Hero

Videos

Slideshows

Articles

Podcasts

Poll

by Devon Price, PhD; New York: Atria Books, 2021.

Editor's Note: As clinicians who treat mental illness, we have undoubtedly seen individuals who are labeled “lazy.” Some of our patients who are suffering the most may be those who have labeled themselves lazy. Fortunately, for those of us who chastise ourselves for taking even a moment away from work to focus on ourselves, and for our patients who cudgel themselves too, 

. Dr Price, a social psychologist and professor at Loyola University of Chicago’s School of Continuing and Professional Studies, recently sat for an interview, conducted via Zoom, on the topic of laziness. The interview will hopefully whet the appetite to read and recommend this truly helpful book.

Q: When I heard that you had written a book about the concept of laziness, the first question that came into my mind was: have you ever been called lazy?

A. I have only ever called myself lazy. I think I have absolutely been a workaholic in the way that I think a lot of academics are trained to be. You get this idea that you need to have a full course load, you need to be doing service to the university, you need to be doing research. And you need to be a self-starter if you want to have even a prayer of a career. They kind of drill that into you even as an undergrad. I think I have always had that bug in the back of my brain telling me that I was not doing enough. Many of us feel pressure to be a self-made individual and to be very individualistic and successful. So I am someone who has not been called lazy too often, because I have been able to check off a lot of society’s little boxes that make you look like a good little worker bee.

Q: I have always thought that when someone comes to me and tells me “my spouse is lazy” or “my employee is lazy,” they are using a lazy word, because it does not really give a useful description of what is going on. Why do you think the word lazy is used so frequently in our society?

A: The word has always had an air of moral condemnation to it. Its root words mean both feeble or weak willed and morally corrupt. A lot of times it is easier to write someone off as lacking essential qualities, lacking some drive or willpower that you need to succeed, than it is to ask what can be done to help. Does this individual have needs that are not getting met? What struggles is this individual facing that are not being taken seriously? What structural problems are getting in their way? When somebody looks lazy, maybe they just see no reason why they should be doing a task. So that is also an important question to ask. Have we failed to motivate them and empower them?

Q: Those are much more difficult questions to ask.

A: It is hard to ask those questions. It is even harder to solve those problems once the questions have been asked. It is much easier to say, “Oh, I give up on this individual. They lack that essential quality that they need for success.”

Q: Your answers make it impossible to ignore the uneven playing field that so many individuals face when trying to succeed in life, and particularly in science and academia. Do you have any thoughts on how inequities affect perceptions of laziness?

A: It is a thorny problem. When you are teaching and mentoring, it is important (as much as possible) to be flexible when you can. At the same time, I think giving honest feedback is essential. “Listen, I understand that you have things going against you. I know that this is not a reflection of some flaw or failure in you. But we do need to get you to a certain level, and I really am invested in seeing you reach that level. So, what can I do to help support you?” There is a lot of social psychology research suggesting that instructors, especially white instructors, are uncomfortable giving critical feedback to black students. Even black students who are doing really well! They are afraid of being perceived as racist, so they overcorrect, and this is true of sexism and other biases as well. If you can, try to level with them: tell them where they need to grow and give them the same critical feedback that you would give anyone else. Also be there to support them through hardships that are not their fault. I think that can really make a big difference. But it is a steep uphill battle.

A: There are so many areas of life where individuals are made to feel like they are not enough. We have already talked about racism, sexism, and things like that. But workaholism pervades almost everything in American culture and life. That affects individuals’ self-image, their depression levels, their anxiety levels, and how much they put on their plate. We know that those things are huge risk factors for all kinds of psychiatric and psychological issues. If you are doing too much, that looks a lot like an anxiety disorder, or anxiety profile, even if maybe you otherwise would not be in that situation.

is an attending psychiatrist at Montefiore Medical Center. He is the Book Review editor at 

Patients and care providers often call themselves lazy. But what are the clinical consequences and cultural meanings of this term? 

Laziness Does Not Exist

GROUP FOR THE ADVANCEMENT OF PSYCHIATRY, COMMITTEE ON WORK & ORGANIZATIONS

Work is central to many people’s lives. The average person spends one-third of their adult life working, yet psychiatrists may neglect work when assessing a patient’s well-being. We address drug use, family life, and psychiatric symptoms, but may not fully appreciate how those factors are relevant to our patient’s work.

Nonetheless, work is tied to the surge in mental health concerns precipitated by the coronavirus disease 2019 (COVID-19) pandemic. As we consider anxiety, depression, substance use, spousal and child abuse, and loneliness, all of which have been found to increase following disasters, we must not forget how the pandemic is affecting our workforce. For instance, during this time of increased social isolation, employers have been using video technology to maintain a sense of connectedness among their employees. This very much reflects the centrality of work to mental health and social cohesion.

