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Tales From the Clinic: The Art of Psychiatry

, we visit the addiction clinic to discuss accidental overdose deaths. Although death by suicide is known to greatly impact psychiatrists, the impact of overdose deaths on physicians is not well studied. Despite the best efforts exerted in treatment, patients on medications for opioid use disorder may die of accidental overdoses on opioids, having misestimated their current opioid tolerance, or overdose on other substances such as sedatives/hypnotics and stimulants. This article is dedicated to 3 patients lost in this past year—AK, EG, and AW—with heartfelt wishes to their families.

“Ms Verona” was a 45-year-old female enrolled in an addictions treatment program and a mother of 7 children who struggled greatly with 

 and anxiety. She was motivated to stop her opioid use, as it was taking a toll on her health and her family. Ms Verona’s children would sense their mother’s lack of engagement with them, as she was constantly preoccupied with how to mitigate the inevitable opioid withdrawal symptoms. She was a good candidate for buprenorphine therapy, as she met criteria for severe opioid use disorder, and she preferred partial agonist therapy as opposed to naltrexone and methadone. Ms Verona was inducted onto buprenorphine, and her dose subsequently increased to 16 mg total daily in order to adequately address opioid cravings.

As treatment progressed, Ms Verona displayed a chronic tendency to arrive more than an hour late to appointments. Despite her tardiness, she would plead to still be seen, often citing traffic or lack of childcare arrangements. The psychiatrist, Dr Smith, would attempt to be flexible, given the understanding of treatment barriers stemming from social determinants of health, as well as recognizing the time-sensitive nature of 

 refills; however, these accommodations were placing Dr Smith and the treatment team under time constraints in a busy clinic. Such accommodation would either cause the psychiatrist to be late for other appointments, or it would lead to the appointment with Ms Verona feeling rushed. After the patient was accommodated for lateness over a few visits, Dr Smith became aware of his growing countertransference toward Ms Verona.

 (ADHD) may have been affecting her presentation. Ms Verona was noticeably circumstantial during sessions and required frequent redirection. She also described a childhood history with symptoms of difficulty concentrating. It was also explored whether her lateness was a manifestation of her inability to focus, organize, and prioritize. She often talked about having gotten Adderall “but not recently, doctor; I know you would not let me.” Dr Smith worked with Ms Verona in problem-solving therapy to help reduce treatment-interfering behaviors and promote punctuality. Ms Verona was also started on bupropion to target ongoing depressive symptoms and simultaneously provide a nonnarcotic option to treat attention-deficit symptoms. There was a concern for her using stimulants or other substances between appointments. Despite these treatment approaches, tardiness to her appointments continued and she appeared even sedated at times, despite negative urine drug screens.

One day, Ms Verona was more than an hour late. She was informed that she could not be seen and had to be rescheduled. She was visibly upset and opted, likely due to splitting defense mechanism, to reschedule to see a different provider in the clinic when this boundary was set. After this, Ms Verona ended up seeing a different psychiatrist for the next 6 months.

One day, Ms Verona’s former psychiatrist met with one of his active patients, Mr Kim, and the following dialog ensued:

Mr Kim: “One of my friends passed away, and I’m attending the funeral. I think you actually used to treat her before.”

Dr Smith: (Somewhat surprised) “I’m sorry to hear about the loss of your friend.”

Mr Kim: “Yea, it was sad… she (Ms Verona) said she used to see you. She was still on buprenorphine, but the suspicion was that she was taking alprazolam the whole time she was in treatment and did not tell anybody, and it is a suspected unintentional overdose. I used to see her all the time, and she would be nodding off. You didn’t hear about this?”

How Do Physicians Cope With Patient Suicide or Overdose?

Dealing with the loss of a patient due to suicide or 

 has a significant impact on the treating physician and is not often talked about. There are a variety of factors that determine how a psychiatrist will be impacted in such a situation. Younger clinicians and trainees are often affected more adversely, as they have not been exposed to the scenario and may feel more vulnerable in terms of their experience and knowledge base.

