Joshua C. Morganstein, MD

is Chair of the American Psychiatric Association Committee on the Psychiatric Dimensions of Disaster.

Videos

If we acknowledge our feelings of grief and loss over the pandemic, we can begin to come together, encourage hope, find meaning, and stay connected. Dr Morganstein talks on this. 

Loss and Managing the Crisis at Hand

Dr Morganstein, Chair of the American Psychiatric Association Committee on the Psychiatric Dimensions of Disaster, talks about where psychiatrists can get COVID-19 information for their practices and patients and what resources are available.

 (APA) has a resource page with a broad range of helpful materials for families, providers, community leaders. There is information about helping homebound children, supporting people through isolation quarantine, provider self-care, and a number of other topics.

The APA also has information on their home page to learn about telepsychiatry services. There are also upcoming educational and other activities to assist APA members in caring for their patients and supporting the health of nation.

Resources for Health Care and Community Leaders

Psychiatric Times’ Resources for Psychiatrists

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 

Podcasts

Is there special guidance for APA members regarding COVID-19 and their practices/patients? What resources are available?

PsychPearls: Supporting the Health of the Nation During the Coronavirus Pandemic

How can psychiatrists practice self-care and avoid burnout? How can mental health professionals balance the needs to protect oneself and one’s family while caring for patients during this pandemic? Here to discuss is Joshua Morganstein, MD, Chair of the American Psychiatric Association Committee on the Psychiatric Dimensions of Disaster.

Self-care will be very important for both the general public as well as psychiatrists and other health care personnel. People are understandably concerned and feeling distracted with a lot of their attention on managing the crisis at hand. It is easy for self-care to be overlooked at a time like this, but it becomes particularly important.

Getting adequate sleep and eating and staying hydrated are going to allow people to think more clearly, solve problems, and respond to challenges more effectively. When parents provide for their own self-care, they are better able to care for the needs of their children.

Exercise is a helpful way to lower stress. It doesn't have to be in a gym or other facility. Going for a walk or other outdoor activities maybe even as a family provides an opportunity to connect with each other as well as neighbors, share ideas, stay close as a family, and just be reminded that we are all in this together.

Articles

PsychPearls: COVID-19, A Critical Time for Self-Care

Dr Morganstein, Chair of the American Psychiatric Association Committee on the Psychiatric Dimensions of Disaster, talks about special measures that psychiatrists should take for their patients during this time of uncertainty.

Suicidal thinking and behaviors as well as other mental health conditions should be managed as they would at any other time. Psychiatrists should certainly encourage people to stay on medications, and this also means avoiding waiting until the last minute to get a refill.

Psychiatrists might also review their patient records to identify patients that may be a risk for worsening symptoms during the pandemic such as people with:

• active or poorly controlled illness concerns
	• delusions
	• obsessive-compulsive thoughts and behaviors
	• previous trauma
	• stressor disorders
	• anxiety
	• substance use

Additional contact with these patients perhaps using telehealth as needed might identify people who need additional assistance before a crisis occurs. There are likely to be challenges with the use of impatient facilities as a result of COVID-19 and proactively taking extra steps to help patients maintain their functioning and avoid having to enter health care facilities will be a very important health intervention.

PsychPearls: Identifying At-Risk Patients During the Pandemic

Dr Joshua Morganstein, Chair of the American Psychiatric Association Committee on the Psychiatric Dimensions of Disaster, answers this question: There is a lot of panic, and anxiety/stress is on the rise, even in people without mental illness. How can psychiatrists advise patients to manage this stress and to remain calm?

How can psychiatrists advise patients to manage their stress and to remain calm?

PsychPearls: Battling Anxiety During the COVID-19 Pandemic

We have invited Dr Joshua Morganstein, Chair of the 

 Committee on the Psychiatric Dimensions of 

, to provide suggestions about helping patients cope with social distancing and loneliness.

What can psychiatrists do to help their patients cope with self-quarantine and isolation practices?

What can psychiatrists do to help their patients cope with self-quarantine and isolation practices? More in this podcast.

