Heidi Anne Duerr, MPH

Suicide risk screening is especially challenging in the time of a pandemic. Data are not yet available to ascertain how COVID-19 will affect the suicide rate. However, the 3-tiered clinical pathway needed to be revised to accommodate mostly telehealth screening. Maryland Pao, MD, Annabelle M. Mournet, and Lisa M. Horowitz, PhD, MPH, revised the suicide risk screening clinical pathways published by Brahmbhatt and colleagues to reflect the need for phone screening and assessments. 

Learn more in the article "Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings," to appear in the July 2020 issue of

Courtesy: National Institute of Mental Health

Articles

Suicide risk screening is especially challenging. Although data are not yet available to ascertain how COVID-19 will affect the suicide rate, the 3-tiered clinical pathway has been revised to accommodate mostly telehealth screening.

Youth Suicide Screening Pathway

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers Peter Yellowlees, MMBS, MD, Chief Wellness Officer at 

 and Professor of General Psychiatry at the University of California, and Jay Shore, MD, MPH, Professor at the Department of Psychiatry and Family Medicine at 

, joined moderator Chris Aiken, MD, Director of the 

, to discuss tips and tricks in making telepsychiatry work in this era of COVID and beyond. The webinar, which was recorded live, is available at 

www.psychiatrictimes.com/career/resources-psychiatric-times-telepsychiatry-covid-webinar

There are a number of tools that can make telepsychiatry easier for the clinician, said Yellowlees, who authored on the 2009 telemental health guidelines. A noiseless keyboard, for example, will make it easier to take notes during a session without disrupting the flow of the conversation. This, in turn, makes post-appointment paperwork quicker and easier. Similarly, an echo-cancelling microphone improves audio quality.

Yellowlees also likes to use multiple screens during telepsychiatry sessions. “I have one screen for the video, I have another screen to the EMR, and I typically have my email or something else going on the third screen,” he explained. “And it’s actually less tiring to have two or three screens, because you don’t have to constantly change the picture, or change the shape of your screen as you’re doing different functions; you literally use each screen for a different function. And that’s a much, much easier way of working.”

Choosing an appropriate telepsychiatry platform is also important. Despite the flexibility during COVID, both Shore and Yellowlees noted it is best to use platforms that are HIPAA-compliant. “You know, the government can easily change the rules and decide they want to come and prosecute people [for not being HIPAA-compliant].”

Choosing a HIPAA-compliant platform now will allow for a seamless transition in a post-COVID world. Just as it may take time for clinicians to learn new platforms, patients may have a similar adjustment period. Since the rules will likely change after the COVID crisis, they added, it makes sense to acclimate your patients to something you can use moving forward.

The speakers agreed that telepsychiatry requires a degree of flexibility and creativity. For instance, psychiatrists should aim to be more animated during a telepsychiatry visit, Yellowlees noted. “I normally say to people to be about 110% of normal—just slightly more lively, slightly more intonation in your voice. . . . And, that may be why some people also find telepsychiatry a little bit more tiring initially, because they’re actually having to speak and enunciate more loudly and more carefully.”

Similarly, clinicians may need to ask patients to be more creative. For example, clinicians can ask patients to weight themselves or use a blood pressure monitor during the video visit, sincemany of the tools used to assess patients’ vital signs can be obtained inexpensively online.

Shore also had some suggestions for patients worried about their privacy. “One of the places that many of my colleagues and I have found useful is car therapy. When the car is not moving and the patient is not driving, it provides a private secure space,” he explained.

opens up a world of possibilities. Yellowlees shared, “I’ll get them to deliberately use an iPad or a phone or mobile device, and I’ll have them show me around the house and walk me out in the garden. I’ll talk to them about their pictures or what they’re having for supper. I’ll get to see their pets, and potentially I’ll meet other members of the family—of course with appropriate discussion beforehand with a patient.”

This can be particularly helpful when doing therapy, explained Shore, Director of Telemedicine Programming for the Department of Psychiatry, University of Colorado Anschutz Medical Campus. “I think there’s a real power to move the treatment into the place where the patient lives.”