 According to literature, about 25% to 60% of psychiatrists will report having a patient who died by suicide during their career.

 The number of physicians who lose patients to overdose is not known. However, the rate of overdoses involving opioids jumped by 200% from 2000 to 2014, and between 2013 to 2019, the synthetic opioid-involved death rate increased 1040%.

 The sheer magnitude of these numbers suggest that most physicians dealing with addiction must have been exposed to patient death by overdose.

With these figures in mind, as well as the significant amount of perceived stigma and guilt surrounding disclosure of these outcomes, and with the fear of lawsuits that may occur in these situations, the overall emotional toll it can have on a clinician can be quite intense. The psychiatrist in this scenario was flooded with feelings of guilt related to potential responsibility for the outcome. In addition, there is a possibility of additional emotions of anger toward the patient who was already deceased. We hear team members often saying, “Oh, but they were doing so well,” or “So sad—they stayed off heroin but could not keep off meth.”

When one is processing the suicide of a patient, one should be mindful to not isolate oneself. Efforts should be conducted to reach out to colleagues, as it is likely they would have dealt with similar experiences in the past and can normalize and validate the experience. Discussion of experiences and coping mechanisms may have therapeutic effects for physicians going through such experiences. Clinicians, as part of an organization or group practice, can utilize case conferences—a pragmatic, systematic, and therapeutic approach to exploring the case outcome in more detail. Risk management reviews or meetings could help with apprehension about any impending or perceived lawsuits. This is especially important for clinicians in private practice, who may be more isolated given their work environment structure. The message we need to hear is that a patient loss does not undo or discard the multitude of meaningful life-changing and life-preserving work done with both living and deceased patients. Support and validation go a long way in reminding us why we do what we do.

How Can We Promote Honesty About Recurrence of Substance Use?

 (SUDs), it may be helpful to try to acknowledge and normalize the fear of disclosure of relapses, as well as to emphasize the importance of honesty in recovery from the very beginning of treatment. Although feelings of guilt and internal shame are common, they are not easy to talk about for patients. Whereas the patient may perceive recurrence of use as “starting from scratch,” the clinician can reframe a recurrence of use as a learning point and a way to troubleshoot the circumstances surrounding the use. Being too harsh or strict with the patient may backfire, lead to sustain-talk, erode the therapeutic alliance, and provoke even more feelings of guilt or shame. Relapses sometimes occur because being off substances uncovers a cooccurring mental illness, or because of stress in real life, to which patients with SUDs are more susceptible.

By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode. Thus, patients should not be terminated from treatment for recurrence of use as if often done—they should actually receive more intense care when in a greater time of need. Although recurrence of use might have clinical significance on modifying treatment plans, patients should be informed that using is only a setback if they do not seek further treatment to address it. Patients may be relieved if asked about any internalized and unfounded fear they may have about being terminated from treatment if they divulge recurrence of use.

If a patient states that they are feeling punished for having more frequent visits during recurrence of use, it may help to first empathize with concerns and then reframe the change in treatment plans as a goal toward well-being as opposed to punishment. Utilization of motivational interviewing may be helpful if the patient is still ambivalent about recovery. It is crucial for a provider to have a nonjudgmental approach toward relapses, both past and present. Subconscious criticism, even in the form of subtle body language, can promote denial or reliance on more primitive defense mechanisms in a patient and lead to poorer treatment outcomes, especially if the patient has a harsh superego or difficulty with trusting others.

Previous recurrence of use may lead some patients to think they are a lost cause and lack the willpower and discipline that might be needed for recovery. Internalizing this belief is characteristic of patients with complicated SUD histories. It is important to modify a patient's internal process and remind them that it is not solely willpower or motivation that determines the ability to improve, but also coping and relapse prevention skills, which can be taught through any type of therapy, but especially cognitive-behavioral therapy.