PsychPearls: Battling Loneliness During the COVID-19 Pandemic

Slideshows

Emerging infectious disease outbreaks cause significant fear and uncertainty. Psychiatrists can play an important role in supporting the well-being of patients and families, health care personnel, and the general public.

The Role of Psychiatrists During the Coronavirus Outbreak

This activity offers CE credits for:
1. Physicians (CME)
2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

To goal of this activity is to understand the etiology of work-associated trauma in physicians, adverse psychological and behavioral responses, and evidence-based interventions.

At the end of this CE activity, participants should be able to:

• Describe the causes of work-associated trauma in physicians

• Understand the consequences of traumatic exposure on physicians

• Identify the interventions available for treating physicians who have been exposed to trauma

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

 This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 

™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants:

 AANPCP and AAPA accept certificates of participation for educational activities certified for 

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Joshua C. Morganstein, MD, has no conflicts to report.

Lori Davis, MD (peer/content reviewer), has no conflicts to report.

 staff and CME Outfitters staff, have no disclosures to report.

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

Physicians are exposed to a range of traumatic events throughout training and professional practice, including workplace violence, disasters, and hazardous exposures (

). Physicians experience psychological and behavioral effects of trauma with the same range of response (eg, distress reactions, health risk behaviors, psychiatric disorders) as does the general population. An understanding of evidence-based interventions can assist with the management of physician work-associated trauma within the unique setting of health care environments.

To understand work-associated trauma, it is first necessary to properly define terms. Trauma is a physical or mental injury. The criteria for PTSD describe traumatic events as exposure to actual or threatened death, serious injury or sexual violence through direct experience, witnessing, or repeated or extreme exposure to aversive details. Traumatic stress refers to the range of distress reactions, health risk behaviors, and psychiatric disorders that can occur in response to traumatic events. Stressors are defined as external stimuli that disrupt the equilibrium of an individual.

Psychological and behavioral responses to trauma

The literature on the effects of traumatic events comes largely from studies of individual and community responses to emergency and disaster events. Most individuals exposed to traumatic events will emerge with limited or no adverse effects, promptly and effectively resuming their social and occupational roles (resilience). Some may experience an increased sense of competence, self-efficacy, and belief in their ability to manage future stressors (often termed “posttraumatic growth”). However, a sizable minority will experience a range of adverse psychological and behavioral effects, including distress reactions, health risk behaviors, and psychiatric disorders (

Distress reactions include insomnia, irritability, and distractibility. Anger, diminished sense of safety, loss of faith, and demoralization may occur. Somatic symptoms may occur, such as headaches, dizziness, and fatigue. Most who seek care present to primary care and emergency settings. Health risk behaviors include increased use of alcohol, caffeine, and tobacco to self-medicate distress symptoms. Decreased social activities and isolation occur as well, which reduce access to helpful social support networks. Intimate partner and community violence may increase as distress escalates.

Approximately 10% to 20% of individuals exposed to a traumatic event present with PTSD, although many more experience milder symptoms that can persist and become problematic. The course of PTSD varies, with symptom escalation over time. Individuals directly exposed to the traumatic event are at greatest risk for psychiatric disorders. Additional risk factors include having an attachment to primary victims, sustaining physical injuries, a personal history of developmental trauma and abuse, or other interpersonal violence.

The element of “repeated or extreme exposure to aversive details” in the DSM-5 definition of trauma typically refers to professions such as child victim units within law enforcement or other professions where exposure to the most extreme events is a routine aspect of professional work. However, the terms “secondary traumatic stress” and “vicarious traumatization” have been used to define a spectrum of psychological and behavioral responses that may result from exposure to traumatic material or the account of patients’ traumatic exposures during clinical care.

Psychiatrists, emergency physicians, and primary care physicians, among others, may experience a range of distress reactions, health risk behaviors, and other traumatic stress symptoms in response to these exposures. It is important to understand that these psychological and behavioral responses may occur for physicians in many different circumstances.

Physicians experience reactions to injury and death throughout their careers and no specialty is immune. In a survey of 113 surgeons, one in five reported symptoms consistent with a PTSD diagnosis, and two-thirds exhibited some symptoms.

