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, SARS-CoV-2, the cause of COVID-19, might be able to enter the brain. Researchers discovered that the spike protein, or the red arms of the virus, can cross the blood-brain barrier in mice.

“We know that when you have the COVID infection you have trouble breathing and that’s because there’s infection in your lung, but an additional explanation is that the virus enters the respiratory centers of the brain and causes problems there as well,” said lead author William A. Banks, a professor of medicine at the University of Washington School of Medicine and a Puget Sound Veterans Affairs Healthcare System physician and researcher.

SARS-CoV-2 binds to cells via the S1 subunit of its spike protein. Binding proteins like S1 alone can cause damage as they detach from the virus and cause inflammation.

According to Banks, “The S1 protein likely causes the brain to release cytokines and inflammatory products.”

The COVID-19 infection causes a cytokine storm, with the immune system overreacting in its attempt to kill the invading virus. The infected individual is then left with cognitive issues, like brain fog and fatigue.

The study also found that the transport of S1 was faster in the olfactory bulb and kidney of male mice rather than females. This observation might relate to men’s increased susceptibility to more severe COVID-19 infections.

Banks had this to say for people not taking COVID-19 seriously: “You do not want to mess with this virus. Many of the effects that the COVID virus has could be accentuated or perpetuated or even caused by virus getting in the brain and those effects could last for a very long time.”

This study was partially supported by a National Institute on Aging-funded COVID-19 supplement to a shared RF1 grant of Banks and Raber.​

1. Rhea EM, Logsdon AF, Hansen KM, et al. The S1 protein of SARS-CoV-2 crosses the blood–brain barrier in mice. 

https://www.nature.com/articles/s41593-020-00771-8

2. University of Washington School of Medicine. Research strongly suggests COVID-19 virus enters the brain. News release. December 17, 2020. 

https://www.newswise.com/coronavirus/research-strongly-suggests-covid-19-virus-enters-the-brain/?article_id=743572&sc=sphr&xy=5013482

A new study considers how the virus might enter the brain and cause cognitive issues. 

Can COVID-19 Enter the Brain?

Inger Burnett-Zeigler, PhD, talks about what societal and social components contribute to loneliness. 

is an associate professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine, and she treats patients at the Asher Center for the Study and Treatment of Depressive Disorders.

What factors make individuals more susceptible to loneliness? Gender? Race? Age? 

Factoring Loneliness

H. Steven Moffic, MD, talks about climate instability, surpassing the 500,000 death count for COVID-19, and an old British proverb.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

After a long, dark week comes the refreshing sunshine. 

Here Comes the Sun After a Harsh Week

2020 has been a year of hardship for all Americans. The COVID-19 pandemic struck our country in a way that we have never seen in living memory. It has infiltrated all corners of the country and killed more Americans than 

. The virus has caused a cascade effect of disruption that not only challenged the physical and mental health of Americans, but also overran our health care system and the economy, causing widespread economic shutdowns and leaving millions without jobs.

Aside from its medical effects, the virus has exposed many of our society’s vulnerabilities, including the darker underbelly of our social fabric: the longstanding, deeply-rooted racism towards Black Americans. 2020 put a magnifying glass on racial disparities in this country, forcing us to confront realities affecting Black Americans that have always been there: economic disparities, health disparities, and police violence to name a few. The virus highlighted health disparities affecting Black Americans, who were 

 from COVID-19, compared to their white counterparts, and twice as likely to die from the virus. Black Americans disproportionately lost their jobs due to pandemic-related economic losses. The virus also reminded us that Black Americans are more likely to be uninsured and less likely to have access to and utilize health care services.

2020 appeared to end with an encouraging turn. Two COVID-19 vaccines were found to be over 90% effective in preventing illness from the virus, and they were approved emergently for use (and now a third vaccine is currently seeking emergency use authorization). This could be the turning point for our country and offer hope for all Americans, right? If only it were that simple.

 found that in December of 2020, 35% of Black Americans stated they definitely or probably would not get the vaccine. This was a significantly higher percentage of reluctance compared to all other ethnic counterparts surveyed. The revelation of this study, in a similar vein to the rest of 2020, reflects a much deeper problem within our society. Many Black Americans distrust the American medical system.

