to a medication'.  It may mean that what you really get used to is feeling sick.  That is why I encourage everyone that I treat to self monitor for side effects, and if they happen we stop the medicine and try something else."

That advice sounds straightforward but it is not.  I still get people who think that they need to "get used to" a medication and will only tell me in a face-to-face interview.

3.  Lack of a clear diagnosis - many of the people I see were started on an antidepressant during an acute crisis situation like the sudden loss of a significant person in their life or a job or their financial status.  There is no real evidence that antidepressants work for acute crisis situations, but some doctors feel compelled to prescribe a medication because it makes it seem like they are trying to help the patient.  I have also heard the placebo response rationalized for these prescriptions.  A similar cluster of symptoms can be observed along with the associated anxiety, but in the short term the main benefits to be gained will be from medication side effects like sedation rather then any specific therapeutic effect.   The real problem is that the medications don't get stopped when the crisis has passed.  I may be seeing a person who has been taking an antidepressants for ten years because they had an employment crisis or divorce at that time and have been taking the medication ever since.  They have been tolerating the medication well for that time, but it now takes a lot of effort to convince them that they don't need the medication and taper them off of it.

I try to prevent those problems on the front end by not prescribing antidepressants for vague, poorly defined emotional problems or crisis situations where they are not indicated.  In my experience, psychotherapy is a more effective approach and it helps the affected person make sense of what has been happening to them.

4.   An unstable physical illness is present - that can mean a number of things.  The commonest unstable physical illness that I routinely deal with is hypertension with or without tachycardia.  Patients and their doctors will often go to extraordinary lengths to avoid treating hypertension even hypertension that is outside of the most current and most liberal guidelines.  I am told that the person has "white coat hypertension".  How do they know that is all that they have?  Have they ever had a normal blood pressure reading outside of a physician's office?  Would they be willing to purchase their own blood pressure device, monitor their blood pressures at home and bring me the readings?  I have had people become angry at me because of these suggestions, even after a thorough explanation of the rationale.  It is almost like patients expect a psychiatrist to hand them a magical pill that takes care of all of their problems.  As an example the following warning if from the FDA package insert for milnacipran but most antidepressants don't include this warning - even when they might affect blood pressure:

"Elevated Blood Pressure and Heart Rate: Measure heart rate and blood pressure prior to initiating treatment and periodically throughout treatment. Control pre-existing hypertension before initiating therapy with FETZIMA"

There are a number of conditions ranging from glaucoma to angina that need treatment before antidepressants can be safely prescribed.  In some cases I am not happy with the pharmacotherapy for associated medical conditions.  Desiccated thyroid rather than levothyroxine for hypothyroidism is a good example.  Why is desiccated animal thyroid gland being used in the 21st century instead of the specific molecule?  In many cases, I will refer the patient to see a specialist and they will never come back because their real problem has been solved.  I posted about cervical spine disease some time ago after I had a number of patients come in for treatment of depression.  What they really had was insomnia from cervical spine disease and when that chronic pain was addressed their depression resolved completely.

I will run into some situations where I insist the patient see a specialist (generally a Cardiologist) to get an opinion on safety of treatment.  This used to be called "clearance" by the Cardiologist but for some reason that term has fallen out of favor.  I think the "clearing" specialists don't want the designation, but from my perspective the patient is not going to get the antidepressant that we discussed unless the Cardiologist agrees.

5.  The patient prefers not to take the medication - I think that patients are often surprised at how easily they can convince me to not prescribe a medication.  Many expect an argument.  I will supply them with the information they want and direct them to reputable sites on the Internet where they can read as much as they want about the medication.  I am very willing to discuss their realistic and unrealistic concerns.  I will attempt to correct their misconceptions  and also provide them with my real life estimate of how many people tolerate the medication and the common reasons why people stop it.  I fully acknowledge that I cannot predict if a medication will work for them or give them side effects.  At the end of that discussion, if they don't want to try the medicine that is fine with me.  I have absolutely no investment in prescribing medication for a person who does not want it.  If the person has clear reservations, I let them know they don't have to come to a decision right in the office - they can go home and think about it and call me with their decision.  I am never more invested in the medication than the person who is taking it.  I will also provide them with feedback on whether or not their decision seems reasonable or not.

6.   Additional patient preferences -  Many people will talk with me about antidepressants and say that they want to solve their problems with psychotherapy, exercise,  or some other non-medical option.  Many people will also talk about drugs, alcohol, cannabis,  hallucinogens, psychedelics, and other drug based treatments for depression.  I can offer people what is known about the scientific basis of treatments for depression and encourage effective non-medical treatment where it is indicated.  I do not endorse the use of the use of alcohol or street drugs for treatment and let people know that I cannot prescribe antidepressant medication if those other substances are being used.  That includes "medical marijuana".  There is a risk for serotonin syndrome with various combinations of stimulants, hallucinogens, and/or psychedelics in combination with antidepressants.  Some web sites that profess to provide neutral advice to people who want to experiment will often have some posts on how to mix these medications to get enhanced effects.  None of that advice should be considered safe or reliable.  It is an indication to me that the person cannot be expected to take the prescription reliably.