 Death of or injury to a child is a particularly traumatic event for physicians. Identification with those who have been severely harmed (“that could have been me”) increases risk for adverse psychological symptoms.

Medical errors are the third leading cause of death in the US and have the potential to occur in every specialty and every setting.

 Physicians involved in medical errors or complications can often recall distressing aspects of the event in extraordinary detail many years later and report ruminative thoughts and distressing recollections about the event that adversely affect work and sleep.

Following a disaster, health care workers may be both provider and victim. Physician disaster responders may be exposed to mass death and injury, grotesque and disturbing sensory input, and extreme distress in patients. After the Christchurch earthquake in New Zealand in 2011, approximately 10% of medical students experienced moderate to severe distress 7 months later.

Environmental hazards include chemical, radiological, and infectious exposures both during routine medical care and disaster response. Exposure to these materials lead to a predominance of somatic symptoms, often termed multiple unexplained physical symptoms (MUPS) or multiple idiopathic physical symptoms (MIPS).

 These somatic symptoms will often be the presenting complaint when care is sought by physicians concerned about exposure or contamination. Infectious diseases may be the biggest threat. The Ebola outbreak of 2014-2015 and highly virulent strains of more common pathogens, such as influenza, have caused considerable distress in physicians and other health care providers and been associated with poor work attendance. Mass violence is a highly traumatic event for the public and health care workers involved. Mass shootings in health care settings have captured public attention and generated significant anxiety and fear. Kelen and colleagues

 reviewed media reports of hospital shooting events between 2000 and 2011 and identified 154 hospital-related shootings, of which 91 occurred inside the hospital. Motives for shooting varied, including grudge (27%), suicide (21%), and euthanizing an ill relative (14%). In 45% of hospital shootings, the victim was the perpetrator, either self-inflicted or shot by security response.

Health care providers are at a relatively higher risk of workplace injury and violence compared with other occupations. US hospitals and nursing care facilities have higher than average rates of non-fatal workplace injuries (

). Verbal violence is the most common. Physical violence occurs most frequently in emergency settings where delays in care, intoxication, and psychiatric disorders account for most cases.

Bullying of health care providers is another form of violence and occurs both in person and online. Bullying is experienced by physicians in various levels of training and across disciplines. Although not generally considered a traumatic event, workplace bullying is a significant stressor associated with the development of a similar range of responses resulting from other well-characterized traumatic events. Consequently, bullying should be considered in the discussion of physicians and work-associated trauma. Physicians who are bullied may experience depression and posttraumatic stress symptoms for years following the event. In a study examining cyberbullying of medical students, fellow trainees outpaced the frequency of bullying by other personnel in the training environment by nearly three-fold.

Physician well-being and performance can be enhanced by organizational efforts to reduce adverse effects and promote recovery; provide thorough assessment of affected individuals; and institute prompt, evidence-based intervention following traumatic events. Important considerations include education about and normalizing of response, prevention measures, effective leadership, and barriers to care. Assessment should examine a broad range of behavioral and psychological reactions to traumatic events as well as level of impairment. Evidence-based treatments focus on reducing distress, enhancing well-being, and optimizing social and occupational function.

Education on stress, normalizing responses, when to get help, and what resources exist are at the core of effective prevention of psychological impairment following traumatic events. Ensuring “adequate equipment” and “protection” increase feelings of safety and reduce perception of risk, allowing health care providers to focus on doing their jobs. It is also important to recognize traumatic events with high-risk characteristics, identify at-risk physicians and system vulnerabilities, and take mitigation steps that promote individual and organizational resilience (

Leaders, including those who manage or supervise medical students, residents, or staff physicians, play an important role in preventing and mitigating the impact of trauma exposure. Active listening, empathy, and support reduce feelings of fear and isolation. In this way, leaders can provide the initial support to health care providers affected by traumatic events, a critical element in reducing distress and promoting recovery. Leaders need to address grief and loss that arise following traumatic events. Grief leadership is the process of recognizing and giving voice to what has been lost following traumatic events, providing a sense of hopefulness about recovery, and a positive outlook on the future.