Telepsychiatry also allows for greater insights and ability to help patients with specific disorders. For instance, if you are working with someone with ADHD, you can see the state of their homes. In patients with eating disorders, clinicians can ask to see the pantry, and for patients with a hoarding disorder, you can monitor their progress as they sort through belongings.

Other special patient populations can also benefit from telepsychiatry, as it evens out the playing field and provides a more egalitarian approach. Patients with anxiety can meet with their physician in a more comfortable environment, which in turn allows them to share more freely. It also benefits children and adolescents, Aiken added. “It can be intimidating to be in an older doctor’s office when you’re an adolescent. In telepsychiatry, we are on their media—this is their domain, the electronic media, so they take it and run with it.”

According to the experts, the literature to date suggests very high levels of patient satisfaction, most likely due to its flexibility. It becomes easier for patients to show up for appointments, with minimal disruptions to their schedule.

The flexibility goes both ways. In the past, taking an extended vacation or attending a convention meant leaving your patients behind, finding coverage, and the like. With telepsychiatry, clinicians can schedule appointments around their travel schedules and leisure time.

Another perk of telepsychiatry is that patients may find it easier to divulge sensitive information. “There’s a big computer science literature showing that people tend to be more honest if they’re talking about sensitive topics to a computer, filling in a questionnaire, or to someone on video on a computer as opposed to in person,” Yellowlees said. “Imagine if you’re a female and you’ve been raped recently. It’s much easier to talk to someone like Jay or myself on video than to come into our clinics and see us there as sort of physically large males.”

With greater opportunities to connect with patients and high levels of patient satisfaction, all three experts agreed the future should consist of a balanced hybrid model as standard care.

“I tend to look at it like video and in-person visits, each has their own strengths and challenges, and it’s variable by the patient population,” Shore explained. “As Peter [Yellowlees] mentioned, I’ve worked with victims of domestic violence and see them first in video to establish a relationship where they feel safer and more comfortable. Now, there are other patients where you may want to see them in person first to establish the relationship, and then do video.”

“What I’m hearing is that in the hybrid model patients might feel more secure in their connection with us, knowing that they can reach us when they’re at the beach, when their car is broken,” Aiken said. “We just have to turn it up a bit, 110%, in our own attunement and energy involvement, and we can actually connect to patients in different ways.” ❒

For full coverage of the webinar and more information, visit us at 

www.psychiatrictimes.com/telepsychiatry/making-telepsychiatry-work-you-and-your-patient

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers joined Chris Aiken, MD to discuss tips and tricks in making it work for you. 

The Future of Telepsychiatry

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers Peter Yellowlees, MMBS, MD, Chief Wellness Officer at UC Davis Health and Professor of General Psychiatry at the University of California, and Jay Shore, MD, MPH, Professor at the Department of Psychiatry and Family Medicine at Colorado School of Public Health, joined moderator Chris Aiken, MD, Director of the Mood Treatment Center and 

 Section Editor for Bipolar Disorder, to discuss tips and tricks in making telepsychiatry work in this era of COVID and beyond. The webinar, which was recorded live on May 18, 2020, is available online at 

https://event.on24.com/wcc/r/2359555/FAB61DFA865C680B16BE9C42AF7BAF30

Yellowlees, who has authored more than 80 articles on telepsychiatry and health informatics, has been conducting telemedicine since 1991. Recognizing the need to address mental health in more rural areas, his first session was with an Aboriginal women with depression in a distant part of Australia. Since then, he has refined his approach and gained much experience. In 2009, he was the lead author on the telemental health guidelines published by the American Telemedicine Association; he is a Fellow and Past President of the 

Although there are a number of things that can make telepsychiatry easier for the clinician, Yellowlees said a clinician could easily get a good setup for about $200. A noiseless keyboard, for example, will make it easier to take notes during a session without disrupting the flow of the conversation. This, in turn, makes post-appointment paperwork quicker and easier. Similarly, an echo-cancelling microphone improves audio quality-it can be easily connected to a desktop computer and eliminates the need for headphones. Throw in a camera, and you are good to go. Even simpler, forgo the desktop computer for a laptop or a tablet, which has a built in camera and speakers.