Psychiatrists will find it difficult to ignore the centrality of work over the coming months, as the the pandemic has led to a surge in unemployment not seen since the Great Depression. Individuals filed more than 58 million initial unemployment benefit claims between March 14 and August 22, 2020, and economists 

When a patient loses their job, a psychiatrist must respond actively and swiftly. Employment fulfills essential biological, psychological, and social needs. It is the means by which we sustain ourselves, comprises a large part of our identity and social community, and determines how we spend most of our waking hours. As such, job loss is profoundly disorienting, challenging the very meaning and purpose of life. It directly affects self-esteem and perceptions of self-worth, precipitates anxiety, and increases the chance of physical and mental illness.

 Unemployment is associated with lower motivation, and an increased risk of substance abuse and suicide.

 This is compounded by the loss of structure and shared experience that work typically confers. Thus, job loss generally leads to a loss of well-being.

When a patient loses their job, the psychiatrist has 4 tasks: (1) triage and treat imminent emergencies; (2) treat acute or latent psychiatric symptoms medically or psychotherapeutically; (3) support the patient by helping them to recognize vulnerability, identify feelings, and enhance personal support systems; and (4) prompt the patient to realistically 

Treating emergencies and psychiatric disorders, as well as discussing the effects of job loss on personal and interpersonal variables can lead to improvement. Clinicians can do this informally or psychotherapeutically. Helping the patient identify their social support systems and how to use them can be helpful. As with any episode of clinically significant depression, anxiety, or psychosis, medication may be indicated.

Returning to work is the ultimate goal for the majority of our patients. To evaluate job prospects realistically, psychiatrists should take a work history once the initial crisis and reactions have been explored. Assessing a work history is not typically taught during residency training and is often not part of a clinical interview. However, a work history provides important information about a patient’s functionality (

 questions help patients identify what they wish to do for future employment, including a change in career. Expectations, skills, and qualifications can be realistically assessed by discussing patient responses. The psychiatrist can serve as a sounding board for the patient’s ideas and help the patient cultivate adaptive perceptions, expectations, and realistic future plans.

How do psychiatrists carry out this function? Perhaps the most important principle to consider is their role in serving as a source of reality testing and as a means of integrating the self. By listening to the patient’s occupational hopes and integrating these with the current reality and the work history, the psychiatrist can explore what is possible in a career. The psychiatrist and the patient may uncover a wider range options for work than the patient would discover in isolation.

It is clear that the pandemic will continue to affect the economy, the job market, and work. It is likely that many aspects of work—such as where, how, and for whom it is conducted—will change, and many changes will persist beyond the pandemic. We may wish to recall that our society, economy, and work situations were far from perfect prior to the pandemic; perhaps the crisis can be reframed as an opportunity for our patients to seek healthier and more meaningful work situations.

Job loss is likely to affect far more people than 

 itself. Psychiatrists are uniquely positioned to sustain the unemployed individual’s sense of efficacy, identity, and purpose during these difficult times. By understanding and supporting our patients, we can help them avoid the downward spiral of helplessness and despair that can otherwise follow job loss.

Dr Morrison is an assistant clinical professor of psychiatry at Chicago Medical School in Illinois. Dr Brown is a department psychiatrist at Boston Police Department in Massachusetts. Dr Sassano-Higgins is an adjunct professor of psychiatry at the University of Southern California, and chair of the Committee on Work & Organizations for the Group for the Advancement of Psychiatry. Dr VanDercar is a forensic psychiatry fellow at the University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine in Ohio. Dr Long is the president-elect for the Group for the Advancement of Psychiatry. Dr White is an adjunct voluntary faculty member at Northwell Health System in New York City, New York. 

1. Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020;180(6):817-818.

2. Chiwaya N, J Wu. The coronavirus has destroyed the job market in every state. NBC News. Updated August 27, 2020. Accessed November 30, 2020. 

https://www.nbcnews.com/business/economy/unemployment-claims-state-see-how-covid-19-has-destroyed-job-n1183686

3. Jin RL, Shah CP, Svoboda TJ. The impact of unemployment on health: a review of the evidence. 

5. Lee AM, Wong JGW, McAlonan GM, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. 

6. Darity WA Jr. Employment discrimination, segregation, and health. 

7. Kawohl W, Nordt C. COVID-19, unemployment, and suicide. 

8. Stam K, Sieben I, Verbakel E, de Graaf PM. Employment status and subjective well-being: the role of the social norm to work. 

9. Committee on Psychiatry in Industry, Group for the Advancement of Psychiatry. Job loss, a psychiatric perspective. 

Unemployment is associated with an array of social and psychological complexities, directly affecting patients' self-esteem and perceptions of self-worth. When a patient loses their job, the psychiatrist has 4 tasks.

My Patient Lost Their Job…Now What? 

Susan J. Noonan, MD, MPH, discusses how schedules can be vital for patients who struggle with day-to-day tasks. Her top tip is to keep to their set schedule, even when they do not feel like it.