In spite of increased awareness and understanding of mental health, stigma continues to serve as a barrier to help-seeking for physicians.

 Health care institutions can also foster a professional culture that stigmatizes the use of help-seeking resources. The requirements to monitor and restrict the practice of physicians who are found to be impaired may serve as a significant barrier to help-seeking behaviors. Health care systems can encourage provider self-identification by minimizing or eliminating measures that will be experienced as punitive, including being publicly identified, confidentiality violations, and loss of pay.

Physicians experiencing significant or impairing distress need timely assessment by personnel trained to understand the unique effects and comorbidity associated with traumatic stress. Employee Assistant Program personnel serve this role in many institutions. Some organizations utilize in-house or contracted medical providers who are able to conduct formal evaluations when traumatic stress is the presenting concern. Assessment should consider not simply the presenting concern or specific traumatic event, but the physician’s entire “network of stressors” (

Treatment for physician work trauma includes early interventions to reduce adverse effects, preserve functioning, and decrease progression to psychiatric disease. When psychiatric disorders occur, evidence-based psychotherapy and pharmacotherapy may help reduce symptoms and functional impairment. Complementary and alternative interventions have an increasing body of evidence supporting their use in the treatment of traumatic stress. A range of behavioral self-help interventions that are patient-centered and provider supported may be used throughout. Many physicians will prefer peer support over formal intervention. A comprehensive treatment plan involves the use of interventions that address the unique circumstances of the trauma in the context of the physician’s preferences (

The Psychological First Aid (PFA) principles serve as an evidence-based framework for interventions designed to support the well-being of individuals and communities in the aftermath of traumatic events and includes promoting the following: safety, calming, individual and community efficacy, connectedness, and hope or optimism.8 Although rigorous studies in physician populations have not been done, the utility of PFA principles can reasonably be extrapolated to the physician population and serve as an important evidence-based guide to developing appropriate interventions. Online and mobile resources as well as web-based training in PFA can help health care personnel enhance their skills to trauma response.

Well-established self-help behavioral interventions for managing distress reactions include diaphragmatic breathing, progressive muscle relaxation, and guided visual imagery. These can be taught by a health care provider or learned through online or other resources by the physician who requires treatment for trauma. These interventions facilitate the essential element of calming and reducing physiological arousal. Their benefits include being easily accessible, having little or no adverse effects, and increasing patient self-efficacy.

Trauma-focused psychotherapies, such as cognitive processing therapy and prolonged exposure therapy, have the best evidence for treating trauma-related disorders. Stress inoculation training and eye movement desensitization and reprocessing have also been found to be helpful in reducing symptoms of trauma. Trauma-focused psychotherapies incorporate imaginal exposure to the traumatic event in conjunction with an examination of cognitions the physician may have about aspects of the event and their meaning.

Pharmacotherapy following a traumatic event should generally be time-limited and symptom focused. Insomnia is a nearly universal symptom following a traumatic event. Because regulating sleep is critical to reducing arousal symptoms (and promoting the “calming” element of PFA), short-term sedative-hypnotic medication may be used to relieve insomnia. Although conflicting evidence exists, some studies suggest that prazosin is effective in treating insomnia and nightmares associated with posttraumatic symptoms.

Complementary and alternative approaches to the treatment of trauma stress have an increasing body of research supporting their efficacy, and preliminary studies as well as anecdotal evidence of benefit are promising. Mindfulness practices have the most robust research base to support their efficacy. Mindfulness is the practice of purposefully focusing on what is going on in the present moment without passing judgment. Animal-assisted therapy, yoga, meditation, and acupuncture are additional alternatives that are increasingly popular and should be considered with patient preference being an important factor in considering their use.

Physician work-associated traumatic events are both common and unavoidable. Common responses to traumatic events include distress reactions, health risk behaviors, and psychiatric disorders. The goal of intervention is to reduce levels of distress in affected physicians, restore their ability to provide care, and minimize the likelihood of lasting symptoms or impairment. Interventions for traumatic stress should incorporate the principles of PFA: safety, calming, self-efficacy, connectedness, and optimism. Providing a range of patient-centered, evidence-based interventions and formal treatment options can enhance compliance and increase well-being for health care providers who have experienced traumatic events.

