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During the past year, the COVID-19 pandemic has exacerbated the already severe substance abuse and mental health crises in the United States. Isolation and economic hardship have triggered spikes in depression, posttraumatic stress disorder, anxiety, and abuse of substances.

This unprecedented confluence of events, along with a welcome decrease in mental health stigma, has fueled a surge in demand for behavioral health services. According to a survey by the National Council for Behavioral Health (NCBH), 

of community behavioral health organizations reported greater demand for services through August 2020, while half of organizations offering substance use disorder (SUD) services saw demand jump last summer.

Unfortunately, many of these organizations are poorly positioned to meet this increased need for treatment services due to financial struggles. Nearly 65% of them have had to cancel programs, reschedule services, or turn away patients due to lack of revenue or pandemic-related restrictions. For some, the situation is dire: Nearly 40% of these organizations reported they may not last 6 months, given their revenue shortfalls.

On top of patient demand and financial struggles, the disjointed and siloed crisis management infrastructure makes it difficult for individuals in crisis to receive the care and resources they need. Lacking access to appropriate behavioral health care, many in crisis turn to emergency departments (EDs). An analysis 

 in February 2021 of nearly 190 million ED visits revealed that “visit rates for mental health conditions, suicide attempts, all drug and opioid overdoses, intimate partner violence, and child abuse and neglect were higher in mid-March through October 2020, during the COVID-19 pandemic, compared with the same period in 2019.”

Even before the pandemic put an immense strain on the behavioral health care system, the 

Substance Abuse and Mental Health Services Administration

 (SAMHSA) was pushing for the standardization of crisis management across the US for any behavioral health condition.

SAMHSA’s goal is to standardize care quality and care delivery processes based on the best evidence-based practices. In other words, we know what works and how to keep individuals out of the medical care and criminal justice systems. We now need to implement the right processes broadly. A key part of the infrastructure is a new number for the National Suicide Prevention Lifeline (NSPL), which is run by SAMHSA. A bill signed into law late last year designates the 

 as the new, easy-to-remember phone number for anyone in crisis trying to reach the NSPL.

The 911 line currently is used for all emergencies, including mental health and substance use emergencies. But behavioral health crisis calls that result in the involvement of law enforcement sometimes result in tragic and traumatizing outcomes. In contrast, calls to the 988 mental health crisis number will be handled by trained NSPL counselors, who can in turn dispatch trained clinicians to a caller’s location. This behavioral health hotline number is expected to go live in July 2022.

Providing a hard-to-forget number will not make much of a difference, however, if we are not able to standardize the quality of crisis care across the US. Currently, there are about 

 that a caller could be patched through to, depending on area code.

 Those crisis lines offer varying degrees of services. Some are staffed by volunteers and non-clinicians who may lack experience and training, while others are staffed by veteran clinicians. Some can quickly connect callers to definitive assessment, treatment, and mobile crisis services. Others do not have these capabilities. 

To address this challenge, in February 2020, SAMHSA released its 

National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit

 Aimed at behavioral health authorities, agency administrators, service providers, and state and local leaders, this document defines national guidelines for crisis care. It also offers tips for implementing care that are in alignment with national guidelines as well as tools to evaluate whether systems are aligned to those guidelines.

The guidelines published by SAMHSA lay out a vision for a 

 integrated crisis system in which, based on the caller’s needs, the appropriate type of care can be quickly identified and provided. Nobody is turned away. Elements of this system include a regional, clinically staffed crisis call center that provides multichannel intervention capabilities and quality coordination of crisis care in real time, a mobile crisis team that can reach any person in the service area, and short-term (23 hours) crisis facilities for receiving and stabilizing patients in a nonhospital environment.

SAMHSA is encouraging all states to set up this standard clinical infrastructure. The states will need the technology to coordinate clinical activity and provide situational awareness—this is where care behavioral-health-specific coordination tools come in. An example of such a tool includes a cloud-based software platform with real-time availability of inpatient and outpatient treatment services, connections to treatment and social support services, and evidence-based assessment tools. It is important to identify a solution that helps clinicians close the loop on their patients’ care.