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

. Dr Noonan offers peer counseling to fellow patients, including physicians and other professionals, and can be confidentially reached through her website at 

Creating a schedule and keeping it can be a huge help to patients with anxiety or depression. 

The Importance of Routine

Throughout 12,000 years of human history, pandemics have killed an estimated 300 million to 500 million people, with the bubonic plague decimating an estimated 60% of the European population during the Middle Ages. Despite modern advances in medicine, 

 has caused more than 1 million reported deaths in less than a year. Aside from the death toll, the pandemic has triggered significant emotional, physical, and economic problems around the world. But even in the midst of this crisis, nations have an opportunity to share and learn from each other’s experiences.

The emerging literature measures the impact of various traumatic stressors related to COVID-19, as well as the effects of less severe types of stress exposures. COVID-19 has already led to diverse mental health problems, including anxiety, depression, posttraumatic stress disorder, and other trauma- and stress-related disorders. Different groups have met the qualifying criteria for posttraumatic stress disorder (PTSD) according to DSM-5 as a result of the pandemic: those who have themselves suffered from serious COVID-19 illness and potential death; individuals who, as family members and health care workers, have witnessed others’ suffering and death; individuals who have learned about the death or risk of death of a family member or friend due to the virus; and individuals who have experienced extreme exposure to aversive details (eg, journalists, first responders, medical examiners, and hospital personnel).

Moreover, studies have explored other stressors adding to individuals’ emotional burdens, such as social isolation, unemployment and economic losses, and working from home while caring for children and other family members. Among health care workers, strains include lack of personal protective equipment (PPE), fears of virus exposure, burnout, patients perishing despite heroic efforts to save them, and difficult decisions about which patients should receive limited resources. A few studies have examined posttraumatic stress symptoms (PTSS), as well as anxiety, depression and other symptoms, and substance use in the general population during the pandemic.

More time is needed, of course, to conduct and publish systematic investigations on mental health sequelae, such as formal psychiatric diagnoses. Studies generally have been conducted through diverse internet platforms, which may affect generalizability. Methods and validated rating scales vary.

At the same time, it is not too soon for clinicians to read the emerging literature and base treatments on the latest research. We will explore some representative international studies of various groups affected by COVID-19, as well as protective factors and suggested interventions to help those in need (Figure).

Much of the current research emerges from China, the first country confronted by the pandemic. A 

 in China exposed to COVID-19 found a PTSD incidence of 16.8%, with highest scores in avoidance symptoms.

 Job satisfaction was associated with lower PTSD symptom scores and positive coping. The authors recommended supporting nurses who are having difficulty coping with their work by providing counseling.

A web-based, cross-sectional survey of more than 7000 Chinese individuals in February 2020 found that health care workers had the highest rate of poor sleep, and those aged 35 years or younger had more mood and anxiety symptoms.

 Overall, 35.1% of respondents reported anxiety symptoms, 20.0% depressive symptoms, and 18.2% poor sleep quality.

Other international studies have examined stress responses in health care workers treating patients with COVID-19. A study of 900 health professionals caring for hospitalized patients with COVID-19 in Singapore and India found relatively low symptoms of anxiety (15.7%), depression (10.6%), and stress (5.2%).

 However, among health care workers reporting these issues, more than half had symptoms in the moderate to extremely severe range. In addition, 67% of respondents reported physical symptoms, especially headache, lethargy, anxiety, and insomnia, suggesting somatic expressions of distress. United Kingdom military health care workers were assessed for the effects of inadequate safety equipment on their mental health during the COVID-19 medical response. Those with inadequate equipment had greater odds of having common mental health disorders (2.49), PTSD (2.99), poorer global health (2.09), and emotional problems (1.69).

Only a few studies of mental health problems among patients hospitalized with COVID-19 have been published, with more to come. A study of hospitalized but stable patients found a high prevalence of PTSS (96.2%).

 A chart review of hospitalized patients with COVID-19 in Spain found more than half of the 841 patients hospitalized with COVID-19 had a neurological symptom. Of these, nonspecific neurological symptoms were identified, as well as disorders of consciousness (19.6%), mostly in elderly patients and in those with severe COVID-19 disease; myopathy (3.1%); dysautonomia (2.5%); and other less frequent symptoms.6

Neuropsychiatric symptoms were reported by 19.9% of these patients, including insomnia, anxiety, depression and psychosis; these were not associated with disease severity.

Some studies have drawn inferences based on other severe respiratory viruses. A meta-analysis of long-term clinical outcomes for survivors of adult severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) who were in the intensive care unit (ICU) revealed PTSD prevalence in 39%, depression in 33%, and anxiety in 30% beyond 6 months after discharge, as well as reduced lung function and reduced exercise capacity.