Post-tests, credit request forms, and activity evaluations must be completed online at 

 (requires free account activation), and participants can print their certificate or statement of credit immediately (80% pass rate required). This Web site supports all browsers except Internet Explorer for Mac. For complete technical requirements and privacy policy, visit 

PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR 18 MONTHS AFTER.

 The views expressed are those of the author and do not necessarily reflect the views of the Department of Defense, the Uniformed Services University, the Department of Health and Human Services, or the United States Public Health Service.

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Expiration date: October 20, 2018

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Dr Morganstein is Assistant Director, Center for the Study of Traumatic Stress, Assistant Chair/Associate Professor, Department of Psychiatry, School of Medicine, Uniformed Services University, Bethesda, MD.

 Warren AM, Jones AL, Shafi S, Roden-Foreman K, et al. Does caring for trauma patients lead to psychological stress in surgeons? 

 Makary MA, Daniel M. Medical error-the third leading cause of death in the US. 

 Carter FA, Bell CJ, Ali AN, et al. The impact of major earthquakes on the psychological functioning of medical students: a Christchurch, New Zealand study. 

 Somville FJ, De Gucht V, Maes S. The impact of occupational hazards and traumatic events among Belgian emergency physicians. 

 Kelen GD, Catlett CL, Kubit JG, Hsieh YH. Hospital-based shootings in the United States: 2000 to 2011. 

 Farley S, Coyne I, Sprigg C, et al. Exploring the impact of workplace cyberbullying on trainee doctors. 

 Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. 

 Hobfoll SE, Watson P, Bell CC, et al. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. 

 Center for the Study of Traumatic Stress. Grief Leadership: Leadership in the Wake of Tragedy. 

https://www.cstsonline.org/resources/resource-master-list/grief-leadership-leadership-in-the-wake-of-tragedy

 The National Child Traumatic Stress Network. Psychological First Aid Mobile. 

https://www.nctsn.org/resources/pfa-mobile

 The National Child Traumatic Stress Network. Psychological First Aid Online. 

https://learn.nctsn.org/enrol/index.php?id=38

Phillips JP. Workplace violence against health care workers in the United States. 

An understanding of evidence-based interventions can assist with the management of physician work-associated trauma within the unique setting of health care environments.

Physician Work-Associated Trauma: Causes, Consequences, and Interventions

The Ebola outbreak has given reason for concern across the globe and most recently in the US. Recent media attention and ongoing coverage of the Ebola outbreaks in West Africa, as well as recent cases in the US, contribute to confusion among many. All this attention has also created fear and distress for our patients and their families and for health care workers. Individuals with preexisting psychiatric conditions may be particularly vulnerable to anxiety and mood symptoms as well as to the use of maladaptive coping, including substance use.

When widespread fear and anxiety about the spread of an infectious disease stress our society, psychiatrists can play a variety of important roles in population health management (

). They can work directly with patients to encourage frank discussion of worries and distress, and they can identify symptoms such as sleep disturbances and exacerbation of underlying mental illness. Psychiatrists can also support primary care physicians and encourage them to address patients’ concerns.

In the community, psychiatrists can educate leaders about risk communication to decrease fear and anxiety. For psychiatrists who work in hospitals that may receive Ebola patients, additional consultation and work with the infectious disease teams and families of the patients (or those in quarantine) are needed. Ensuring optimal care for patients requires that psychiatrists understand the clinical aspects of Ebola and the principles of risk communication.

Ebola virus disease (EVD) is rare but potentially fatal; it is caused by infection with one of the Ebola virus strains. There are 5 identified Ebola virus species: 4 cause disease in humans; 1 causes disease only in non-human primates. Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo; it has now spread to several other African countries. Since its discovery, outbreaks of Ebola have appeared sporadically in Africa. The natural reservoir host of Ebola virus remains unknown, but researchers believe the most likely reservoir is bats.