How Do You Find a Balance of Boundaries With the Patient?

Finding the right balance in setting boundaries can be a challenge in a busy schedule, and it requires being mindful of the patient’s perspective while simultaneously acknowledging a patient’s subconscious need for structure to meet treatment goals.

It was important in Ms Verona’s case to validate her struggle with circumstances in her life. After all, the social determinants of health (ie, social, behavioral, and environmental factors) are a predominant influence on treatment outcomes.

 In addition, it is important to acknowledge the role of untreated ADHD (like in Ms Verona’s case) in reducing recovery success.

 At the same time, the medical ethics concept of justice should also be considered. Although justice in this situation may apply to acknowledging Ms Verona’s barriers to care, it may also expose the caveats of this approach since other waiting patients were affected by the patient’s tardiness. A provider is tasked with collectively benefiting all of their patients, treating all with equity and making accommodations where necessary, and without putting 1 patient at risk at expense of another.

In this case, did the boundary-setting change the course of Ms Verona’s clinical treatment? Yes. Would it have been better without it? Not necessarily. Part of the treatment frame is for both physician and patient to be accessible, at a mutually convenient time. Reneging on appropriate boundaries may distort or enable certain expectations of the patient, which can undermine the patient’s perceived responsibility in treatment, reduce the patient’s ability to problem-solve, and lead to the approach that the physician drives the treatment, instead of the dyad making a shared and mutual responsibility. The physician can communicate these messages with empathy and genuine concern in the hopes that the patient will adopt that responsibility. In the case of mitigating overdoses—a poorly understood field—it is essential to know if the patient is using secondary substances outside the opioid being the target of treatment. Secondary substance use significantly increases risk of overdose.

From a larger perspective, a physician’s taking of the alternate approach can contribute to burnout and distress, and potentially adversely affecting outcomes for the other patients. Thus, boundaries can be a mechanism of protection for both the patient and the physician.

Triple Threat of Death: Suicide, Unintentional Overdoses, and COVID-19

Although there is growing literature about how patient 

 can impact physicians, there is a lack of data particularly on how substance overdose may impact a physician’s mental well-being. The lack of data on overdoses and how to cope with them is further compounded by the problem that busy schedules or shift work may inadvertently reduce the physician’s ability to access resources for support while the physician also thinks that “I must carry on.”

In addition, it would be important to differentiate how suicide and overdose are not necessarily the same. Overdoses are not always done with the intention of taking one’s life. In fact, most overdoses are accidental, but ultimately occur due to overestimated tolerance, unknown ingestion, or increasing amounts taken during stressful/inciting events. In 2014, only 12% of drug overdoses were intentional according to the Centers for Disease Control and Prevention (CDC).

 Although the percentage of intentional overdoses is the minority, another thing to consider is whether clinician perception of guilt is more intense if the overdose is intentional. A physician can be vulnerable to guilt for not effectively being able to treat a patient’s addiction or form a close enough relationship to know of their usage—even if the patient knowingly did not disclose use. Then there is the question of whether some severe addictive disorders could be considered like a “terminal illness,” where a clinician may feel that no matter how many treatment approaches have been tried, it is a matter of “not if, but when” in regards to either overdose or a chronic decompensation toward death.

Although we have seen that doctors who hear about their patients overdosing may actually reduce the amount of their opioid prescribing,

 mental health clinicians may be affected in a somewhat different capacity, as their role is also tied inevitably into also treating comorbid depression, anxiety, and suicidal ideation. The COVID-19 pandemic has further exacerbated this problem, as the estimated prevalence of suicidal ideation today is higher in comparison to the prevalence prepandemic.

If a clinician’s natural tendency to do more and become more hypervigilant following the loss of a patient, it is noteworthy to mention that most physicians suffer from burnout at one point in their life. A cross-sectional study was able to demonstrate that increases in suicidal ideation endorsement were significantly correlated with physician burnout rates.