 Italian experts also concluded that we might anticipate similar outcomes in survivors of COVID-19.8

Acute respiratory distress syndrome (ARDS) in ICU survivors of COVID-19 may occur, with an expected survival rate of approximately 25%. Survivors of ARDS may experience persistent fatigue and poor exercise tolerance, pain and weakness, neurological sequelae, and the psychological effects of prolonged ICU stays, as noted in patients with MERS and SARS. Stressors included immobility, separation from family and friends, prolonged sedation, anxiety about health conditions and survival, and subsequent job loss. The authors emphasized the need to identify PTSD (anticipated in up to 30% of ARDS survivors) and other mental health problems, and to provide appropriate and timely multidisciplinary therapy that should continue after discharge.

 A literature review of studies linking panic disorder with patients who had SARS suggested that aggravation of panic attacks is highly likely in survivors of COVID-19 in the face of prominent respiratory symptoms, as panic may be triggered by fear conditioning to abnormal breathing problems.

 The authors urged monitoring for panic as well as obsessive compulsive disorder, PTSD, and generalized anxiety disorder.

Some mental health care advocates believe the general population may be suffering from various levels of vicarious traumatization, although strictly speaking this would not qualify for PTSD’s Criterion A for trauma exposure. Along these lines, in August 2020 the CDC published results of a large US web-based survey of more than 5000 adults (

 in which 40.9% endorsed at least 1 adverse mental or behavioral health problem related to the pandemic. Symptoms of a trauma- and stressor-related disorder were reported by 26.3%, symptoms of anxiety or depression by 30.9%, substance use to cope by 13.3%, and serious consideration of suicide in the prior days by 10.7%. Suicidal ideation was significantly higher for younger respondents aged 18 to 24 years (25.5%), minority groups (Hispanic individuals, 18.6%; Black individuals, 15.1%), nonpaid caregivers for adults (30.7%), and essential workers (21.7%). The authors stressed the need to identify at-risk individuals to develop policies to address health inequities, and to increase resources for identifying mental health problems and offering new treatment options, including telehealth treatments.

In a study of home-quarantined youth in China during the first month of the COVID-19 outbreak, 12.8% had PTSS levels consistent with PTSD, with PTSS and distress associated with negative coping styles.

 Symptom levels were expected to increase with time as quarantine continued. This is important since a formal diagnosis of PTSD requires symptoms to persist for more than a month.

In another online survey conducted early during the Wuhan outbreak, researchers looked at anxiety and depression symptoms (rather than specific PTSS) in relation to social media exposure (SME) to COVID-19 news. The study, which included approximately 5000 adults in China, found high SME was positively associated with higher odds of anxiety and a combination of depression and anxiety, compared with low SME.

 A longitudinal survey of the general population in China during the initial outbreak, and again 4 weeks later, found the mean Impact of Events Scores to be above the cutoff scores for PTSD symptoms at both times, with moderate to severe stress, anxiety, and depression levels.

Results of an Italian cross-sectional, web-based 

 showed a relatively high percentage (29.5%) of PTSS related to the pandemic, suggesting that the pandemic itself could be considered a traumatic event.

 Similarly, an online survey of almost 3500 people in Spain found symptoms of PTSD (15.8%), depression (18.7%), and anxiety (21.6%), with loneliness the strongest predictor of symptoms.

 Other factors associated with these problems were female gender, previous mental health or neurological problems, having physical symptoms similar to those of COVID-19, or having a close relative infected.

Nursing home residents have been particularly vulnerable to poor health outcomes; early in the COVID-19 pandemic many facilities adopted strict lockdown policies. However, social isolation is particularly detrimental to the elderly, who may have increased risk for depression, anxiety, worsening dementia, and even earlier death.

 Given these issues, the Centers for Medicare and Medicaid Services (CMS) recommended safe communal activities for locked-down nursing homes.

In Canada, researchers explored prenatal maternal distress before and during the COVID-19 pandemic.

 Women assessed during the pandemic had higher levels of depression and anxiety, with levels more likely to be clinically significant, compared with women assessed before COVID-19. During the pandemic, dissociative and PTSD symptoms and negative affectivity were also greater, underscoring the need to carefully assess pregnant women to help prevent negative, stress-related outcomes in mothers and infants.

Perhaps not surprisingly, when compared with a control population, psychiatric inpatients in China had more PTSD, anxiety, and depression symptoms; more anger, impulsivity, and worries about health; and intense suicidal ideation.18 Hospitalized psychiatric patients and their mental health caregivers are at high risk for COVID-19 infection, compounding their existing stress. This was noted early in February 2020 in Wuhan, when the virus was diagnosed in at least 50 inpatients with psychiatric disorders and 30 mental health professionals. Factors included lack of protective gear and difficulties isolating.

 Outpatients with psychiatric disorders are also vulnerable to emotional distress during a pandemic. An online survey of more than 2000 outpatients in China discovered that 20.9% of patients with preexisting psychiatric disorders had seen their symptoms get worse during the pandemic.

How can we help individuals whose mental health has been harmed by COVID-19?