According to Yellowlees, clinicians often overlook things like proper lighting and video presentation issues. He suggested havinf a light overhead, almost directed between you and the camera screen, and to avoid having too much light behind you to avoid shadows. Always check to see that you are centered properly, with your head about two-thirds of the way up the screen. “You don’t want your eyes to be far away from the actual camera,” he explained. Since the camera is a few inches above the eyes, this placement allows the clinician to make “eye contact” with the patient in a more natural way.

Choosing an appropriate telepsychiatry platform is also important. Despite the flexibility being afforded to health care providers during COVID, both Shore and Yellowlees noted it is best to use platforms that are HIPAA-compliant. “You know, the government can easily change the rules and decide they want to come and prosecute people [for not being HIPAA-compliant]. They really haven’t changed the HIPAA rules at all; they’ve just decided that they weren’t going to prosecute.”

In addition, picking the best platform right off the bat will allow for a seamless transition in a post-COVID world. Just as it may take time for clinicians to learn new platforms, patients may have a similar adjustment period. Since the rules will likely change after the COVID crisis, they added, it makes sense to acclimate your patients to something you can use moving forward. Fortunately, there are a number of user-friendly platforms from which to choose (

Not surprisingly, many of the attendees’ questions surrounded reimbursement issues. Also not surprisingly, Shore, who also got his start in telemedicine to treat patients in rural areas noted the situation is complex, as insurance companies may have their own set of rules and CPT codes. Shore currently serves as the Director of Telemedicine Programming for the Department of Psychiatry, School of Medicine; as Director of Telemedicine for the Helen and Arthur E. Johnson Depression Center University of Colorado Anschutz Medical Campus; and as Chief Medical Officer of AccessCare, a provider of telemental health services of rural and underserved populations. As such, he is well aware of the intricacies of the reimbursement tango.

Shore reported that there is a loosening of requirements in the federal programs, including additional codes in Medicare and Medicaid. Yet, there have been weekly if not daily changes in coding, so he suggests clinicians check for specific directions on insurance company websites. Similarly, the American Psychiatric Association’s telepsychiatry page has many resources to help clinicians.

Certainly, as the COVID pandemic evolves, both Shore and Yellowless expect the reimbursement rules to change and evolve. Before the pandemic, Yellowlees routinely obtained prior authorization for telepsychiatry visits for each new patient. He noted this would be good practice moving forward for all clinicians to consider.

All speakers agreed that telepsychiatry requires a degree of flexibility and creativity to make it work. For instance, psychiatrists should aim to be more animated during a telepsychiatry visit, Yellowlees noted. “Try to be lively and be reasonably friendly, you know, perhaps a bit more than you necessarily would in your own clinic. I normally say to people to be about 110% of normal-just slightly more lively, slightly more intonation in your voice. . . . And, that may be why some people also find telepsychiatry a little bit more tiring initially, because they’re actually having to speak and enunciate more loudly and more carefully.”

Similarly, clinicians may need to ask patients to be more creative. For example, clinicians can ask patients to weight themselves or use a blood pressure monitor during the video visit-many of the tools used to assess patients’ vital signs can be obtained inexpensively online. Patients with limited funds might be able to visit a local drug store to assess blood pressure and pulse readings.

Shore also had some suggestions for patients worried about their privacy. “One of the places that many of my colleagues and I have found useful is car therapy. When the car is not moving and the patient is not driving, it provides a private secure space,” he explained. “I actually have patients who park near places like a local library or health care center with good bandwidth . . . I have had patients park in front of their relatives’ houses and use their WiFi passwords.”

On the other hand, telepsychiatry opens up a world of possibilities. Yellowlees shared, “I’ll get them to deliberately use an iPad or a phone or mobile device, and I’ll have them show me around the house and walk me out in the garden. I’ll talk to them about their pictures or what they’re having for supper. I’ll get to see their pets, and potentially I’ll meet other members of the family-of course with appropriate discussion beforehand with a patient.”