This is understandable. Our country’s medical establishment has a longstanding history of abusing Black Americans. One of the most heinous generational traumas was the 

, in which a massive cohort of Black participants were recruited with the incentive of free medical care. In truth, they were diagnosed with syphilis without being informed or offered treatment, but instead deceitfully monitored to study the progression of the disease.

When doctors and research scientists today pursue basic research training, all must review the tenants of the Nuremberg Code, a globalized set of research principles drafted in 1947 that emphasize the ethics of patient consent for research participation. The 

 was established after the 1941 Nuremberg trials, which sought justice for the heinous experiments by Nazi doctors involving torture, poisoning, and mass murder of Jewish individuals in concentration camps during World War II. What we as modern doctors and researchers tend to overlook is that the Tuskegee experiments here in the United States, that involved no informed participant consent, no knowledge of their infection with a deadly disease, and withholding of proper treatment for their illness, ran from 1932 all the way up until 1972.

It is no wonder, then, that when the COVID-19 vaccine trials began, social media posts among Black Americans erupted with references to Tuskegee. Even though the trials ended in 1972, the trauma remains etched in the Black community’s historical memory.

As psychiatrists, most of us were trained with a clinical framework that considers a patient’s feelings towards the doctor. But with our focus on mental health, we are prone to view other domains of our patients’ physical health and wellbeing as beyond our purview. Consequently, many of us are reluctant to confront the topic of 

 with our patients; however, it is important for us to do so in order to establish trust with our patients. The reluctance of Black Americans to get the COVID-19 vaccine reflects a deeper distrust of the medical system as a whole, that not only failed them, but also took advantage of them and deliberately hurt them. So how can we as psychiatrists overlook such a critical underpinning of our Black patients’ transference towards us as their medical doctors?

I, like many others, only just began in 2020 to take a hard look in the mirror and confront my own implicit biases towards my Black counterparts and patients. I recently began to talk with my Black patients about their racial experience, and I have been astonished and humbled by the revelations of everyday racism that my patients would share with me. Explorative conversations about race have proven to be invaluable, and have brought me closer with my patients and helped me grow as an individual and a doctor. As we see these discrepancies in trust over the 

vaccine (one of our only hopes to resume social normalcy), I think we must take the conversation further.

We as psychiatrists can and should start talking with our patients about the COVID-19 vaccine. COVID-19 does not only affect our patient’s physical health, but also has devastating mental and emotional consequences. We need to engage in conversations with our patients about their mistrust of the health care system, as we are part of it. Educating our patients about the seriousness of the illness and the benefits of the vaccine can go a long way. Providing them with reliable resources, especially if it comes from trusted agencies, organizations, faith leaders, professionals, or a nationally-recognized African American figure, may make a difference.

Advocating for our patients’ wellbeing is a basic responsibility of being their psychiatrists. With our additional support, we can continue our efforts to help our patients live healthier and happier lives—and rebuild broken trust.

is a clinical instructor of Child and Adolescent Psychiatry, and of Psychiatry at New York University’s Grossman School of Medicine. 

is Clinical Professor of Psychiatry, University of Missouri- Columbia, Columbia, MO.

1. Hamel L, Kirzinger A, Munana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020. 

Kaiser Family Foundation: Health Policy Analysis, Polling and Journalism

. December 15, 2020. Accessed February 19, 2021. 

https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/

A case for why psychiatrists should discuss the COVID vaccines with their patients.

Black Americans’ Distrust of the COVID-19 Vaccine

Literature is emerging on the effects of the coronavirus disease 2019 (COVID-19) pandemic on patients with bipolar disorder. This is part of the much larger literature on assessment and management of mental disorders during the 

Our group of 11 clinicians at the US Department of Veterans Affairs Bipolar Disorders Telehealth Program recently 

 of lessons learned from using telehealth modalities (videoconferencing and telephone contact) with more than 3000 veterans whose caregivers submitted consultation requests.

 is the way many, if not most, patients currently are being seen by clinicians. Many patients will continue to use this method even after the pandemic has waned. Telehealth has some specific effects on patients with bipolar disorder.

Video sessions and calls generally are very much welcomed by patients who are isolated to various degrees because of COVID-19. Their usual social outlets are diminished, and their access to in-person visits with clinicians is much reduced or eliminated. Hence, contact with an upbeat, thorough, authoritative, and supportive consulting clinician can have a tremendous effect in reassuring patients that help is available. In fact, 

 may diminish immediately during the call.