To support medical caregivers assigned to the front line during the pandemic, experts advise addressing burnout, as prolonged problems may overlap and lead to acute stress disorder and PTSD.

 Suggestions have ranged from practical measures (such as ensuring adequate PPE, handwashing, and decontamination of surfaces) to developing personnel policies that reassign at-risk medical personnel away from high-risk sites, ensure the safety of their family members, and stress the importance of self-care.

 Also recommended is providing health care workers access to child care services during expanded work hours and school closures. Workers should have adequate rest and breaks, be excused from less-essential tasks, and have regular information and feedback sessions with managers and the community. In many areas, hospitals provide telephone hotline teams trained to provide psychological assistance. Professional organizations offer physician wellness programs to provide free, confidential sessions to deal with burnout, adjustment problems, family issues, and other mental health sequelae.

The increasing numbers of people who were seriously ill with COVID-19 should be assessed for physical symptoms of chronic pain,

 with physical therapy and medications adjusted to avoid opioid dependence. Survivors of ARDS should receive evidence-based medications, cognitive behavioral therapy, and other psychotherapies for PTSD, panic, depression, and other mental disorders.

To combat isolation among locked-down nursing home residents, CMS recommends safe communal activities such as book clubs, movies, bingo, and outdoor family visits (ie, on lawns or in parking lots) with precautions of social distancing and PPE. Some nursing homes have provided live music, parades, therapy animals, recordings and photos of loved ones, physical contact with loved ones through plastic protective barriers, and even physical and occupational therapy sessions held outdoors.

Psychological first aid provided by trained community personnel might help the general population as they experience distress during the COVID-19 pandemic.

 For individuals enduring fallout from personal stressors, experts have recommended expanded use of telehealth to identify and treat mental health conditions, including depression, PTSD and other trauma-related disorders, substance use disorders, and suicidal ideation. Self-help groups, 12-step programs, spiritual and religious services, interest groups, and employee groups working from home are all increasingly using interactive internet-based platforms. And it is essential for societies to provide citizens with assistance for jobs, housing, food, medical care, education, internet connections, and many other basic survival needs.

The current international pandemic and possibly future ones will challenge us and give us the chance to continue to learn and share with other nations, hopefully linking us cooperatively rather than polarizing us.

 is professor and vice chair of education, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. 

is assistant professor and residency training director, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. Authors have no relevant financial conflicts of interest. This article was originally posted on October 5, 2020, and has since been updated.

 Factors associated with post-traumatic stress disorder of nurses exposed to corona virus disease 2019 in China

2. Huang Y, Zhao N. Mental health burden for the public affected by the COVID-19 outbreak in China: Who will be the high-risk group? 

3. Chew NWS, Lee GKH, Tan BYQ, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. 

4. Simms A, Fear NT, Greenberg N. The impact of having inadequate safety equipment on mental health. 

5. Bo HX, Li W, Yang Y, et al. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. 

6. Romero-Sánchez CM, Díaz-Maroto I, Fernández-Díaz E, et al. Neurologic manifestations in hospitalized patients with COVID-19: The ALBACOVID registry. 

7. Ahmed H, Patel K, Greenwood DC, et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalization or ICU admission: A systematic review and meta-analysis. 

8. Vittori A, Lerman J, Cascella M, et al. COVID-19 Pandemic acute respiratory distress syndrome survivors: pain after the storm? 

9. Javelot H, Weiner L. Panique et pandémie: revue de la littérature sur les liens entre le trouble panique et l’épidémie à SARS-CoV-2 [Panic and pandemic: Review of the literature on the links between panic disorder and the SARS-CoV-2 epidemic]. 

10. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. 

11. Liang L, Gao T, Ren H et al. Post-traumatic stress disorder and psychological distress in Chinese youths following the COVID-19 emergency. 

12. Gao J, Zheng P, Jia Y et al. Mental health problems and social media exposure during COVID-19 outbreak. 

13. Wang C, Pan R, Wan X, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. 

14. Forte G, Favieri F, Tambelli R, Casagrande M. 

COVID-19 Pandemic in the Italian Population: Validation of a Post-Traumatic Stress Disorder Questionnaire and Prevalence of PTSD Symptomatology

15. González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. 

16. Abbasi J. Social isolation—the other COVID-19 threat in nursing homes. 

17. Berthelot N, Lemieux R, Garon‐Bissonnette J, et al. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. 

18. Hao F, Tan W, Jiang L, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. 

. 2020;87:100-106.19. Xiang YT, Zhao YJ, Liu ZH, et al. The COVID-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform. 

. 2020;16(10):1741-1744. Published 2020 Mar 15.

20. Zhou J, Liu L, Xue P, et al. Mental Health Response to the COVID-19 Outbreak in China. 

21. Restauri N, Sheridan AD. Burnout and Posttraumatic Stress Disorder in the Coronavirus Disease 2019 (COVID-19) Pandemic: Intersection, Impact, and Interventions. 

22. Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. 