This can be particularly helpful when doing therapy, Shore explained. “You’re doing [therapy] in this artificial environment, not in the environment where they live and they’re dealing with their symptoms. And so, I think there’s a real power to move the treatment into the place where the patient lives.”

Similarly, telepsychiatry also allows for greater insights and ability to help patients with specific disorders. For instance, if you’re working with someone with ADHD, you can see the state of their homes. In patients with eating disorders, clinicians can ask to see the pantry to see what might tempt them. For patients with a hoarding disorder, you can monitor their progress and watch as they sort through things.

Other special patient populations can also benefit from telepsychiatry. The most obvious group includes older and immunosuppressed patients during the COVID environment, who benefit from care that does not endanger their lives. Telepsychiatry also evens out the playing field and provides a more egalitarian approach. Patients with anxiety can meet with their physician in a more comfortable environment, which in turn allows them to share more freely. It also benefits children and adolescents, Aiken added. “It can be intimidating to be in an older doctor’s office when you’re an adolescent. In telepsychiatry, we are on their media-this is their domain, the electronic media, so they take it and run with it.”

The flexibility goes both ways. In the past, taking an extended vacation or attending a convention meant leaving your patients behind, finding coverage, and the like. With telepsychiatry, clinicians can schedule appointments around their travel schedules, appointments, and leisure time and still be able to monitor their patients.

With greater opportunities to connect with patients and high levels of patient satisfaction, all three experts agreed the future of psychiatry should consist of a hybrid model of care. Aiken noted, “As we emerge [from this pandemic], psychiatry will have this tremendous opportunity to figure out the right balance [of telepsychiatry and in-person care].” This balanced hybrid approach should really be the standard of care, he added.

“What I’m hearing is that in the hybrid model patients might feel more secure in their connection with us, knowing that they can reach us when they’re at the beach, when their car is broken,” Aiken said. “We just have to turn it up a bit, 110%, in our own attunement and energy involvement, and we can actually connect to patients in different ways.”

Telepsychiatry and Health Technologies A Guide for Mental Health Professionals

Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals.

 American Psychiatric Association Publishing; 2018.

How can telepsychiatry improve quality and access to care as well as reduce physician burnout? Telepsychiatry pioneers

Making Telepsychiatry Work for You and Your Patients

Before the pandemic took front and center stage, the US Food and Drug Administration was busy in the field of psychiatry. With a number of medications in the pipeline, new indications for old familiar faces, and the industry’s desire to share information with clinicians and patients alike, the FDA will likely remain busy, both policing the field and making approvals.

Pharmaceutical company makes the FDA’s naughty list

A warning letter was sent from the FDA’s Office of Prescription Drug Promotion (OPDP) for misleading advertising for the drug ProCentra, an oral solution used to treat attention-deficit/hyperactivity disorder.

 The warning letter was in response to a sponsored link on Google.com that failed to include risk information and use the medication’s established name. The letter also noted that the FDA Bad Ad Program received complaints.

The OPDP explained that the ad suggested the drug’s efficacy and ease use by pointing out its “Bubblegum Flavor” and “Liquid Treatment Option,” all of which easily would appeal to parents as desirable for children, without including any risk information.

These violations are especially concerning from a public health perspective because they create a misleading impression about the safety of ProCentra, a drug that is a schedule II controlled substance used in the vulnerable pediatric patient population, and bears a Boxed Warning that describes the high potential for abuse, that administration of amphetamines for prolonged periods of time may lead to drug dependence, and states that misuse may cause sudden death and serious cardiovascular adverse events.

The letter was sent to Stefan Antonsson, CEO of Outlook Pharmaceuticals, with specific corrective actions requested. For starters, the company was told to “immediately cease misbranding.” In addition, they must respond in a letter detailing not only how they will comply with this request, but, since the violations are deemed serious, they must include “a comprehensive plan of action to disseminate truthful, nonmisleading, and complete corrective messages about the issues discussed in this letter to the audience(s) that received the violative promotional materials.”

According to Regulatory Focus, the ad has been removed and the CEO will respond.

