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As this issue went to press, the Centers for Disease Control and Prevention reported that about 

 had received at least 1 dose of the COVID-19 vaccine. Despite new variants and continued behavioral challenges worldwide, the progress made in addressing the pandemic is enormous, reminding us that we can—and should—do better in other areas of medicine, health care, and societal issues.

. While the opioid epidemic raged through the country and caught the attention of doctors, lawmakers, and others, the methamphetamine epidemic lurked in the shadows. This problem received less consideration even though, as 

, discusses in the lead article, the 2 drugs are often used concurrently. Great strides have been made toward understanding and addressing the opioid epidemic; hopefully, in the future, we will report the same for methamphetamine.

Cynthia M. A. Geppert, MD, MA, MPH, MSBE, DPS, MSJ

, reflects on the progress of the COVID-19 vaccine distribution but asks, “What about us?” In her commentary, Geppert ponders parity and whether patients with serious mental illness and substance use disorders (as well as the psychiatrists caring for them) were properly prioritized in the receipt of the vaccines. In doing so, she renews the call for advocacy for patients with mental illness to improve care now and in the future.

 on sexual and gender minority youth, a population facing increased challenges and at risk of mental health issues. With thanks to Special Report Chair Jack Turban, MD, this collection of articles shines a light on a population for whom the health care system can do better. As Turban explains, psychiatrists are in a unique position to foster positive affirmations for youth, both as a part of clinical care and as educators in the community.

™ features clinical pieces with practical guidance for supporting the patients in your care. This month’s Research Update looks at the pharmacotherapies that are most effective for schizoaffective disorder. Meanwhile, 2 articles explore the impact of psychiatric illness on the whole patient and provide suggestions to protect their well-being. 

, explores lithium dosing in renal patients, and Lawson Wulsin, MD, and Juliana Zambrano, MD, discuss treatment dilemmas in patients with comorbid depression and coronary heart disease.

As we have learned from our tango with COVID-19, there is no challenge we cannot overcome when we work together to find and implement solutions. Our country and the field of psychiatry continue to face these and other difficult issues. Yet, with continued dedication on behalf of all of you, we are sure to realize more successes and positive outcomes in the days, months, and years to come! ❒

Chairman and Founder, MJH Life Sciences™

An introduction to the May issue of Psychiatric Times.

Tackling the Big Issues

“The current opioid crisis has been responsible for the largest increase in deaths associate with opioids that we have ever known,” said Nora D. Volkow, MD, at the 2021 Virtual American Psychiatric Association Annual Meeting.

Volkow, Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, discussed how the pandemic has exacerbated the opioid crisis in the session, “

Collision of the Opioid Crisis and the COVID-19 Pandemic.”

In March 2020 during the outset of the pandemic, the number of people reporting drug use rose significantly.

 The top 4 drugs were nonprescribed fentanyl, cocaine, heroin, and methamphetamine. Overdoses increased up to 42% per month during the pandemic.

 If an individual had SUD and were infected with SARS-CoV-2, the likelihood of dying increased, especially for black men.

As the amount of drug use increased, so did the problems. The pandemic presented a number of key challenges for individuals with substance use disorder (SUD), Volkow noted, including: stigma, isolation, and loss of work/homes. These challenges prevented individuals with SUD from getting proper care, or worsened their condition. Volkow gave an overview of these issues and their impacts.

“We know that people with opioid use disorder… are terribly stigmatized,” Volkow stated. “It’s very hard sometimes to convince people with an opioid use disorder to go to a hospital because they don’t like to be discriminated against or mistreated.”

Stigma and the belief they will not receive thoughtful care already kept some individuals with SUD from checking into a hospital; the pandemic worsened this likelihood. Both hospitals and prisons became hotbeds for the SARS-CoV-2 virus, places often with higher concentrations of individuals with SUD.

“In order to reverse an overdose, someone has to give them naloxone,” Volkow said. “But if you are isolated, and start shooting by yourself, the likelihood of getting naloxone is much less likely.”