 Considering that overdoses can be as lethal as suicides, it would be a fair but unproven assumption that it would also similarly contribute to physician burnout.

We believe further research is necessary to understand the many ways in which patient overdoses are affecting physicians, as well as developing more efficient strategies and support for dealing with the aftermath. 

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He is Director of Harris Health Substance Addiction Treatment Program and Associate Program Director for Baylor College of Medicine Addiction Fellowship Program. 

is currently a resident in psychiatry at Baylor College of Medicine. 

 is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the 

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My Patient Overdosed and Now I Feel Guilty… 

For the second year in a row, life expectancy in the United States has dropped.

 In 2020, the US experienced the largest drop life expectancy since World War II: 1.8 years.

 Now, life expectancy is yet another year lower, and declines in all individual 50 states. Declines differed significantly amongst race/ethnic groups.

Although COVID-19 obviously played a huge role in this decline, with states hardest impacted by COVID suffering larger declines, the picture is more complicated than that.

Robert Anderson, NCHS Mortality Statistics Chief, when asked about other leading causes of death that contributed to this decline, stated, “The main one is unintentional injuries, and this is mostly drug overdoses. There are some other causes that are grouped with unintentional injuries, including motor vehicle accidents and falls. But what really stands out in terms of sort of increasing mortality, and which is responsible for the decline in life expectancy, would be the drug overdose deaths. It’s second to COVID-19 in terms of its impact.”

Anderson noted that it is difficult to say whether individual overdose cases are related to pandemic stress; however, there was a flattening and even a slightly declining rate of drug overdose deaths prior to the pandemic. Now, in the wake of COVID-19, there is a steep increase in overdose deaths, with ‘unintentional injuries’ accounting for 15.9% of mortality increases. According to the NCHS data on drug overdose deaths, during the year-long period ending in March of 2022, over 109,000 overdose deaths occurred.

American Indians were amongst the race/ethnic groups most affected with a 1.9-year decline in life expectancy. “For the American Indian population, the decline was 6.6 years from 2019 to 2021. That’s just astounding,” said Anderson.

 “For the Hispanic population it was a 4.2-year decline; for the black population about a 4-year decline; for the white population 2.4 years; and for the Asian population 2.1 years.”

Read more about the overdose epidemic: “

The AMA’s 7 Recommendations for Reducing the Opioid Crisis

A Whirlwind Tour of OUD Treatment Strategies

The Opioid Epidemic Is Alive—And Unwell

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https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf

2. Life expectancy fell in 2021 for the second year in a row: interview with NCHS Mortality Statistics Chief Robert Anderson. Centers for Disease Control and Prevention. August 31, 2022. Accessed September 1, 2022. 

https://www.cdc.gov/nchs/pressroom/podcasts/2022/20220831/20220831.htm

3. Provisional Drug Overdose Death Counts. Centers for Disease Control and Prevention. Accessed September 1, 2022. 

https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

New data shows a decrease in life expectancy in the United States. Here’s why.

The Overdose Epidemic and the “Astounding” Life Expectancy Drop

COVID-19 has become a global pandemic affecting the lives of millions worldwide.

 Widespread outbreaks like COVID-19 have been found to be closely associated with symptoms of mental illness such as anxiousness, increased stress, feelings of hopelessness, and depressed mood.

In the elderly population, living under quarantine during previous disease outbreaks has led to increased incidences of depression, irritability, insomnia, and suicidal behavior.

 Adverse psychological sequelae of social isolation, which will be discussed in greater detail, have been shown to be correlated with female gender, toddler- and adolescent-aged children, higher-educational status, student status, and having symptoms resembling a COVID-19 infection.

 In elderly individuals, additional risk factors include having a negative perception of aging, health care-related occupations, abundant exposure to COVID-19-related information, knowing someone infected with COVID-19, and having a history of medical concerns.