Meanwhile, its likely Outlook is not alone in such missteps. According to AdComplyRx, more than 30 major prescription brands inadvertently ran 

 Nonetheless, the warning letter, which is the first of its kind for this calendar year, showed that the FDA is watching and will hold companies responsible for irresponsible action.

On a more positive note, the FDA reviewed and accepted the New Drug Application (NDA) for LY03005, a serotonin-norepinephrine-dopamine triple reuptake inhibitor (SNDRI). Developed under Luye Pharma’s New Chemical and Therapeutic Entities Research and Development platform, the company has 

patents covering the chemical compound, crystal form, and formulation of LY03005.

Unlike other available antidepressants, it is believed the SNDRI class of medications will be relatively beneficial in preserving patients’ sexual functions. Data also suggests SNDRIs will have a better safety profile, produce a more rapid onset, and provide better efficacy.

SNDRIs fall under the category of triple reuptake inhibitors (TRIs), since they simultaneously target serotonin transporters, norepinephrine transporters, and dopamine transporters. TRIs are emerging as a promising class of antidepressants. It is theorized that, compared with monoamine transporters, their broader spectrum inhibition would lead to 

 and faster antidepressant response while also addressing a broader range of symptoms (including anhedonia).

The company originally filed for the NDA in late December 2019 after consensus was reached with the FDA under End-Of-Phase 2-CMC meeting and Pre-NDA meeting.

 Luye Pharma has made a commitment to their central nervous system pipeline; they currently are working on compounds for the treatment of schizophrenia, bipolar disorder, and Alzheimer disease.

“The global patient population affected by depression and other CNS diseases is large and growing, with serious distress caused by these diseases greatly affecting both patients and their families. We look forward to bringing more high-quality and innovative drugs to the market, helping these patients in need,” a senior management representative from Luye Pharma Group said in a press statement.

1. Haffer AST. Warning Letter: Re: ANDA 040776 PROCENTRA® (dextroamphetamine sulfate) oral solution, CII MA 60. US Food and Drug Administration. February 21, 2020.

2. AdComplyRx. Homepage: 2018 Brand Safety Report. 

OPDP Warns Pharma Company for Sponsored Link on Google. Regulatory Focus

NDA Filing for Luye Pharma’s Antidepressant Drug LY03005 Accepted by the U.S. FDA

Triple reuptake inhibitors as potential next-generation antidepressants: a new hope?

Release. Luye Pharma Submits New Drug Application in the U.S. for Its Antidepressant Drug LY03005. December 26, 2019

New hope for depression on the horizon and other updates.

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Staying Healthy During the Pandemic: FDA Updates

Are there any neuropsychiatric symptoms associated with the COVID-19 virus?

 It is early to speak with confidence about any real chronic aspects or consequences of the virus. There was a small 

recently looking at the people in China where the virus began, and they found the primary psychiatric symptoms were post dramatic posttraumatic stress 

(PTSD), because PTSD symptoms have to last for 30 days or longer. However, it is significant in a related fashion.

Not surprisingly, when you look at the SARS outbreak which was seemed to be a lot more dangerous and aggressive than the current COVID-19 virus, PTSD was the number one psychiatric complication both in health care providers and people who were affected by the virus. It seems like in some ways, not surprisingly, that this is a major life upheaval, and people are hypervigilant and that creates an experience of a traumatic intrusion. So, as of now, it seems like posttraumatic stress-like symptoms are the primary psychiatric comorbidity so to speak.

 How do you think this pandemic will impact psychiatry as a field?

What it is doing in our own clinic here in a matter of one week is where testing out the utility of having a virtual treatment model where basically we are able to interface with a lot of people without person-to-person contact, although telepsychiatry has been growing (in our clinic it hasn't been a big piece of what we do), in some ways this is going to be a real test of what is the utility what is the effectiveness of this of telepsychiatry and how does it make sense to fit in.