According to Volkow, reports from the community suggest an increased number of overdose deaths in homes where the individual was alone.

“Economic challenges are some of the stress source that leads people to take more drugs to try to cope,” Volkow relayed.

Homelessness was also associated with an increased likelihood of contracting the SARS-CoV-2 virus, due to social distancing problems.

Volkow wants to increase research on topics like telemedicine and changes in the justice system, and how they can be furthered post-pandemic. Expanding access to treatment of comorbid conditions via telemedicine, and releasing nonviolent inmates with SUD, are just a few ideas she has.

Volkow posed the following question for the audience to ponder: “What is the structure we need to provide for these individuals to be successful in adjusting to their community and not be at risk for relapse?”

1. Millennium Health. Signals report COVID-19 special edition. July 8, 2020. 

https://www.millenniumhealth.com/news/signalsreportcovid/

2. Overdose Detection Mapping Application Program. 

3. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. 

According to Nora D. Volkow, MD, Director of the National Institute on Drug Abuse, drug use and overdose deaths have significantly increased since the outset of the pandemic. What made it worse?  

A Tale of Two Crises: Fighting the Overdose Problem During the Pandemic 

Most health care professionals are aware that medical care in this country varies a great deal based on the patients’ race and ethnicity. We only have to look at the current coronavirus disease 2019 (COVID-19) crisis, in which Black individuals have been 

 both in number of infections and deaths as a result of a myriad of psychosocial, genetic, and environmental factors.

On top of unequal access, some individuals hold discriminatory beliefs about pain experienced by individuals of different racial and ethnic groups. In 1892, S. Weir Mitchell, MD, the father of American neurology, wrote about the experience of pain in White people of Northern European ancestry in comparison with Black and Native American people. He stated, “In our process of being civilized, we have won, I suspect, intensified capacity to suffer. The savage does not feel pain as we do.”

This view of pain was often used to rationalize the mistreatment of enslaved and Native American people: when violence was inflicted on them, they did not suffer as White people did. Pre-Civil War, 19th century New Orleans physician Samuel A. Cartwright, MD, said he identified “dysaesthesia Aethiopis,” an inherited disorder specific to Black individuals that made them insensitive to pain.

These views were perpetuated solely based on racism, without any science to support them. However, we now know that genetics can play a significant role in disease. Different races and ethnicities can be more at risk for certain diseases, such as sickle cell disease among Black people and Tay-Sachs disease among people of Ashkenazi Jewish ancestry. Thus, there is still the question of whether pain is experienced differently by individuals from different backgrounds.

A complicating factor in this discussion is how the experience of pain is affected by culture. It is readily apparent that it is more acceptable in some cultures and societies, often based on race or ethnicity, to complain about pain. How much of this is due to actual differences in the pain experience versus cultural acceptability of reporting pain—nature versus nurture—remains unclear.

 the effects of race and ethnicity on the care individuals received for chronic pain.

 The review identified trends in the effects of race and ethnicity on the experience of pain and how it is treated. Among the multitude of previous studies, one can find many different results, ranging from race and ethnicity playing significant roles to playing virtually no role.

Some studies have reported that Black individuals and people who belong to certain ethnic minority groups have higher pain thresholds, while other studies have 

 Minority patients, especially those from groups in which there are relatively small numbers of represented physicians, may have their level of pain underestimated by their caregivers.

Several studies have examined affects of race or ethnicity on the prescribing of opioids for pain. The most common finding was that Black patients were less likely to be prescribed opioids than White patients; however, it is worth noting that 

 patients were less likely to receive opioids than non-Hispanic White or non-Hispanic Black patients.

 Furthermore, some studies found that Black patients who were prescribed opioids were monitored more closely for misuse than White patients.