Effort must be made, however, to deal effectively with wireless connectivity issues that may render speech garbled with dropped words or pronunciations that are difficult to understand.

 It is important to slow down the conversation, adjust volume or microphone or video placement, be mindful of the time lag that can occur between speech and the transmission of the speech, and avoid interrupting the patient by responding too quickly. Video and phone transmission might make it difficult to determine if the patient is becoming tearful or 

, and it is important to ask if this is occurring.

Another issue associated with the pandemic is the loss of usual routines of behavior associated with previous mood states before isolation can result in new outlets (eg, buying online instead of in stores during manias). The clinician should be prepared to ask questions to uncover new syndromic behaviors.

 issues that are relatively unique to the COVID-19 era were summarized in a recent review by experts from Spain.

 Medication adherence is often reduced during isolation, so it is important (after establishing a therapeutic alliance using some of the previously noted suggestions) to inquire about adherence. Similarly, after examining the possible causes of nonadherence (eg, real or feared adverse effects, the feeling of being controlled by the medication, missing periods of euphoria), clinicians should educate their patients about the importance of adherence. Help may be needed from significant others in the household to monitor adherence, with the patient’s permission.

Substance use disorders may increase in severity in the isolation setting, and these should be ruled out or managed, if necessary. Patients may be fearful of initiating new medications without an in-person encounter, especially if bloodwork is required or patients have concerns about entering a medical facility for

 The importance of lithium levels and kidney function tests will need to be reiterated and the benefits weighed against the risks associated with going to get the tests, which can be minimized with appropriate social distancing and masks.

 with medications used in the treatment of patients who have COVID-19, if the patient requires hospital treatment.

 Dexamethasone can induce mood switches to mania or depression. Dexamethasone’s metabolism is induced by carbamazepine and, to a lesser extent, by oxcarbazepine. Initiation of these anticonvulsant mood stabilizers should therefore be avoided if possible. They also induce the metabolism of remdesivir, and carbamazepine may add to the risk of liver dysfunction caused by this antiviral agent. If the patient is already on one of these mood stabilizers, appropriate dosage adjustments of the COVID-19 drugs and lab monitoring will be needed. Chloroquine and hydroxychloroquine should be avoided in patients with COVID-19 and bipolar disorder because they increase risk of mania, psychosis, and 

is associate professor of psychiatry, Harvard Medical School, and co-lead psychiatrist at the US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, Massachusetts.

1. Bojdani E, Rajagopalan A, Chen A, et al. 

COVID-19 pandemic: impact on psychiatric care in the United States

2. Burgess C, Miller CJ, Franz A, Abel EA, et al. 

Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemic

4. Hernández-Gómez A, Andrade-González N, Lahera G, Vieta E. 

Recommendations for the care of patients with bipolar disorder during the COVID-19 pandemic

As we learn about the effect of COVID-19 on patients with bipolar and other psychiatric disorders, clinicians should be prepared to ask questions to uncover new syndromic behaviors.

COVID-19 Pandemic’s  Effects on Assessment & Psychopharmacological Management

“Race paralyzes our natural inclination to ask certain questions and listen to the answers that follow. The inability to have honest, albeit difficult, conversations that lead to change is 

 So write past presidents of residency training and organized psychiatry. Psychiatry as a field is a place where honest conversations happen in psychologically safe spaces. It is difficult to talk about painful subjects in our lives. It is especially difficult to talk about trauma we have tried to forget. Racism has caused more than its fair share of trauma, including the intergenerational transmission of trauma. Any challenging conversation should be guided by principles of avoiding defensiveness; staying calm; being respectful; conveying curiosity; and listening deeply.

Although it is most expedient to prescribe medication like a “psychological surgeon,” psychiatrists should explore deeper and more challenging issues by first establishing a positive relationship with a patient. To overcome the understandable reluctance to talk, psychiatrists must establish a therapeutic alliance through confidentiality, concern, compassion, and competence. Indeed, achieving trust is often the most important 

It is common to hear one must accept being uncomfortable in discussions of race and racism, especially if one is being labeled white or a white supremacist. But that does not seem psychologically sound, or in line with best practices for having difficult conversations. The expectation that people in general conversation accept their own complicity with racism may well attract those who already agree, or who feel guilty and will readily take criticism as a just punishment. However, awkward discussions are likely to repel those who do not agree or feel they are being unjustly accused of being a bad individual. These non-participants may be critical to advancing the conversation. Similar to working with patients, uncomfortable dialog too early in a relationship often leads to leaving the situation entirely.