The pandemic has triggered an array of emotional, physical, and economic issues but in the midst of this crisis, nations have shared and learned from each other’s experiences.

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

Biohaven Pharmaceutical Holding Company recently announced the start of a pivotal phase 3 clinical trial. It will assess the efficacy and safety of troriluzole for the treatment of obsessive-compulsive disorder (OCD).

“We look forward to advancing our Phase 3 clinical trials of troriluzole 280 mg for the adjunctive treatment of OCD. If approved, this would provide hope to many who suffer with OCD and for whom standard of care medications do not provide adequate relief. No new treatments for OCD have been approved for over two decades. With its novel mechanism of action compared to currently available therapies, troriluzole would provide a significant advance in treatment for the many patients who either do not respond or continue to experience residual symptoms with standard medications,” Elyse Stock, MD, Chief Medical Officer at Biohaven said to the press.

Biohaven decided to advance the 280 mg once-daily dose of troriluzole into 2 identical, study-designed phase 3 clinical trials. They plan to enroll approximately 600 patients in each of these trials across study sites in both the United States and Europe. The recently completed phase 2 trial (a proof of concept study) showed clinically meaningful effects at all study timepoints in patients who had an inadequate response to standard treatment. While the study sample size in the phase 2 trial did not demonstrate statistical significance, the data was instrumental in refining the phase 3 studies.

“We are excited to begin these new studies as approximately one third of patients with OCD do not respond to currently available medications and new therapies are urgently needed. We believe troriluzole, which normalizes neuronal glutamate, could offer a promising alternative treatment with a new mechanism of action for OCD sufferers who are not adequately responding to currently available treatments,” Loren Aguiar, MD, Vice President of Research and Development and Biohaven said to the press.

Troriluzole is a new chemical entity and modulating agent that normalizes glutamate. Biohaven was awarded 2 US patents covering troriluzole, and international patents are pending. All the patents have statutory expiration dates in 2039.

The executive director of the International OCD Foundation, Jeff Szymanski, PhD, had this to say: “There is a significant need for new treatments for those suffering from OCD. We applaud Biohaven for their ongoing research and moving forward with these upcoming trials.”

1. Biohaven. Biohaven begins pivotal phase 3 trial of troriluzole in obsessive-compulsive disorder. News release. January 4, 2021. 

https://www.biohavenpharma.com/investors/news-events/press-releases/01-04-2021

A new phase 3 trial recently started for the novel treatment troriluzole.  

Developments in Trials of a New OCD Treatment 

Susan Noonan, MD, MPH, talks how small, broken down tasks and a system will help patients maintain their mental health. 

Daily routine and structure will decrease a patient's stress and give them a sense of accomplishment. 

Manageable and In Control 

As a result of the coronavirus pandemic (COVID-19), 2020 was a very challenging year. Concerns about contracting the infection, loss of income/employment, disruption of routines, physical 

 from friends and family, restriction of leisure activities, and school and daycare closures caused significant stress for patients and clinicians. Although the stress may not meet the diagnostic criteria for an anxiety disorder, the symptoms can affect quality of life. Tips for addressing stress and anxiety related to the pandemic can be used for other natural disasters and events (

. A major concern for many patients is contracting the virus, and sometimes the fears are based on misinformation. Empower your patients by educating them on COVID-19 transmission and epidemiology and dispelling myths. I have patients who are so fearful of getting infected that they do not want to leave their house, go to the grocery store, or conduct any essential activities. When a patient knows how to protect themselves from infection, they will less anxious. Remind them that certain precautions reduce their risk: staying 6 feet apart, wearing a face covering, keeping hands clean at all times, and not touching hands to face. If they follow these rules, they will feel less stress when leaving their homes. 

Advise patients who are highly anxious to limit screen time and news/media.The media is inundated with information that can increase a patient’s anxiety. Patients should spend the extra time on self-care activities, like taking breaks from work; engaging in physical exercises, 

, and yoga; spending time with their loved ones; listening to music; watching a good show; or reading a novel. Any activities that helps alleviate stress and gives them pleasure is recommended.

Educate patients about normal responses to stress and trauma. Normal responses can include anxiety, apprehension, disbelief, anger, insomnia, concentration problems, fatigue, and irritability. Increases in pain and other physical symptoms are also common. These stress reactions are usually transient and will likely resolve once patients adapt to the pandemic-related changes. If a patient reports stress response symptoms that do not resolve after a few weeks, or that are severe enough to cause significant distress or interfere with daily functioning, then they should be assessed for the development of adjustment disorder with anxiety, acute stress reaction, or new onset generalized anxiety disorder (GAD).

Assess treatments and adjust accordingly. Patients with underlying anxiety disorders, especially GAD, may experience exacerbation of their anxiety. If their symptoms were previously controlled by medication, consider an adjustment.