In light of the prescription epidemic in this country, resulting in rising rates of misuse and overdoses, it could be argued that more restrictive prescribing and closer monitoring might be a positive thing. If so, Black patients might accidentally benefit from these prescribing patterns. However, there is no indication that physicians are more carefully looking out for their Black patients than for their White patients. Even if the result is positive, there is no apparent intent. Furthermore, research has shown that Black patients and non-White Hispanic patients may have a more difficult time than White patients filling opioid prescriptions, as pharmacies in their neighborhoods may carry 

Unfortunately, there has been a tendency to have limited participation of non-English speakers and immigrants in studies of 

, and this may have resulted in an unrepresentative sample. Considering that pain is a subjective complaint that must be self-reported, limited language skills could impair patients’ ability to convey the presence and severity of pain, all important factors in determining proper treatment protocols.

The extent to which race, socioeconomic status, and 

 contribute to the apparent discrepancies in the management of pain remains unclear. The issue of poor access to health care may extend beyond just the pain itself and may also affect the identification and treatment of underlying disorders that may be causing or exacerbating the pain. This includes mental health issues, most notably depressive and anxiety disorders, which can play important roles in the development and maintenance of 

It is not too surprising that so many factors may explain variances in pain among different racial and ethnic groups. We know that there are many elements involved in the development of pain, especially chronic pain, including genetic, cultural, psychological, and environmental influences. The importance of each factor can vary from individual to individual.

The authors of the current study noted that there are no easy answers to pain management discrepancies, especially between Black and White individuals in the United States. More research is needed to identify the reasons for these discrepancies and the best methods for addressing them. Physicians should be aware of biases, including unconscious ones, and the methods for assessing and managing pain, especially among patients who may belong to different racial and ethnic groups than they do. Viewing all patients as complex individuals whose pain may involve many factors is crucial.

is in private practice in Philadelphia, Pennsylvania.

2. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. In: Caplan AL, McCartney JJ, Sisti DA, eds. 

Health, Disease, and Illness: Concepts in Medicine

Racial and ethnic disparities in the treatment of chronic pain

4. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. 

5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. 

6. Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. 

Access to care for chronic pain: racial and ethnic differences

7. Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. 

Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting

8. Hollingshead NA, Vrany EA, Stewart JC, Hirsh AT. 

Differences in Mexican Americans’ prevalence of chronic pain and co-occurring analgesic medication and substance use relative to non-Hispanic white and black Americans: Results from NHANES 1999-2004

9. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. 

10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “

We don’t carry that”--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

Pain as a cultural construct considers conscious and unconscious biases, as well as methods for assessing and managing pain in all patient populations, including those with mental health challenges.

Race, Ethnicity, and Chronic Pain

One year ago, Amilcar Arnaldo Tirado, MD, MBA caught coronavirus disease-2019 (COVID-19). He was hospitalized and honestly feared for his life. “This is it,” he told himself. “This is how your story ends.”

. More recently, he wrote a follow-up reflection on his experience and what he has learned: “

In this Mental Health Minute, Dr Tirado discusses his latest article and elaborates on the personal, medical, and political dimensions of the pandemic.

is a forensic psychiatrist at Lincoln Medical Center in the Bronx, New York, and assistant clinical professor of psychiatry at Weill Cornell Medicine, New York, New York. The author reports no conflicts of interest concerning the subject matter of this article.

How has the pandemic affected your practice? 

Share comments with your colleagues by emailing 

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

A year after being hospitalized with COVID, a physician considers the pandemic’s larger meaning for American medicine—and for American society.   

Lessons From a Difficult Year

In 2018 more than 20 million Americans met criteria for substance use disorder, particularly alcohol abuse (73%). During the COVID-19 pandemic, alcohol sales have risen sharply, up 54% from the previous year.

In this Mental Health Minute, Judith J. Prochaska, PhD, MPH points out that the pandemic has made it difficult for patients to seek traditional forms of counseling. She discusses a digital therapeutic that can be an adjunct for traditional therapies, and 

 on the treatment’s efficacy for substance abuse and mood disorders.

 is a professor in the department of medicine at Stanford University with the Stanford Prevention Research Center and a member of the Stanford Cancer Institute.