Just ask master interviewers their strategy to engage with others. Tributes poured in after Larry King recently passed away, lauding him for his ability to get his interviewees to open up to him. He has said that starting the interview with soft questions creates a comfortable environment, in which the interviewer can ask harder, more uncomfortable questions later.

Since race is a psycho-social construct, it must serve a crucial psychological function. That function may be to scapegoat the “other,” or the target, in order to maintain self-esteem and security. Human beings may be hardwired to fear the other, leading them to muster the power to ward off perceived danger. By denigrating individuals they want to control, they must exert power. Consequently, the issue of race has been used as a technique to manage human differences in politics, policing, education, health care, and elsewhere. Race and racism are not dangerous issues to talk about. There is more to gain than to lose in keeping an open mind.

Another reason race is hard to talk about is the climate of political correctness. Saying something about race that is deemed inappropriate may evoke a furious response. Calling out racism may appear to be a corrective action, but not if the recipient feels psychologically wounded or humiliated. That can lead to anger and a desire for future retaliation.

Given the structural and ubiquitous nature of racism, people of all ages, gender, and socioeconomic status should have a conversation about it. The experience of elders can supplement the values of the youth.

There are many ways for individuals to explore these topics (

). Potentially, conversations with a cultural mixture of individuals would be best, as that reflects the diversity of the United States, and hopes for its unity. In psychiatry, these conversations can occur in patient, care, collegial interactions, publicly, and within personal relationships.

Conversations on race can also happen in numerous places. It can and should be done at home, and at schools, including medical schools. It can be in casual circumstances or planned discussions. It can be done live and/or online. Whatever works for a given individual is best.

Terminology can help or hinder conversation. What words will be inviting or repellent to would-be discussants? Are the current preferred colloquial names of racial groups unifying or divisive? Are Black, white, and brown the best terms for so-called racial groups when we are all people of color, some darker, some lighter? White people generally have lighter skin, but who among the lighter colors are not white? Where do light skinned Jews, Muslims, Hispanics, or individuals of mixed racial ancestry fit into this categorization? Misidentifying someone is unlikely to contribute to an alliance. Given that so-called “white supremacy” is associated with the “alt-right” politically, does that term backfire when applied to all whites?

The term “race,” in of itself, could be considered a contribution to racism. It implies there are important differences among people who are virtually the same genetically. Ironically, it is a term of unity.

Given our country’s long history of racism against Blacks, Indigenous, and other minorities, some degree of structural, institutional, and individual racism is inevitable and ubiquitous for now. Racism is harmful. Harming another generally calls for an apology to achieve healing forgiveness and reconciliation. It is self-evident that a country and an institution cannot apologize because they are not individuals and cannot thereby talk or write. It takes those who are spokespersons for them to do so. That is what recently happened in psychiatry with the American Psychiatric Association (APA).

On Martin Luther King, Jr. Day, Monday, January 18, 2021, the 

 toward members, patients and the public who are “Black, Indigenous, and People of Color” (BIPOC). Moreover, we should be experts on how to apologize. It is a psychological process, after all. The late psychiatrist Aaron Lazare, MD, was an expert on apology.

 He warned us: apologies are often helpful, but they can be meaningless or even harmful if not done properly and well.

We all know that full apologies are difficult. Any parent will receive multiple apologies from children without a change of behavior. In medicine and psychiatry, mistakes can also be inadvertent because of the science and standards of the time, so well-intentioned professionals may still be called upon to apologize later, even though they were doing the best they could at the time.

Will the APA’s apology advance or hinder the conversation? Time—and how the apology is processed—will tell. It does meet some of Dr Lazare’s criteria for an effective apology. The apology is clearly stated and explained, many historical examples are provided, and some remorse is expressed. It rather uniquely includes Indigenous and people of darker color. It did not discuss how antiracism will be monitored and reported, but there is a Task Force that has already been working on this challenge. Although the psychological impact of any apology can be helpful, follow-up up corrective actions are crucial for full impact.