I do believe that although telepsychiatry is really important and helpful during this during this period of time, there are a lot of patients that I would still want to see in person and especially doing things like monitoring their metabolics in their blood pressure and pulse and doing an abnormal involuntary movement scale exams, and I personally find a lot of important information being with the person sitting across from me and seeing the body language and getting the big picture. My hope is it doesn't move us too far in the direction of telepsychiatry but that we find the useful niches for telepsychiatry and this is certainly going to put that to the test

Have more COVID concerns and clinical tips? Email us at 

. We may share your stories, queries, or thoughts in a future editorial or even as a standalone piece. Check out our 

Prevalence and risk factors of acute posttraumatic stress symptoms during the COVID-19 outbreak in Wuhan, China.

 March 10, 2020. medRxiv. doi:org/10.1101/2020.03.06.20032425.

2. Das DK. In China, COVID-19 Outbreak Leads to Posttraumatic Stress Symptoms. Psychiatry Advisor. March 17, 2020. 

https://www.psychiatryadvisor.com/home/topics/anxiety/ptsd-trauma-and-stressor-related/in-china-covid-19-outbreak-leads-to-posttraumatic-stress-symptoms

How will the coronavirus pandemic impact psychiatry as a field? Are there any neuropsychiatric symptoms associated with the COVID-19 virus? Those questions answered in this video.

Facing This Major Upheaval Together

In this video, John J. Miller, MD, discusses self-quarantine components of the COVID-19 pandemic with Heidi Anne Duerr, Associate Editorial Director of 

. Dr Miller is is Medical Director, Brain Health, Exeter, NH; Editor in Chief, Psychiatric Times; Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; and Consulting Psychiatrist, Insight Meditation Society, Barre, MA. He is Editor in Chief of 

What are you telling your patients regarding the pandemic both in terms of your office policies and preparing for self-isolation and quarantine as well as dealing with uncertainty?

I tell my patients the same thing I told my wife and my son and the same thing I tell my family and friends-that is, the situation literally is changing daily so stay tuned. I personally visit the CDC website on a daily basis so I am getting up-to-the-minute accurate information. In New Hampshire, we have a public health website that I also access daily to see what is happening in our state.

The big thing is staying inside, staying in the house, not going out, avoiding large crowds-the things you're hearing everywhere from everyone. The biggest challenge for us is convincing young healthy people to realize that even though they are at low risk, they may not even know they're infected. If they visit an elderly friend or parent or go to a store or someplace where other people are that are higher risk, they could be the transmitter of the virus.

It is really the action or inaction for all of us to protect each other. We need to think beyond our own needs and expectations and take care of the country as a whole. That is going to be one of the biggest challenges-convincing the young and the healthy to flatten the curve and prevent more infections regardless of their own risk.

Are you seeing more panic and anxiety in your patients at this time or are things pretty much the same?

 A few of my patients who have significant anxiety disorders are actually doing quite fine with it. They say they have been dealing with anxiety all their lives, and for them, they are seeing people who are not normally anxious get nervous. Now that us just my own experience with a few patients and I'm sure it's going to differ everywhere you go. I’ve found that initially I was surprised by that, but the other side of the coin is whenever you delve into the unknown and you're not expecting it, anxiety is going to be there.

 What do you think the impact of self-isolation and everybody working at home is going to be in the long run?

To start out on a light note, I read an article that said that the population that is having the most difficult time adjusting are all the pets at home. Our dogs and cats and birds and fish wonder if something different is going on because everyone is around.

On the more serious side, households where one or both of the primary adults are usually working and out of the house during the day, children and adolescents are at school, and young adults are working or in college-all of a sudden everyone is home taking virtual classes or working in virtual environments. So now you have a whole new kind of family culture that has developed literally overnight. Instead of everybody having schedules and a lot of time away, everyone is in a small contained area, probably fighting for the computer screens. Everyone is trying to do things virtually. I can only imagine that in some situations, it is going to be incredibly stressful.

It is going to be a good opportunity here for family self-therapy, learning to work together and cooperate and how to re-experience the core family just being with itself all the time. So there is a silver lining in there, but it is a huge adjustment. It is going to be very stressful and we still don't know how long this will continue, which I think is another piece of stress.