Any given population under quarantine is more likely to experience heightened anxiety. Unwavering and occasionally sensationalized media coverage, sometimes perpetuating misinformation, may precipitate mass hysteria, stockpiling of supplies, xenophobia, and social unrest.

 Families unable to see loved ones in the hospital before their deaths are vulnerable to anger, resentment, and trauma.

 Rates of domestic violence have risen as more time is spent with those living in the same home.

Individuals who are predisposed to anxious tendencies may find that their anxiety manifests in the form of obsessive behaviors, such as increased temperature checks and more frequent sterilization.

 Patients previously treated for underlying psychiatric illness(es) may discontinue therapy and/or medications due to strict policies placed on health care access.

 In infected individuals, posttraumatic symptoms have been noted to develop during isolation, the severity of which correlated with the length of quarantine.

 It appears that virtually no demographic can escape the psychological pressure that quarantine imposes, resulting in various expressions of mental illness among the population as a whole.

In the setting of this public health crisis and subsequent mass psychological distress, society relies on health care professionals to support mental health. Abruptly increased patient volume can present new challenges for clinicians regarding their ability to meet these demands in a timely and effective manner. Because of the pandemic, telemedicine is being utilized more frequently to help provide better access to care.

 New technological advances have made it possible to provide a virtual platform for medical care that minimizes physical exposure.

To illustrate the challenges and opportunities for improvement in access to COVID-19-related mental health care, we present a case of a 58-year-old female who tested positive for COVID-19. Shortly thereafter, the patient developed symptoms of psychological and emotional distress, which necessitated mental health services.

History (Obtained During the Initial Psychiatry Assessment)

“Ms Harris” is a 58-year-old, single, Black-American woman with no significant psychiatric history. Ms Harris had been employed fulltime as a primary caregiver. She was referred to psychiatry for anxiety and concerns for possible depression. Ms Harris reported limited social support and no close relationships with family members.

Prior to her first appointment with psychiatry, the patient self-isolated at home for 3 weeks after testing positive for COVID-19. The patient agreed to a telephone visit, given the circumstances of an ongoing outbreak. During her initial psychiatric consult, Ms Harris endorsed feeling extremely “down and depressed,” noticing changes in her mood and behavior after learning of her positive test result. She said that she received no follow-up care from any health care provider since being in quarantine and isolation, and she described feeling as though she has been “abandoned and left alone.” Ms Harris speculated that “Maybe there is nothing they can do for me,” and disclosed severe feelings of anxiety regarding her health. Due to in-house quarantine measures, Ms Harris had not been working and was worried about being able to support herself financially. She stated that she had been living in fear, unsure if or when she would recover.

Ms Harris was diagnosed with adjustment disorder with anxiety and depression after a clinical psychiatric telephone interview. The patient was counseled regarding coping strategies and skills and provided with both online and telephone resources related to COVID-19. Ms Harris was scheduled for a follow-up telephone appointment with psychiatry 3 weeks after her initial consult, at which time she reported that her mood had improved and that she was less anxious about her health. Given her improvement, no medications were prescribed. Afterward, Ms Harris attended 2 subsequent appointments in which she demonstrated gradual improvement in her mental health. Ms Harris missed her fourth appointment and did not return the clinic’s calls thereafter.

In order to limit the spread of disease, quarantine and isolation procedures have been implemented during the COVID-19 pandemic. Quarantine was recently implemented during the 2003 SARS epidemic and the 2009 H1N1 epidemic.

 Studies of psychological symptoms during those periods found that being quarantined may be associated with a wide range of negative responses, including symptoms such as depressed mood, increased stress, irritability, insomnia, anger, fear, and emotional exhaustion.

 Other studies concerned with the long-term psychological sequelae of quarantine demonstrate that quarantined individuals may be at higher risk of posttraumatic stress disorder (PTSD) and depressive symptoms up to 3 years later.