Would you recommend a digital therapeutic to your patients? 

A recent study tested a new digital therapeutic for effectiveness on both substance abuse and depression. 

Could Artificial Intelligence Improve Cognitive Behavioral Therapy?

 (COVID-19) crisis continues, we hear more and more about the current—and projected—mental health fallout from illness, lockdown, job loss, forced relocation, loneliness, loss of friends and family, and death. Data about the direct neuropsychiatric sequelae of COVID-19 infection in addition to the indirect social or economic consequences are also mounting. Yet we do not hear about individuals with social anxiety disorder, or individuals on the high end of autism spectrum disorder (ASD), who are also socially anxious and relieved to be working from home.

Free from the social pressures of the job site, many of these individuals report feeling less distress overall. They are not necessarily free from anxiety altogether; their anxiety focuses on fears of being forced to return to offices when the epidemic ends. They are perturbed by the prospect of sacrificing the social obligation-free sanctuary that they have serendipitously and unexpectedly enjoyed during this strange time.

 taken of a group of workers; it found 80% wanted to continue to work remotely at least part of the time after the pandemic. Individuals with social anxiety disorder presumably comprise some small part of the 80%, yet it is unlikely that all 80% of the WSJ sample want to work remotely for the same reasons as the patients I am discussing. The article, “Is a Home Office Actually More Productive? Some Workers Think So,” detailed the motivations of generic employees, focusing on financial and family drivers of their choice of workplace, but does not break down data by personality type or DSM diagnosis.

Before commenting on experiences relayed to me by the aforementioned subgroup of my patients, let us first look at the better publicized psychiatric fallout from the COVID-19 crisis. Centers for Disease Control and Prevention (CDC) 

 from late June 2020 state that 40% of the American population were facing COVID-related depression, anxiety, stress-related disorders, or substance use.

high-risk groups, noting that financial stressors, including epidemic-related job loss, along with limited savings to cushion the blow, increased an individual’s risk for mental health sequelae.

 about increasing drug and alcohol use are equally grim from a medical and mental health point of view, given that liquor sales skyrocketed during lockdown, as per several articles in the WSJ.

 Anonymous liquor store owners have said that demands for their stock during the epidemic rivals sales seen only during weeks between Christmas and New Year’s.

We can estimate the long-term mental and medical impact of alcohol overuse, even though many medical consequences of alcohol overuse do not surface for 20 years. The potentially lethal cardiovascular, oncological, as well as gastrointestinal consequences are not as obvious or immediate as motor vehicle accident-related deaths or fatal subdural bleeds from slip-and-fall accidents that occur while intoxicated. Yet those later sequelae are just as deadly in the long run, so much so that 

 is twice that of the better-publicized opioid-related mortality,with alcohol claiming over 95,000 lives per year,

 compared with 46,800 annual opioid overdoses.

Opiate overdoses have already exploded. If we extrapolate from data related to September 11, 2001, when 

 in Manhattan remained high long after posttraumatic stress disorder symptoms subsided,

 we can anticipate (but not guarantee) similar consequences from this epidemic.

Alarmist claims about projected increases in suicide hit the press, having borrowed data from CDC websites and embellished it with artistic license not appropriate to scientific studies. Some of the most ominous predictions have been refuted; after reading the fine print, we can see that these highly publicized numbers about suicide pertain to individuals who were contemplating suicide rather than to completed suicides. In response to those data, some British medical journals 

 readers that “supposition, however, is no replacement for evidence,” and that “the literature on the effect of COVID-19 on suicide should be interpreted with caution.”

Although reports of increased suicidal ideation since the start of the COVID-19 crisis were striking enough to enter the CDC logs, we must recall that suicidal ideation is not the same as attempted suicide, and that attempted suicide is not identical to completed suicide.