7.  Context - very important consideration.  Seeing a person who has just survived a suicide attempt in the intensive care unit is a much different context than seeing a long  line of people who are dissatisfied with life for one reason or another.  Twenty three years of acute care work taught me that medical interventions are much more likely to work for clear cut severe problems than vaguely defined problems.  There are many people who are looking for a fast solution to difficult problems.  When I suggest to them that environmental factors need to be addressed or that they may benefit from psychotherapy or even more explicitly that psychotherapy will work better for your problem than medications - I am often met with resistance.  Common replies are that they cannot commit that kind of time or energy to psychotherapy.  Since most managed care companies discriminate against psychotherapy - many will tell me that their copays are too expensive.  If I point out that their work schedule or job is the problem - they will give me many reasons why they can't change it.  Treatment becomes conditional - as in - I am hoping that this antidepressant will work because I cannot change my life in any reasonable way and I can't do psychotherapy.

8.  Commitment to treatment - too many people come in and expect the prescription of an antidepressant to not only solve the problems but that nothing else is required of them except to show up for an occasional appointment.  If I want to see medical records like exams, labs, imaging studies, ECGs. EEGs, pharmacy records or other information it is generally not an option.  I need that information before any prescription occurs.  The same is true if I need to order these tests and see the results.  I am quite capable of having a discussion of the costs of these orders and that is why I have a preference for not repeating tests and looking at existing results.  That does not prevent the occasional complaints about how I am interested in making money off the person by ordering basic tests, even though I do not get anything at all for ordering tests.

The other part of treatment does involve agreeing to take the medication reliably and following the other recommendations that can be very basic.  If someone tells me that they are drinking two pots of coffee per day and they are anxious and can't sleep but are unwilling to stop the coffee because: "I know that I can drink two cups of coffee and still fall asleep" - I am probably not going to be able to do much with an antidepressant.  The same is true for somebody binge drinking a 12-pack of beer every night after work.  The effects of common substances like caffeine and alcohol are contrary to the goals of treating anxiety and depression with or without medication.

9.  Mania - it is possible for people who have taken antidepressants for years to become manic either while taking the antidepressant regularly or when the antidepressant has been disrupted.  Even though the incidence of mania from antidepressants is low and the treatment of bipolar disorder depressed includes an antidepressant-atypical antipsychotic combination (olanzapine-fluoxetine combination or OFC) stopping the antidepressant acutely is the best idea.  Many people discover at that point that mood stabilizers seem to work much better for their periods of depression than antidepressants.                              
10.  Misunderstanding the treatment alliance - fortunately treating depression and anxiety is not like treating standard medical problems.  Most office visits for new general medical and surgical problems are one or two visits in duration.  A medication is prescribed and it either works or it doesn't.  When it doesn't the problem either resolves on its own or becomes a chronic problem.  One of the best examples anywhere is acute bronchitis.  Over the past decades - tons of antibiotics have been prescribed for no good reason.  Acute bronchitis generally resolves on its own in young healthy people.  I try to be very clear with people that their response (good or bad) to the medication is in no way guaranteed.  I let them know that these medications are moderately effective at best and then only in the hands of somebody who knows how to rapidly switch them up and in some cases augment them.  Even then there will be some people who do not respond.  The key to all of that treatment is communication and it may require significant patience on the part of the patient.  It may also require more frequent appointments then they anticipated especially is associated problems like suicidal thinking and psychosis are also being addressed.

Those are my thoughts about the question of who I would not prescribe an antidepressant to.  I hope to transform those thoughts into dimensions in a useful graphic.  Feel free to let me know if I missed anything.



George Dawson, MD, DFAPA

News Flash From the StarTribune - Psychiatric Patients Have "Nowhere To Go"

Not to be outdone by the local television stations, the Minneapolis StarTribune came out with their own stunning analysis of the problems with psychiatric care in the state.  At least the opening line was stunning:

"Hundreds of Minnesotans with mental health problems are languishing in hospital psychiatric units for weeks, even months, because they have nowhere to go for less intensive care, according to a comprehensive study to be released this week. " 

Notice the expertise in this sentence - we now have a comprehensive study.  We have a comprehensive study of what every inpatient psychiatrist in the state of Minnesota has known for the past 30 years!  There is a lot behind this headline that is not included in the story.  For example, they left out the part that inpatient psychiatrists and social workers are routinely scapegoated by administrators and government officials for the problem.  The system is not blamed for patients staying in the hospital too long - the doctors are.  I had the opportunity to work with outstanding social workers when I was in this setting and at some point they have to quit.  One of my social work colleagues spent all day, calling over 30 facilities to try to get the patient discharged and she failed.  She failed for two reasons.  First, the infrastructure for accepting patients with chronic psychiatric disabilities has been rationed out of existence by state and county officials.  Second, the existing facilities do not want to accept people with psychiatric problems especially if they have had a history of aggression or suicidal behavior.  The next sentence makes even less sense:

"As a result, private hospitals are absorbing millions of dollars in unreimbursed costs, while patients who are well enough to be released are being deprived more appropriate care at a fraction of the cost."