For instance, perhaps the hardest racism topic to discuss and act upon is the question of reparations. Since we live in a country founded upon principles of equality, opportunity, and freedom, many individuals fail to see the continuing remnants of 400 years of slavery and discrimination that limit fulfillment of those principles. One solution is reparations, not solely in the form of monetary compensation, but in services such as quality education and health care that are key to prosperity for all. One example is 

, one of the largest health care systems in Milwaukee. It is refining the current category of vaccinating patients by prioritizing “those most vulnerable based on risk factors including age, health conditions, and those who live in zip codes disproportionately impacted by COVID.” In effect, it helps to redress some of the health care disparities putting those people at current higher health risk for COVID-19.

1. Advance the Conversation by Expanding It

 To get a sense of how psychiatrists are reacting to the apology, surveying is needed. This step is especially important because the APA membership was not canvassed in any way during the development of the apology. Be more transparent about how the apology was reached. 

2. Advance the Conversation by Monitoring It

  In past APA Annual Meetings, controversial matters such as psychiatrist burnout have been discussed in town halls. These forums for discussing racism should be set up and heavily publicized in future meetings. Other subspecialty and related psychiatric groups should consider their own apologies and discussions. Each year, on Martin Luther King Jr Day, the APA could make an annual antiracism report.

3. Advance the Conversation by Improving It.

 suggests, a key to unlock antiracist optimism is already available to all.

 It is a trial-and-error process to see if the key fits, and we must explore whether the locks have changed. Psychiatrists should try different models and share the results. In most cases, the principles for establishing a therapeutic alliance and processing difficult conversations are essential to the process. Partnerships trump rivalries.

4. Advance the Conversation by Normalizing It. 

The dialog needs to touch all levels of racism: societal, institutional, and individual. Because it may exist anywhere, from the pictures on the walls to staff composition, it needs to be routinely kept in mind for everyday activities in psychiatry. Silence generally conveys acceptance of the status quo or resistance to change.

5. Advance the Conversation by Continuing It.

 Since racism has been embedded in the United States for so long, talking about race should be ongoing. Merely responding to racial crises as they happen is inadequate and will only maintain the status quo. As Martin Luther King Jr has 

, “Shallow understanding from people of goodwill is more frustrating than absolute misunderstanding from people of ill will.”

 Thus, the basics should be tested for in certification of psychiatrists, then supplemented by continuing education. And when the conversation does not go well, as it did not between President Biden and Vice President Harris during an early debate for the Democratic nomination, gracious processing of the issues and ironing out any misunderstandings can lead to a trusted partnership. In their case, their collaboration resulted in being chosen as 

, reflective of their current unity in diversity. Could we follow their model and propose the 

Antiracist Mental Health People of the Year 2021

 Conversation should not be taken literally; it goes beyond verbal exchanges. Nonverbal communication and actions convey messages as well. We have tried to take the first step with the dedications of this article. The first dedicatee is Henry (Hank) Louis Aaron, a man of relatively few words. Nicknamed “Hammerin’ Hank,” he used his bat successfully not only for baseball, but also for hammering down the nails of racism.

 Larry King, who was white, and Hank Aaron, who was Black, died 1 day apart in January. King interviewed him several times. In 1991, right after Aaron’s autobiography came out, they talked more about racism than baseball.

 This article is dedicated to Hank Aaron. May his memory be a blessing. He bravely played baseball (1954 to 1976) for the Milwaukee Braves, and then the Atlanta Braves when the team moved to the deep South and a center of the Civil Rights struggle (1966), where he broke the home run record. At every stage of his career, he dealt with racism with dignity and determination. He kept all of the hateful letters he received, including one that said, “If you come close to Babe Ruth’s 714 homers, I have a contract out on you.” Instead, Aaron later received the Presidential Medal of Freedom and lived until January 22, 2021, the day the first draft of this article was written.

 serves as Assistant Dean of Clinical Education at Charles R. Drew University and Chief Medical Officer of Kedren Health Systems Inc. He served as president of the National Medical Association and chair of the American Medical Association’s Commission to End Health Disparities. He currently is a member of the American Psychiatric Association Board of Trustees. Throughout his career, Dr Bailey has worked with underserved and minority populations and has authored numerous papers on the topic.