In addition, a New York City Health Department 

 “Mental Health in New York City: Impact of COVID-19 on Mental Health in New York City,” published in September 2020 and emailed widely in January 2021, offered even more 

 It dissected the data, breaking it down by race and ethnicity, and ferreted even more risk factors for anxiety and depression. It focused on the greater New York area, where most of my patients reside. Similar to the 

data, the 3 top drivers of psychological distress included “feeling cut off or distant from people,” “job loss or reduced hours,” and “overwhelming or above-average financial stress.” Interestingly, many individuals on the spectrum specifically prefer to be “distant from people,” although individuals with pure social anxiety disorder often lament their limitations in partaking in such social activities.

What do these data tell us about the socially phobic individuals who report less stress during the lockdown, but experience more stress when contemplating the possibility of a return to onsite work? Let me point out that although the data showed that 40% of the American population endorsed symptoms of depression, anxiety, or trauma during the shelter-in-place mandates and work-from-home policies, this is not the same as saying that 100% of the population is suffering similarly.

My clinical experience indicates that some individuals are benefiting from limits on social interactions; they prefer the work-at-home policies and appreciate convenient excuses to avoid after-work get-togethers and sit-down holiday dinners.

Admittedly, I cannot offer elegant statistics to rival numbers garnered from formal population-based quantitative studies. All I can share are anecdotal reports gleaned from my large private psychiatric practice, originally based in New York City, but now relocated offsite to upstate New York. Yet those anecdotal reports are impressive. Gainfully employed but socially phobic patients and those on the high end of the autism spectrum (who also tend to be debilitated by social anxiety) are doing better than baseline now that they are freed from the pressures of office politics, enforced personal interactions, and water cooler–style conversations.

In many instances, such individuals experienced an unexpected sense of relief, as well as a sense of accomplishment, after seeing that they could meet their work responsibilities even better without expending extra mental energy ruminating about social interactions, wondering if they said the right thing, and worrying about being forced to speak up in meetings. Having witnessed how much easier their lives can be without the usual social stresses, they identify a different source of anxiety: fear of forced return to the workplace.

Before proceeding, I must point out that the patients to whom I refer are actively and gainfully employed—and so they do not fall into the high-risk categories identified by the 

article. They did not experience the stressors, such as job loss or lack of savings, that predispose individuals to COVID-19–related psychological distress. Because they were working before the pandemic, they likely accrued savings that further buffer them from the financial stressors listed in the 

Recall that socially phobic individuals are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations.

And that is where we as psychiatrists can help. Selective serotonin reuptake inhibitors (SSRIs) and supportive therapy go only so far in ameliorating their symptoms and relieving their distress. Advocating for changing their external environment—while we change their internal environment through psychotropic medications and psychotherapy—can offer them so much more relief.

 accommodations that may allow them to continue to work from home even after the epidemic ends (with some caveats). Familiarizing ourselves with the Department of Labor website (

) will enable us to educate our patients and to direct them to standardized sources without offering legal advice that exceeds our clinical training or purview.

At a time when so many psychiatrists are concerned with climate change and its impact on mental health, should we not also concern ourselves with adapting workplaces to meet the needs of our patients? We can advocate for change, simply by following the laws that are already in place for such purposes.

 is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

1. Stamm S. Is a home office actually more productive? Some workers think so. 

https://www.wsj.com/articles/is-a-home-office-actually-more-productive-some-workers-think-so-11609563632

2. Centers for Disease Control and Prevention. Coronavirus disease 2019. Accessed February 10, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/index.html

3. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. 

4. Chaudhuri S. Coronavirus closed the bars. America stocked the liquor cabinet. 

https://www.wsj.com/articles/coronavirus-closed-the-bars-america-stocked-the-liquor-cabinet-11586511001

5. Jakab S. The WHO are a bunch of party poopers. 

https://www.wsj.com/articles/the-who-are-a-bunch-of-party-poopers-11587046692

6. Chaudhuri S. Online beer sales soar at brewers of Budweiser, Miller Lite. 

https://www.wsj.com/articles/online-beer-sales-drinking-at-home-boosts-budweiser-brewer-11603968729