The onset of symptoms is usually abrupt, generally starting 8 to 10 days after exposure. However, the incubation period can range from 2 to 21 days. People become contagious once they begin to show symptoms. Fever, anorexia, and weakness are common, along with chills, myalgia, and malaise. The nonspecific nature of these symptoms can be confused with other, more common diseases, such as influenza and meningococcemia, so a high degree of suspicion is needed.

Additional symptoms that may present around day 5 of the disease course include an erythematous maculopapular rash that can desquamate and a range of GI problems (eg, abdominal pain, profuse diarrhea, nausea, vomiting). Patients may also experience chest pain, shortness of breath, headache, confusion, conjunctival injection, hiccups, seizures, and frank bleeding. When early symptoms are severe, mortality is increased and generally results from multiorgan failure and septic shock. Mortality rates range from 55% to 75%; patients who receive early aggressive treatment fare better.

Despite ongoing media coverage of the issue of Ebola being aerosolized, epidemiological evidence suggests this is not a mode of transmission. Ebola virus is spread by direct contact with blood and other body fluids, such as vomitus, urine, fecal matter, or breast milk, of an infected person or someone who has recently died of Ebola. Infection can also be transmitted by surfaces or objects contaminated by body fluids of an infected person. Persons who handle dirty linen, clean examination rooms, or perform other support tasks in hospitals are at increased risk and need to be educated about safety procedures.

The issues of sexual transmission can create family burdens and distress after a patient has survived an initial infection with Ebola. Ebola virus has been detected in semen up to 3 months following recovery from infection, and media reports suggest that women who have recovered from EVD may be capable of transmitting the disease through vaginal fluids. Thus, experts recommend abstaining from sex (including oral sex) for 3 months after recovery.

EVD can only be confirmed by laboratory testing. Treatment of EVD is supportive, with an emphasis on preventing dehydration through the use of intravenous fluids and oral rehydration. While there is currently no specific treatment or medication that cures EVD, case reports of patients who improved following a blood transfusion from a recovered patient are prompting additional research into mechanisms for enhancing or transferring immunity.

Although many patients will be concerned about Ebola, it is expected that very few will actually contract the disease in the US. “Very few” for medical people (eg, tens, hundreds) does not necessarily translate to usual community language; most people want or expect zero risk and no cases. Fear is a normal response to threats that we do not fully understand.

Health care workers directly caring for Ebola patients need adequate training and protective equipment to reduce their anxiety and decrease the likelihood of making mistakes. Community education (schools, community leaders, stores/sales people, and your hospital and medical community) can be very helpful as well.

Psychiatrists can listen without judgment to a patient’s fears and concerns about Ebola. Avoid simple reassurances that are often experienced as dismissing patient concerns, such as, “There’s nothing to worry about,” or “Everything will be fine.” When patients are presenting for psychiatric care with an underlying concern about Ebola, a thorough medical screening is helpful. Patients also need to be evaluated for exacerbation of preexisting psychiatric illness. Stress often leads to the onset or worsening of maladaptive coping responses, such as use of alcohol, tobacco, and other drugs of abuse as well as social isolation and violence. A comprehensive risk assessment should be performed and emergency issues managed appropriately.

For patients without exacerbation of significant underlying psychiatric illness, Psychological First Aid (PFA) can be used to manage stress; it can also be used for those who have contracted EVD. The principles of PFA include optimizing safety, calming, connectedness to others, self-efficacy, and hopefulness. Teaching the patient (and his or her family) ways to maintain hopefulness and optimism are evidence-based interventions for acute trauma responses.

Help patients understand that it is essential to avoid contact with persons who are infected or traveling to areas with Ebola outbreaks. Regular hand washing is vital to infection control. Because influenza and EVD share common nonspecific symptoms during the course of illness, reducing the incidence of influenza may decrease the number of patients presenting for evaluation-encourage patients to get their flu shots.