Cautiously consider the addition of anti-anxiety medications. Patients may present and ask for medications, like 

, but alprazolam or lorazepam should not be prescribed without a thorough assessment. Since PRN benzos can take 30 minutes to an hour to work, PRN dosing is not effective in preventing a panic attack, which usually comes on within 10 minutes. It is preferable to start patients on a selective serotonin reuptake inhibitor. As recurrent panic attacks are often due to an underlying anxiety disorder or depression, it is vital to assess the patient. 

 is past president of the Orange County Psychiatric Society and a distinguished fellow of the American Psychiatric Association. ❒

Strategies for educating patients on COVID-19 transmission and epidemiology, as well as dispelling myths

Lessons Learned From Treating COVID-Related Anxiety

Pay attention to places of tension and stress, then let go of it. Neda F. Gould, PhD talks through the methodical release of stress points on the body. 

Johns Hopkins Bayview Medical Center Anxiety Disorders Clinic

Johns Hopkins Department of Psychiatry and Behavioral Sciences

Listen to the sounds of nature and release the tension you are holding. 

Reducing Stress Through Mindfulness

more than half of gay, lesbian, and bisexual individuals who abuse alcohol or tobacco also have a co-occurring psychiatric disorder, whereas only one-third of heterosexual individuals have the same correlation.

“The degree of disparities in alcohol, tobacco and other psychiatric disorders by sexual identity was very surprising,” Rebecca Evans-Polce, assistant research scientist at the University of Michigan School of Nursing and first author of the study, said to the press. “The differences for women are more striking.”

Previous studies have demonstrated that LGBTQ+ individuals are at greater risk for both substance use disorders and psychiatric disorders. Evans-Polce noted that the new study, which gathered data from 35,796 responses from the National Epidemiologic Survey on Alcohol and Related Conditions, is 1 of the few to examine this risk.

An interesting finding of note is the prevalent comorbidities for bisexual women. When compared to heterosexual women, bisexual women were found much more likely to have an anxiety disorder (32.5% bisexual, 16% heterosexual), mood disorder (35% bisexual, 15% heterosexual), and post-traumatic stress disorder (21% bisexual, 6% heterosexual). According to the data, 63% of bisexual women misusing tobacco also had an anxiety disorder, mood disorder, or PTSD. In contrast, only 46% of heterosexual women with a tobacco use disorder also had a psychiatric issue.

Bisexual individuals overall were 4 times more likely to have PTSD than heterosexual individuals.

The reason for this association is unconfirmed, but researchers suspect discrimination and trauma may be to blame. Sexual orientation discrimination, the number of stressful life events, and the number of adverse childhood experiences were strongly associated with greater risk of comorbidities.

Researchers determined that the data demonstrates a need for integrated substance use and mental health prevention and treatment programs, particularly for individuals who identify as sexual minorities. Additionally, more research is needed to comprehend why data repeatedly points to such a high risk for bisexual women.

1. Evans-Polce RJ, Kcomt L, Veliz PT, Boyd CJ, et al. Alcohol, Tobacco, and Comorbid Psychiatric Disorders and Associations With Sexual Identity and Stress-Related Correlates. 

2. University of Michigan. Sexual minorities, especially women, who misuse substances more likely to have psychiatric disorders. News release. 

https://medicalxpress.com/news/2020-11-sexual-minorities-women-misuse-substances.html

Sexual minorities with alcohol and tobacco addictions are at a higher risk for comorbid psychiatric disorders, bisexual women in particular.

LGBTQ+ Individuals who Abuse Substances Are More Likely to Have Psychiatric Disorders

Anxiety disorders are impairing, distressing, and pervasive throughout society.

 Thus, research is focusing on how to develop and refine effective, evidence-based treatments for anxiety. To date, cognitive behavioral therapy (CBT) is the most effective psychotherapy available for anxiety disorders.

 assumes that anxiety and other emotional disorders are associated with maladaptive cognitions and behaviors.

 A typical course of CBT for anxiety disorders includes psychoeducation on the nature of 

 and the particular disorder, cognitive restructuring techniques, and exposure to feared situations, objects, or memories.

Before the exposures, the therapist helps patients identify situations they avoid as well as subtle behaviors (ie, safety behaviors) in which they engage to ease their distress. It is generally believed that individuals develop specific fears due to conditioning that occurs in a particular context; in turn, these generalize to other contexts. The individual tends to avoid the feared situation due to the false belief that situation is dangerous or unmanageable. Avoidance is assumed to maintain the fear as well as this false belief. During exposure therapy, patients systematically enter anxiety-provoking situations until there is a significant reduction in the anxiety response due to extinction learning.

 In addition, exposures serve as behavioral experiments aimed at testing the validity of maladaptive cognitions and feared outcomes. By modifying these maladaptive cognitions, emotional distress and engagement in maladaptive behaviors will decrease, and the individual can learn a new safe memory associated with the previously feared stimulus or context.

Despite the superior efficacy of CBT, there is still considerable room for improvement.