7. Centers for Disease Control and Prevention. Deaths from excessive alcohol use in the US. Accessed February 15, 2021. 

https://www.cdc.gov/ALCOHOL/FEATURES/EXCESSIVE-ALCOHOL-DEATHS.HTML

8. Centers for Disease Control and Prevention. Drug overdose deaths. Accessed February 15, 2021. 

https://www.cdc.gov/drugoverdose/data/statedeaths.html

9.Packer S. Tele-teatime during the quarantine. 

https://www.psychiatrictimes.com/view/tele-teatime-during-quarantine

Trends in suicide during the covid-19 pandemic

. 2020;371:m4352. doi:10.1136/bmj.m4352.

11. New York City. Mental health in New York City: Impact of COVID-19 on mental health in New York City. September 2020. 

https://www1.nyc.gov/assets/doh/downloads/pdf/covid/covid-19-mental-health-impacts-hop.pdf

Patients who are report social phobia are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations. That is where psychiatrists can help.





The Other Side of the COVID-19 Crisis: The Silent, Socially Phobic Minority 

When the pandemic hit in 2020, individuals disappeared into isolation. And so did I.

I got through by returning to my childhood of 60 years ago. Someone once told me that what makes us happy as adults is what made us happy at age 7. At that age, I loved my Lionel train, movies, making up stories, and plays.

I grew up in the North Carolina mountains. My father was a high school principal, World War II medic, basketball star, and a summer outdoor theater manager. When I was 9 years old, he dragged me to

, a play that dramatized the settlement of High County. He thought it would teach me business principles. During breaks from business lectures, I sneaked into summer stock theatre rehearsals. I was stunned by the truths declaimed in Tennessee Williams and Eugene O’Neill plays. Certainly not the truths I heard and saw at our family’s dinner table. Tennessee? Eugene? You guys hooked me.

One day I announced to my father, “I want to audition for a role in 

” Dad wanted to shield me, concerned I would be devastated if I lost competing against New York actors. After weeks of the air being sucked from me, Dad gave in. I landed a role. When I jogged to him and announced out of breath that I was cast, he said he looked at my face and knew I was lost to the business world forever.

Outdoor drama led to summer stock theater. Before long, I organized neighborhood children and my cousins to perform in plays that I wrote. My parents’ garage was our theatre and the garage door our curtain.

At age 9, I learned I was legally blind and required glasses. No wonder I could not catch Dad’s pitches. I could not even see the ball. Blindness was a good reason to spend afternoons in my grandfather’s movie theater, sitting in the front row. I could see people’s gigantic faces and expressions. Childhood blindness was a gift that led me to music, theater, writing, and eventually medicine.

Mom and Dad were not parents who read to their children. My teachers and librarians did. After I got home from school, I read to my little brother. Dad said I used to grab napkins, paper bags, anything I could write on, and sit at the end of the hall and write. He liked showing his basketball friends that if I was writing he could not distract me. Writing was necessary to me, like breathing.

All the while, I loved my chemistry set, math, and physics. (To this day I still read 

 cover to cover.) In fifth grade, I learned to play the clarinet and joined the marching and symphonic bands.

At the University of North Carolina at Chapel Hill, although I majored in chemistry and played in the symphony, I took theatre courses, acting and directing. I also took electives in creative writing, novel writing, short story writing, feature story writing, and playwriting. What skills the university could not fit into my schedule, I studied in art schools, from ballet, stage dance, choreography, stage and television light design, and editing to screenplay writing.

In medical school, I composed music and gathered classmates who also adored writing. We put on a full-blown musical: an allegory of Merlin the Magician apprenticing to become a Medicine Man in days of old. Students in our class joined in acting, singing, dancing, playing instruments in the pit orchestra, building sets, making costumes, running sound and lights. It was a smash hit.

During psychiatry residency, professors asked if I could combine show business with teaching. What a terrible idea, I thought. They dragged me into it. Using drama to teach landed me on the UNC-Chapel Hill psychiatry faculty. Following passions opens unexpected doors.