The author here clearly does not know how state and county officials think.  There is an assumption that they want cost effective and appropriate care.  In my 23 years on an inpatient unit - there is no evidence that those motivations exist.   To any career long student of the system, it should be abundantly clear that all of these administrators and bureaucrats want free care.   Only the Orwellian rhetoric of managed care could spin free care into appropriate care.  I will elaborate on free care instead - how does that happen?  It basically happens in four ways:

1.  The patient is admitted to a psychiatric unit and is too disabled to be discharged to either the street, an apartment, or their original living situation .  The hospital needs to get the patient out in 6 days or less in order to make a profit on the limited payment they get for admissions or discharges (a DRG payment).  The patient is stranded for much longer.  The patient's care is essentially free at that point.  Not only that but if the county rations placement options - they don't spend any money on placements.

2.  The patient is admitted and ends up on a probate court hold or a civil commitment.  In this case they can be stranded for months waiting to get to a state hospital.  Insurance companies and the state do not pay for people in this situation.  The care again is for free.  

3.  Homeless psychiatric patients circulate in an out of the emergency department.  They come in because they are in distress.  They know that they need to verbalize serious problems in order to get admitted.  If not they are discharged back to the street only to appear in the emergency department at a later date.  There is a large circulating population of these patients who may get briefly admitted but never get stabilized.  Apart from the nominal emergency department fee - their care is free.  But of course they are really getting no care.  

4.  Up to 2/3 of people with substance use problems have psychiatric disorders.  Many of them will show up in the emergency department with various levels of symptomatology.  If they are intoxicated they will be sent to county detox facilities - where once again the care is free but it is not psychiatric care.  

These are well hidden secrets of modern psychiatric care.  First, psychiatrists have nothing to do with how the system is managed.  Second, the myth that care is expensive.  People would always ask me if they were being charged a mythical "$1,000/day" fee to be on a mental health unit.  I can assure anyone that when all of the discounts and free care is rolled into the meager reimbursement from insurance companies, the actual reimbursement is more like hotel rates without the hotel accommodations.

The article also discusses the differences between general medical surgical care and psychiatric care. The question is asked if cancer patients were stranded and could not get to tertiary cancer care - would it be as acceptable as the case for psychiatric care?  That question minimizes the scope of the problem.  The problem with the "bottlenecks" described in the article is that they are all a result of rationing of psychiatric services.  There is nobody rationing cardiology or oncology services.  Any middle aged person who goes into an emergency department with chest pain will get state of the art care for chest pain and have all of the necessary testing.  There are no similar services available for psychiatric illnesses.  As soon as a person is admitted the current goal is to get them stabilized and discharged as soon as possible.  The resources are so meager that people frequently do not get the care that they need, because it is rationed.   The article also points out that inpatient treatment at some level is little more than containment.  With administrators rather than clinical psychiatrists running the system, there is no longer an emphasis on a therapeutic environment.  In many cases the experience is sitting around in a facility with little to do, waiting to talk with a doctor about getting released.

So - don't believe what you read in the papers.  Nothing in this article is news.  The system of psychiatric care in the state of Minnesota is dysfunctional by design.  It has been designed by managers at all levels who routinely ignore what psychiatrists have to say and who don't want to spent an additional penny on psychiatric care.

That produces deficiencies at both ends of the spectrum - the people who need to be admitted for psychiatric care as well as the people who need to be discharged.  People with mental disorders should get the same level of care as people with medical and surgical disorders.  That will never happen as long as rationing psychiatric care is justified as being "cost effective".

George Dawson, MD, DFAPA 

References:

Chris Serres.   Nowhere to go, psychiatric patients languish in Minnesota hospitals.  StarTribune August 10, 2016.

George Dawson.  News Flash From Channel 5:  "There is a shortage of psychiatrists."  Link

Supplementary 1:

Every now and then the news media comes up with a shocking story about the rationing of psychiatric services at least they are hyping it that way.   One of my favorites is on Greyhound Therapy and yes this also happens in Minnesota and probably every other state in the USA.  When it comes to rationing and denying care - nothing beats the cost of a bus ticket.

Supplementary 2:

For a look at how modern medical managers and bureaucrats running managed care organizations view psychiatric services - read this post on the Dog Quadrant.

Supplementary 3:

I posted two brief sentences and a link to this post on the page with this story on the StarTribune website.  It was deleted.  If you are reading this please direct anyone interested to this post of what is really happening with mental health and psychiatric care in the state of Minnesota and everywhere.