Can we talk? The role of organized psychiatry in addressing structural racism to achieve diversity and inclusion in psychiatric workforce development

Difficult Conversations: How to Discuss What Matters Most

The therapeutic alliance: the fundamental element of psychotherapy

How to Talk to Anyone, Anytime, Anywhere: The Secrets of Good Communication

TM. 2020;37(12)1;12-13. Accessed January 29, 2021. https://www.psychiatrictimes.com/view/optimistic-prognosis-2021

Letters to a Birmingham Jail: A Response to the Words and Dreams of Dr. Martin Luther King, Jr

Person of the year: Joe Biden and Kamala Harris

 Harper Perennial, Illustrated edition; 2007.

What are best practices for difficult conversations about racism? How can psychiatrists help? The authors present 6 ways to advance discussions about racism in psychiatry.

If We Had a Hammer

Julie Smirl, LCPC, discusses the difficulties of the home-work environment, and how the veil of the professional setting is thinner than ever. 

is an assistant professor at Bradley University and a counselor at Alliance Counseling Services. 

How has the transition to work from home placed a burden on the shoulders of parents? 

Blended Rules: The Home-Work Environment

H. Steven Moffic, MD, talks about the extreme loss toll from COVID-19 and the effect it has on our collective mental state. 

There are 525,600 minutes in a year. How many COVID-19 related deaths have we seen in the thousands of minutes since this began? 

525,600 Minutes and the Prolonged Grief of COVID-19

Early on, perhaps around April or May, much to my chagrin I failed to look up my bank’s new COVID-19 hours. Thinking the bank opened at 9:30 am, I discovered on arrival that I would have to wait an extra hour to access drive-through banking. I ended up doing my banking the old-fashioned way—in the bank.

Upon returning home, I started to berate myself: “Why did I not wait the extra hour for drive-through? Did my need for efficiency overrule possible exposure to the virus, allowing for the bank’s attentive COVID precautions? Is my social circle also now at risk, and who might they be at this point? If necessary, how do I go about informing them? And at the end of the day, do I really want to bother with all of this?”

What finally assuaged my anxiety was the empathic listening of my support network. One friend told me, “You didn’t commit a crime. You simply went on an errand.” So true and logical, in retrospect. However, at the time, the uncertainty inherent to the pandemic compromised my ability to make a balanced self-appraisal.

 has commented, “our brains are literally overburdened by the pandemic…things we had relegated to the brain’s autopilot function…now require serious thought and risk analysis. As a result, we have less bandwidth available for higher order thinking…”

 Her observations could not be more resonant with my own experience. Every time I step out the door, there is a safety-related checklist that can feel burdensome—remembering a mask, weighing in on the day’s logistics so as to maximize social distancing, and prioritizing what is essential versus non-essential activity. The net effect is a heightened awareness that is not only mentally exhausting but, in certain cases, can lead to an insidious onset of intensified reactivity. Prior to the pandemic, cognitive therapists might have labelled this as a tendency to catastrophize, but now it is an understandable variant of pandemic anxiety.

Pandemic anxiety is driven by the highly contagious and potentially lethal nature of SARS CoV-2. We have read numerous reports of individuals in their prime tragically struck down by the virus, leaving mourners in their wake. Many of us have experienced the trauma of losing someone to COVID-19 first-hand.

Months of social restriction coupled with well-intentioned public health messages have also taken their toll. Of all the holiday warnings circulating this past November, several in particular were striking. Roughly distilled, they read, “Dining with your family member today could result in their ICU admission tomorrow.” Some public health officials found such stark warnings to be excessive, counter-productive to promoting safe travel in their degree of shaming. Acknowledging the beneficial intent—to curb irresponsible behavior—this team of experts nevertheless felt that public health messages needed to be more nuanced to avoid compounding an already heightened level of fear.

As psychiatrists, we face the challenge of sorting out normal pandemic anxiety from more pervasive anxiety disorders, not only for our own self-understanding, but also to help our patients. And yet, diagnosing anxiety disorders can be tricky if we are simultaneously processing empathy for our patients with verifying our own near COVID-19 misses. Returning to the opening vignette, what distinguishes an acute attack of pandemic anxiety, which can hijack the mind, from an obsessive-compulsive disorder (OCD) obsession? In their international mini review, Sulaimani and Bagadood comment that “the constant warnings about coronavirus and incessant reminders to keep high levels of hygiene have created an obsessive-compulsive nature for doing things

Documentation of anxiety disorders linked with pandemic anxiety include phobias, health anxiety, and obsessive-compulsive disorder, plausibly connected by an underlying theme of intolerance for uncertainty.