And so, in Chapel Hill; Morgantown, West Virginia; Australia; and New Zealand, I spent over 30 years teaching psychiatry while a half day a week I taught theatre. I recruited drama students to play patients for my medical student classes. One hundred-ten medical students gathered, eager to raise hands and each pose a single question to the patient—they often forgot “the patient” was an actor.

If medical students messed up, they got to do something they could not do on the wards: have second and third chances to rephrase questions. And those classes were favorite activities for my West Virginia University theatre students.

, friends, and theatre students portraying patients and used those videos to teach. That led to cofounding a company in San Diego where we produced over 400 videos of simulated patients using New York and Los Angeles actors. Those videos teach in classrooms across the country. Meanwhile, I continued writing plays for local community theatres, occasionally acting and directing.

Then in the blink of an eye, I got old. Amazing how fast that happens when you are having fun. I decided to narrow my focus. No more doctoring. No more acting or directing. No more producing plays or videos. Just write. Just breathe. Get better at it. Eight hours, 9 hours a day. Expose myself to others’ works. Learn.

 hours to become an expert. Working 8 hours a day, except for an annual 2-week vacation, means 3 and a half to 4 years to become an expert. I think—no, I know—it takes longer for writers.

Every day I improve. And thank gosh for collaborations. My multitalented friends and colleagues at the 

 are producing a video series on the history of psychiatry. During the pandemic, by using 

, we were able to continue producing videos.

During a decade of so-called retirement, I have had plays performed nationwide in universities, community theatres, and professional theatres. 

is the story of a young United States soldier with Afghanistan nightmares being treated by a military psychiatrist still suffering from traumas in Vietnam. Tons of conflicts in that therapy.

 garnered the Cleveland Critics Circle Theatre Award and moved onto Chicago and New York. It was made into a video by a theatre company in Carlisle, Pennsylvania. It was the first serious drama to be performed in an Alaskan indigenous village where during a performance, children crawled onto the set to examine props. At least they were well behaved.

Far more important than awards, audiences cry. Audience members hug and thank the cast. They say they feel understood. Talk about their own heartbreaks. Or their sons and daughters’ heartbreaks. Or fathers and mothers’ tribulations.

I write more—lots more. I breathe. My mind aches to fill blank pages. My characters act up while I am still lying in bed. They scream at me to vault out of bed, to scribble and then type. They surprise me. They enchant me. They teach me truths I do not even know I know.

Maybe they spring to life because I am old, old enough to have lived adventures with individuals from varied cultures. Australian Outback tribes, Persian Gulf mountain Bedouins, Kodiak Alutiiqs, New Zealand Maori, Appalachian rural folks—and of course: the college students, adolescents, adults, and elderly blessing my psychiatry office. Truth poured out from those people. I was a collection vessel. I tap into that fullness, shape bits of lives into plays, novels, stories, into daydreaming.

And what about memories of life journeys with family and friends? They are the glue that holds my center together.

Time flies. And what about this pandemic? It is becoming more fodder in my rearview mirror.

was an endowed chair of education psychiatry at West Virginia University. He is also a decorated playwright and founder and senior clinical consultant at Symptom Media.

Do you have a passion you would like to share with your colleagues? Please contact us at 

The pandemic has driven a psychiatrist into isolation, but his long history in the arts helps him reconnect. 

Calling on the Arts to Thrive During a Pandemic

Between mid-February and mid-March 2020, the number of sleep prescriptions in the United States rose by 14.8%. The increase may be due to the pandemic, says Manoj Malhotra, MD. Based on his experience, he says “the current environment, with myriads of shifts in our day-to-day lives, is a perfect storm for sleep challenges.”

In this Mental Health Minute, Malhotra explains how to distinguish between a general lack of sleep and chronic insomnia, and how to treat the latter.

 is vice president, United States medical affairs for the neurology business group at Eisai.

Have you seen more patients with sleep problems during the pandemic? 