 Researchers have supplemented CBT with anxiety-reducing pharmacotherapies, as some individuals do not improve—or improve sufficiently—with exposure alone. However, augmenting exposure with anxiolytic drugs has resulted in minor success. Furthermore, these augmentation strategies may result in less successful treatment outcomes, as individuals may attribute treatment gains to medication rather than to their own effort, thereby undermining self-efficacy. More recent approaches have focused on strengthening CBT education, utilizing pharmacotherapy that affects the neurobiology implicated in the fear extinction processes.

 This approach aims at enhancing the memory processes underlying extinction. 

Fear extinction is a prime area of research in the anxiety literature, as researchers continue to investigate novel and effective ways to reduce the salience of distressing memories and replace these with more neutral memories. One such pathway, the N-methyl-D-aspartate (NMDA) receptor in the basolateral amygdala, is known to play an important role in controlling neural plasticity and memory. Recent research suggests that NMDA activity mediates fear extinction.

 As such, a compound known as d-cycloserine (DCS) has been demonstrated to augment extinction learning by serving as a partial NMDA agonist.

Because DCS has long been used as an antibiotic medication for treating tuberculosis at high dosing for an extended period of time, it can be safely administered as a cognitive enhancer in exposure therapies for anxiety disorders at much lower dosing for a much shorter period of time. Accordingly, a vast body of research focuses on translating preclinical basic neuroscience findings about DCS into clinical trials with humans diagnosed with a large range of anxiety disorders.

The first human trial of DCS as an augmentation strategy for exposure in patients with anxiety yielded promising results.

 The effects of a single dose of DCS taken prior to exposure sessions by patients with acrophobia were examined. Results revealed that DCS significantly enhanced extinction learning after the 2 sessions of acute treatment and at 3 months follow-up. Patients randomly assigned to the DCS condition subsequently reported less avoidance of heights in their daily activities after study completion. Therefore, DCS appeared to enhance the memory of successful exposure experiences and influence subsequent willingness to confront fearful situations. This promising study led to a further line of research that aimed to elucidate the possible enhancing effects of DCS on various anxiety disorders.

Subsequent studies from our group on social anxiety disorder and panic disorder found similarly successful results for DCS as an augmentation strategy.

 Other studies, however, presented null effects.

 Of particular interest and concern was 1 trial with 

 (PTSD). It found that patients who received DCS reported more symptoms at posttreatment than those who received placebo.

 As will be discussed further in this article, this study suggests that DCS might also augment fear memory reconsolidation and, therefore, might produce counter-therapeutic effects under certain circumstances.

These studies revealed the complex therapeutic and counter-therapeutic effects of DCS. The 3 main literature findings should be carefully considered when using DCS in exposure therapy: (1) Effect of dose and timing of administration; (2) DCS as an accelerator of early treatment response; (3) Specific conditions in which DCS can lead to fear reconsolidation and worsen symptoms.

Effect of Dose and Timing of Administration

DCS Dosing and dose timing could explain the inconsistent findings from previous studies. The results from several animal and human studies suggest that DCS only shows the extinction augmentation effect when administered in low (eg, 50 mg) and isolated (ie, acute) dosing, but not when administered chronically (ie, repeatedly over an extended period of time).

Timing is another important issue. Peak blood levels of DCS typically are evident 4 to 6 hours after ingestion. Extinction learning processes usually happen at the end of an exposure session. Therefore, DCS is likely to be most effective when administered within 1 to 2 hours before an exposure session. Indeed, studies demonstrated that DCS administration 1 to 2 hours before exposure achieved greater effects than studies DCS administration multiple hours before exposure.

 These results hint at a rather narrow therapeutic window of DCS, as it appears DCS needs to be administered acutely and in small doses approximately 1 to 2 hours before exposures.

DCS as an Accelerator of Early Treatment Respons

Rather than directly targeting anxiolysis, DCS is used to enhance consolidation of the therapeutic learning offered by CBT. As DCS is a cognitive enhancer, it was reasonable to expect that DCS would strengthen the benefits of CBT through faster learning. Studies that examined the application of DCS for obsessive-compulsive disorder (OCD) revealed that DCS had an effect that attenuated with subsequent administrations.

 These results provided the first hints that DCS primarily acts by accelerating treatment response in the early part of therapy.

Furthermore, with repeated exposure sessions, studies have revealed that exposure alone can eventually show similar effects to the initial DCS augmentation effects. This apparent catch-up effect has also been shown in animal models and human trials for social anxiety disorder, agoraphobia, and panic disorder.

 Although these studies did not show an advantage at the end of treatment in terms of response or remission rates for DCS, faster treatment response can have far-reaching effects. For example, a rapid reduction in distress and disability is linked with a lower dropout rate, as treatment gains are realized more quickly.

D-cycloserine may help patients with anxiety disorders, or it might make their anxiety worse. Find out how to use it safely. 

Anxiety & Stress Disorders