 Literature on the current and prior quarantines have uncovered a plethora of risk factors for developing or exacerbating depression and anxiety, of which Ms Harris had several: female gender, advanced age, Black-American race, unemployment, recent health care occupation, single status, and lack of offspring.

Black Americans have been found to have higher rates of infections, unemployment, death, and anxiety related to the financial recession during the pandemic.19 Despite these experiences, in the same study, it was found that Black Americans had lower rates of anxiety and depression overall compared to non-Black Americans.

 Conversely, another study found that Black Americans experienced higher rates of anxiety and depression.

 Given the discrepancy between these 2 studies, it may be worthwhile to further investigate the psychological effect of the COVID-19 pandemic on Black Americans.

As previously discussed, health care workers are also at increased risk for adverse psychological outcomes during and after quarantine. Health care staff forced to isolate themselves at home may experience feelings of worthlessness.

 As a result of unrelenting exposure to acutely ill patients, those who continue as clinicians may experience apathy and withdrawal.

Relationship status is another notable demographic. Isolation for married couples can lead to increased anxiety due to a perceived imbalance in support, while nonmarried couples may struggle with increased jealousy.

 Moreover, single individuals have been shown to experience feelings of loneliness and depression.

Given the inordinate list of stressors that a population faces under quarantine, it is imperative that measures are taken to mitigate adverse mental health outcomes. Firstly, sleep difficulties are associated with suicidal behavior, so anyone with such a history should be evaluated for suicidal ideation.

 Furthermore, engagement in group activities and psychological interventions aimed at addressing maladaptive thought processes related to loneliness have demonstrated efficacy.

 In addition, elderly individuals may ameliorate the burden of the pandemic by strengthening social connections via virtual means (eg, group chat rooms, video chats), practicing good sleep hygiene, and engaging in cognitive stimulation.

An additional hurdle that individuals face during a pandemic is seeing a health care clinician in person, which causes many patients to participate in telemedicine. Telemedicine provided access to mental health services for Ms Harris while she quarantined and involved a phone interview with 2-way, real-time communication via audio only.

However, other telemedicine modalities are now being implemented as well. We are accustomed to some of these mediums (eg, electronic medical records, mobile phones, email, SMS text messaging, videoconferencing), while others have not yet been as widely incorporated (eg, patient portals, smartphone applications, social media). Clinicians seeking to utilize these modalities must be deliberate in determining the clinical function they serve while assessing the clinical impact that the modality may have on a particular patient.

The primary consideration should be that disinhibition between the patient and clinician can occur using any of these virtual platforms, the degree of which varies with the modality.

 As Jay Shore, MD, MPH, outlines in his evaluation of digital health care, virtual disinhibition may actually lead to the patient being more genuine about their experiences, although the modality itself may lead to more miscommunication.

Other constraints must be considered as well. Without video, clinicians are limited in their ability to observe nonverbal cues and perform physical exams.

 A sense of mutual connectedness and understanding between the patient and clinician may also be limited, as well as between physicians and their team.

 Studies have shown that phone-centered (as opposed to video-centered) telemedicine further decreases the ability to maintain positive therapeutic relationships, as facial expressions are perceived to facilitate communication.

 Even with video accessibility, it is a challenge to assess suicide risk, interpret body language, and provide appropriate therapy.

Some studies show that, with telemedicine, patients expect more frequent consultations, while others become less engaged.

 Patients often do not answer the phone when called, or they may conduct visits while they are at the grocery store, driving, at work, or otherwise distracted, which might greatly alter a psychiatric interview. During interactions, misunderstandings may arise from the use of abbreviations and emojis, or the possibility of a household member eavesdropping and/or otherwise influencing the patient’s report. The clinician should compensate for miscommunication by regularly asking if the patient’s message is being understood correctly. Ms Harris did not return for additional follow-ups after only a few telemedicine appointments, underscoring one of the major pitfalls of telemedicine: difficulty in building a therapeutic alliance

The preferred medium for telemedicine can vary according to the age of the patient and/or clinician. In a recent study, 75% of adults over 18 years old used phone-to-phone communication while individuals under 18 used video conferencing 50% of the time.