Key considerations for healthcare providers seeking to manage their patients’ insomnia.  

The COVID-19 Pandemic Is a Perfect Storm for Sleep Challenges

In mid-March, as we reached the 1-year anniversary of COVID-19’s designation as a world pandemic, there were scores of media articles about what that year meant to our country and world, unsurprising given how unprecedented the year has been in our lifetimes. I meant to do one from the psychiatric perspective, but wanted to obtain the perspectives of both colleagues and the public.

I also thought these perspectives should be brief, given the potential numbers of them, and how that would dovetail with their popularity on social media. Therefore, in a mid-March video, I asked viewers for their preferred word or 2 to describe the year, or more if necessary, and repeated my request to those who I know follow my videos and articles.

Psychologically speaking, we know that when we name something, that in itself provides some comfort in knowing what we are dealing with. Some of that reaction depends on our personal history of responding to stress and trauma, and some to our current circumstances. Therefore, we each differ, and each of us can differ within ourselves over time.

, posted on St. Patrick’s Day, I provided my 2 single words and why I came up with them. First was BEWARE, which came to mind because March 15th is the Ides of March, the day when Julius Caesar ignored the warning of a seer, culminating in his assassination. Second came EGAD, because of its Oxford dictionary definition that combines anger, affirmation, and surprise, a mix-up of what I had seen over the year.

To both my surprise and not surprise, from adolescents to the elderly, I received many words, well over 50. One-word responses dominated, and they are reflected in Word Cloud #1. They seemed to break down into the following categories.

 One of the traditional activities in psychiatry is INTROSPECTION, both for the clinician and patients. That was mentioned 5 times. One goal is ENLIGHTENMENT, and that was mentioned 3 times.

 Many words conveyed positive psychology: COMPASSION, HOPEFUL, RESILIENCE, OPPORTUNITY, KINDNESS, and GRATEFUL twice.

 Though not necessarily a reflection of clinical concern, certain words we often encounter in psychiatry were chosen: LOSS or ALONENESS 5 times, along with SADNESS and DEPRESSION. Other negative words were: FATIGUE, STRUGGLING, DISCOURAGED, and UNAPPRECIATED.

 For me, hearing 2 clergy use x-rated words was a surprise, even if they seemed to be conveyed with a bit of tongue-in-cheek. The word SURREAL was unexpected, and I had to look up what INTERREGNUM meant.

 Perhaps reflective of mixed feelings were pairs of words that were opposites: YIN and YANG; FRIGHTENING and ENLIGHTENING; PARALYZING and CATALYZING; FEAR and NO FEAR: LOSS and GAIN; and CERTAINLY UNCERTAIN.

After reviewing that list, I thought of several words that I anticipated being there, but were not. ZOOM was one, given how common it is now. Perhaps it escaped mention precisely because it has become so routine. LOVE is another. Certainly, passionate love is more of a 4-letter word in psychiatry, given the ethical principle against that between a clinician and patient. But what about the increase of being home more with loved ones? Then there is the love of care and compassion, the kind of love I recommended for administrators when I received the Administrative Psychiatrist Award from the American Psychiatric Association in 2016. HELP was yet another, perhaps because it is not clear when and what kind of help is needed for normal reactions to an abnormal situation.

Given the promise of the vaccines, someone like myself might assume that more individuals would be optimistic about year 2 of COVID-19. Yet, the first week indicated how unrealistic that may be. Our country was hit with at least 4 major crises. One is the horror on our border with Mexico, the children who are alone with an uncertain future. The second one was predicted by many, but allowed to occur anyways, which was the spring break crowds in Florida, with some added mayhem. Then, after the COVID-19 year of markedly reduced mass murders, we had 2 in a single week: one near Atlanta where 8 were killed, 6 of them being Asian women; the other in Boulder, where 10, including a police officer racing to the scene to help, were killed in a grocery store where our basic need for food is fulfilled.

What meanings and values can be found from the past year, and what words will be found going forward? 

Coronavirus