To ensure that patients have the most accurate, up-to-date information, steer them toward well-established sources of information, such as the CDC. Suggest that patients and their families limit exposure to news and social media, which may exacerbate stress and anxiety. Episodes of excessive fear and anxiety can also be reduced by simple measures, such as diaphragmatic breathing and progressive muscle relaxation, both of which can be taught quickly and easily.

EVD is not thought to produce neuropsychiatric symptoms directly; however, patients infected with the virus may experience a range of psychological responses. Those with underlying psychiatric illness may experience an exacerbation of symptoms, complicated by unique aspects of necessary treatment, such as the need for quarantine.

A particularly significant aspect of treatment for EVD is the need to quarantine, which can increase distress for both the patient and his family. Consultation-liaison psychiatrists can suggest ways to reduce isolation, such as addressing institutional barriers that limit visiting hours or using creative IT solutions (eg, webcam). Clinically significant symptoms among those who are exposed and quarantined may include depression, acute stress disorder, PTSD, sleep disturbances, and anxiety symptoms.

Helping health care providers and the family understand how the patient is affected by symptoms of Ebola and the various aspects of treatment can be beneficial in maintaining the health care provider’s working relationship with the patient and may decrease the family’s worries of separation.

The patient’s family and friends may also express concerns, including fear of the patient’s death and anxiety about contracting the illness themselves. Because family and friends are important for enhancing the patient’s social support, addressing ambivalence in family and friends can be particularly helpful. Patients with EVD also present unique challenges for physicians, nurses, technicians, and others who provide care. Working with members of the health care team to understand their particular fears and concerns can enhance their resilience and sustain them throughout the experience.

Psychiatrists may also be in a position to advise community leaders and policymakers on ways to communicate health information to larger populations or organizations. When providing this type of consultation, consider well-established principles of risk communication.

 Begin by recommending that messages be considered and planned in advance, including anticipating questions that will be asked. What an audience wants to know, as well as what the person speaking wants them to know, should be taken into consideration. Specifically, during acutely stressful situations, most people want to know if they and their loved ones are safe and what actions they can take. Accurate information about what is known as well as what is not known should be provided.

Those in leadership positions may believe that people do not want to hear “bad news” when in fact what people really want to hear is accurate and reliable information from trusted leaders. When there is a question for which an answer is not known, leaders can commit to finding out in a timely manner and reporting back. Accurate and reliable information and keeping a promise to follow up with answers builds trust and enhances rapport.

Psychiatrists have an important role to play in the evolving impact of Ebola in the US; that role is to support the well-being of individuals, enhance health, and provide a range of consultation services. An awareness of our own emotions regarding Ebola is a critical foundation for providing effective interventions.

Psychiatrists must have an appreciation for the pathogenesis, transmission, and treatment of Ebola as well as for the unique facets of the disease and its treatment and how these can affect patients, their loved ones, and their health care providers. An understanding of effective risk communication strategies allows psychiatrists to advise leaders and policymakers in relevant Ebola health messaging.

The views expressed are those of the authors and do not necessarily reflect the views of the Department of Defense, the Uniformed Services University, the Department of Health and Human Services, or the United States Public Health Service.

Dr Morganstein is a Commander in the United States Public Health Service; Assistant Professor and Assistant Chair, department of psychiatry, and Scientist, Center for the Study of Traumatic Stress at the Uniformed Services University School of Medicine in Bethesda, Md. Dr Ursano is Professor and Chair, department of psychiatry, and Director, Center for the Study of Traumatic Stress at the Uniformed Services University School of Medicine. They report no conflicts of interest concerning the subject matter of this article.

 Covello VT. Best practices in public health risk and crisis communication. 

 Vineburgh N, Ursano R, Hamaoka D, Fullerton C. Public health communication for disaster planning and response. 

 Substance Abuse and Mental Health Services Administration (SAMHSA). 

Communicating in a Crisis: Risk Communication Guidelines for Public Officials

. 2002. http://store.samhsa.gov/product/Risk-Communication-Guidelines-for-PublicOfficials/SMA02-3641. Accessed November 24, 2014.

When widespread fear and anxiety about the spread of an infectious disease stress our society, psychiatrists can play a variety of important roles in population health management. 