 Pandemic phobia might, for example, center around an exaggerated fear of a public place, such as a mall, grocery store, or restaurant. Health anxiety, on the other hand, might be focused on the fear of receiving a positive COVID-19 test result, thus triggering fears of illness, hospitalization, incapacity, and potential long-term sequelae.

OCD, by contrast, is more elusive and multi-faceted. Its presentation can overlap with pandemic anxiety: both might lead to harboring intrusive fears of contamination and heightened de-contamination rituals. According to Pascale Moraille, MD, Medical Director of the Outpatient Psychiatry Division at Hoboken University Medical Center, “One difference between pandemic anxiety and OCD is that pandemic anxiety can be adaptive, leading the individual to safe behaviors during these stressful times. In contrast, an anxiety disorder like OCD can be exacerbated, often requiring many different treatment approaches.”

The impact of the pandemic on OCD, with an estimated United States lifetime prevalence of 1.8%, remains an open area of clinical investigation. Pandemic-related treatment barriers to OCD might include defining what is ordinary versus pathological fear; variability in presentation and severity of OCD itself; the recent adaptation of virtual technology for psychiatric care; and the tendency of those with profound OCD to avoid reaching out for professional counseling when confronted with severe stressors.

 This tendency to isolate may be a telltale distinguishing feature from pandemic anxiety, where the tendency is to maintain connection (

Respectfully, maybe it is time to hit the pause and reset button for a few theories underlying anxiety treatment. Starting with cognitive behavioral theory, should there not be qualifiers when interpreting the 10 classic cognitive distortions, especially in the context of global crises like COVID-19 or severe weather change?

 Rather than labeling the patient’s thinking patterns as distorted per se, why not counter belief systems with scientifically credible data? Likewise, given the paramount importance of hand hygiene, how wise is exposure and response prevention therapy (ERCP), an OCD behavioral therapy aimed at extinguishing compulsive rituals through in vivo exposure to the feared source of contamination? How many times per day do we all wash our hands to avoid microbial contamination? I confess I have recently lost count.

practices psychiatry in northern New Jersey. She is affiliated with Morristown Medical Center, Atlantic Health System.

Acknowledgments: Jon W. Green, Esq; Janina Kaldan, MLS, AHIP; Pascale Moraille, MD

1. Murphy K. Pandemic-proof your habits. 

https://www.nytimes.com/2020/11/28/sunday-review/pandemic-habits-routine-brain.html

2. Everett R. The COVID-19 outbreak. Shame, fear hurting NJ’s pandemic fight. 

https://www.nj.com/coronavirus/2020/12/why-shame-and-fear-are-hurting-njs-battle-against-cov 

3. Sulaimani MF, Bagadood NH. Implication of coronavirus pandemic on obsessive-compulsive-disorder symptoms. 

4. Wheaton MG, Messner GR, Marks JB. Intolerance of uncertainty as a factor linking obsessive-compulsive symptoms, health anxiety, and concerns about the spread of the novel coronavirus (COVID-19) in the United States. 

5. Aardema F. COVID-19, obsessive-compulsive disorder and invisible life forms that threaten the self. 

6. Burns DD. Feeling Good: The New Mood Therapy. The New American Library, Inc; 1981.

What are the differences between disorders like OCD and pandemic anxiety? 

Fresh Perspective on Pandemic Anxiety 

Many patients who are recovering from COVID-19 will experience long-term effects. Among these effects are chronic fatigue, brain fog, dizziness, and an increased heart rate. Some of these symptoms are caused by postural orthostatic tachycardia syndrome (POTS), a blood circulation disorder. In this Mental Health Minute, Tae Hwan Chung, MD, explains the symptoms of POTS, and the best treatment options.

 is assistant professor of Physical Medicine and Rehabilitation at Johns Hopkins Medicine. He has a second appointment with the department of Neurology.

Have you seen patients with post-COVID brain fog? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

How to recognize postural orthostatic tachycardia syndrome—and treat it. 

Coronavirus