This is a whole new virus the experts don't know about, yet it is a slow learning process. We all have to be patient and respectful of what is asked of us and appreciate the hardworking commitment of the scientists and the epidemiologists. We then follow on the directives of the primary health care providers that are getting their mandates from the people who are overseeing the whole management of this pandemic.

What do we tell patients regarding the pandemic both in terms of office policies and preparations for self-isolation and quarantine as well as dealing with uncertainty?

Preparing and Helping Patients Deal With Self-Isolation

Psychiatric Times has collected information to answer your most pressing questions, including how to prepare your office and staff, resources for patients, and information you need to implement telepsychiatry.

Mental Health Resources and Guidance: Coronavirus

As we navigate uncharted waters on the pandemic front, John J. Miller, MD, shares his thought about this important topic and what he is both professionally and personally. Dr Miller is is Medical Director, Brain Health, Exeter, NH; Editor in Chief, Psychiatric Times; Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; and Consulting Psychiatrist, Insight Meditation Society, Barre, MA. He is Editor in Chief of Psychiatric Times.

Heidi Anne Duerr, MPH (HAD): What are you doing differently during this pandemic both professionally and personally?

 On the personal front, I'm doing what we all have been encouraged to do, which is basically staying at home. I did I work Monday at our clinic, which is right in the town I live, and I worked all day. A little over half of my scheduled patients showed up but, from that point forward and virtually on a daily basis, we are continuing to modify clinic policies to minimize risk and maximize safety for everybody.
	Professionally, one of the big things for us was the canceling of the annual American Psychiatric Association Meeting. It is always a great meeting. You get to collaborate, see lots of colleagues, and we have our Psychiatric Times meeting there. All of that that was cancelled on Sunday night and we have to put safety ahead of everything else-so that's where we stand.

How have things changed for you in your clinic over the past few weeks?

 We have an excellent team from our CEO right down to the psychiatrists and the nurses and all the team leaders. We have about 260 employees. We have two clinical sites, one in the town where I live and one about 15 miles away. We see about 6000 patients in total and so it is a pretty large population. Our team goes out on a daily basis to see high-risk patients; we have case managers that do things like bring patients to appointments or grocery shopping or checking in. We have outreach therapists that go to go to clients’ houses and will actually do therapy right in the house if patients have trouble getting into the clinic. We go into the school systems and we do consults at the local hospital.

We cover the emergency department, so we are pretty big system and we traditionally have been opened 8:00 AM to 8:00 PM Monday through Thursday and all day Friday. So just in this past week, there have been literally daily changes in response to the dynamic situation here at the beginning of the week here in New Hampshire. I believe we had 12 confirmed cases and now we are at just over 30 confirmed cases, so we're a small state but the numbers are slowly heading up as they are everywhere.

Some of the big changes we have enacted this week is we are limiting our clinic hours to shorter periods of time and then a major change at both clinics before anyone can come in the front door, they have to go through the CDC-recommended screening questions. If there is any concern or possibility that the person might be infected, we ask them not to come into the building. We then give them appropriate options as alternatives.

Secondly, an important and necessary decision is we do a lot of intramuscular injections for long acting injectables and other various medications. The psychiatric nurses at both clinics have developed a protocol where they are only going to do injections half a day on Tuesdays and Thursdays, whereas before it was pretty flexible. Before, the case manager could bring patients in when it was convenient or when there was an appointment, but now we have those very clear limited times that patients will be able to come in and get their injections, again as long as they pass that screening before they enter the clinic.

The biggest changes the clinic is aggressively working with our excellent IT team to roll out a platform like Zoom. It is one of the platforms are we using as well as Telepsych. We are going to do as much direct patient care as we can, so case managers, therapists, outreach specialist, psychiatrists, nurse practitioners, and psychiatric nurses that whenever possible, at least for the foreseeable future, we will be doing as much telepsychiatry as we can so that will be able to deliver our treatment for our patients but at the same time maximize safety and through isolation and kind of reinforcing the importance of the self-quarantine.

As we navigate uncharted waters on the pandemic front, John J. Miller, MD, shares his thought about this important topic and what he is doing differently both professionally and personally.

Author | Heidi Anne Duerr, MPH