 Reductions in treatment success can occur when patients and/or clinicians use a telehealth format that they are not skilled with. However, in their study, Landes et al concluded that 48% of telemedicine challenges reported by clinicians were resolved over time after the clinicians became accustomed to the system.

 Early education on how to incorporate telemedicine into patient care could mitigate these challenges before they arise.

Although we are headed in the right direction in adapting to these difficult times, there are still concerns to be addressed and further investigated. Continued research should be conducted on the disparities in mental health, specifically related to the use of telemedicine, which relies heavily on digital devices and electronic tools. The best strategy to mitigate risks associated with digital care might be to have a combination of face-to-face appointments interspersed with telemedicine visits. In their study, Tse et al determined that 83% of patients would prefer a mix of the 2 services.

One possibility could be to mandate initial consultations as face-to-face, while additional follow-up visits could be performed either virtually or in person. Alternatively, physicians could implement a system in which a patient must have a certain number of in-person visits each year. Further research needs to be performed to assess which strategies would work best for patients. Discussion of the telehealth channel should occur with the patient prior to its use and continue after as the clinician and patient adapt to its impact.

The psychological consequences of living through a pandemic and being in quarantine are significant and should promote a sense of urgency to find ways to support the expansion of access to mental health care. Striving for improvement in the population’s access to care will not only help during this crisis, but also cause permanent changes in future health care delivery. As we continue to make innovative advancements in medicine, physicians must strive to be informed regarding the strengths and limitations of current practices and take into consideration the population being served to provide the best patient care.

 is a clinical assistant professor in the Department of Psychiatry at the University of Illinois College of Medicine in Chicago, Illinois. 

 is a member of the psychiatry residency faculty at Advocate Lutheran General Hospital in Park Ridge, Illinois. 

 is a fourth-year medical student at Rosalind Franklin University of Medicine and Science in North Chicago, Illinois.

Note: The views expressed in this paper are those of the authors and do not necessarily represent the official position or policy of institutions represented by the authors.

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Telepsychiatry in the Setting of COVID-19 and Beyond

In his presentation, “Psychiatric Complications of COVID-19” at the 

2022 Annual Psychiatric Times™ World CME Conference

 in San Diego, John J. Miller, MD, explored the broad range of psychiatric and neuropsychiatric effects of COVID-19.

“We’ve all seen it and we’re still dealing with them,” said Miller. “The mental health crisis is not only for people with the infection itself, but care for their parents, their families, and us as clinicians.”

According to research, the most common psychiatric symptoms include depression, anxiety, insomnia, posttraumatic stress disorder (PTSD), fear, grief, phobias, social avoidance/isolation, increased substance abuse, suicidal ideation, psychosis, and obsessive-compulsive behaviors.

 One systematic review and meta-analysis of long term physical and mental sequelae found at least 1 sequelae symptom occurred in 50.1% of COVID-19 survivors for up to 12 months after infection. Some of the symptoms included cognitive deficits (19.7%), depression (18.3%), and PTSD (17.9%).

“We know that any type of stress will only bring out underlying genetic and biological and epigenetic vulnerabilities,” Miller said.

As to neuropsychiatric symptoms, some of the most common are delirium (50% of COVID-19 ICU patients), confusion, fatigue, memory impairment, encephalopathy, seizures, cerebral vascular accidents, and more.

“The bottom line is every person is going to have a different trajectory in terms of how their immune system, how their body, the probabilities of their genetics, other psychosocial circumstances, how their comorbidities will impact their journey through the virus.”

What are the long term psychiatric and neuropsychiatric complications of COVID-19? 

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