These goals and guidelines for behavioral crisis management are welcome news. Yet some would argue that instead of spending time and money 

 is not synonymous with prevention, but the goal of an end-to-end crisis system is to divert individuals from the inpatient beds and prisons, where they rarely get definitive behavioral healthcare. In addition, crisis systems provide preventative care: some of the data regarding crisis center calls shows that only 10% end up with a mobile team being dispatched to someone’s home. Of those calls, 80% are stabilized and do not require transfer to an inpatient care setting. Finally, of those who are transferred to a 23-hour crisis stabilization center, I estimate 75% are discharged home.

A very high percentage of the calls are being deescalated right on the line. But what then? With the right clinical and technology infrastructures in place, behavioral health crisis centers can refer callers to appropriate definitive assessment and treatment. In doing so, they can play a role in preventing callers from suffering a worsening of their current clinical condition, recurrence of this, or involvement with the medical care system and law enforcement.

To act in a preventative capacity, behavioral health organizations need technology infrastructure capabilities (

). States have been awarded planning grants to set up the clinical and technology infrastructures for behavioral health management. But how do we ensure the states are effectively implementing their technologies and clinical workflows?

Creating a set of standard quality measures is a logical step. For example, the standard length of time it takes from call to mobile crisis team disposition could be set to a time interval, based on geography. If a team cannot meet that benchmark, there should be consequences. After all, taxpayers are giving states a lot of money to set up these systems. We need to know they are working. There is simply too much at stake.

is Chief Medical Officer for Appriss Health, co-founder of OpenBeds, and an emergency medicine and critical care physician.

1. The National Council for Behavioral Health. COVID-19 continuing to impact behavioral health organizations in need of relief. Accessed June 29, 2021. 

https://www.thenationalcouncil.org/wp-content/uploads/2020/09/200903_NCBH_SCR.png

2. Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. 

3. Substance Abuse and Mental Health Services Administration. National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit. February 2020. Accessed June 29, 2021. 

https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf

4. Everett A. Groundbreaking developments in suicide prevention and mental health crisis service provision. Substance Abuse and Mental Health Services Administration. May 14, 2021. Accessed June 29, 2021. 

https://blog.samhsa.gov/2021/05/14/groundbreaking-developments-suicide-prevention

5. National Suicide Prevention Lifeline. Our network. Accessed June 29, 2021. 

https://suicidepreventionlifeline.org/our-network/

Yes, we need better crisis management, but what we really need is better crisis prevention.

The Need for Better Crisis Prevention

The initial wave of COVID-19 flooded New York City hospitals with patients who urgently needed medical attention. Despite the potential dangers, psychiatrists and other physicians rushed to their aid. There were examples of inspiring teamwork and mutual support everywhere. At the same time, many physicians found themselves in new and unfamiliar roles, sometimes without the necessary mental health resources to cope with what they were seeing and doing.

, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, talk to 

, about their experiences in the early days of the pandemic.

Many physicians have undergone traumatic experiences during the COVID-19 pandemic. If you or anyone you know needs mental health resources, consider contacting the 

’s national hotline (800-662-HELP) or the 

is an anesthesiology Critical Care Medicine Fellow at University of California, Los Angeles Health

is a PGY 3 resident and co-chair of the Psychiatry Residents Diversity Alliance at Columbia University Medical Center.

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan.

is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of

Conquering Lyme Disease: Science Bridges the Great Divide

and has interests in medical education, psychotherapy, and medical humanities.

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry

In the early days of the COVID-19 pandemic, physicians were thrust into unfamiliar roles, where they sometimes had to make life and death decisions. Here are a few of their stories. 

Teamwork and Trauma: a Conversation With Kasey Grewe, MD, and Niesha Voigt, MD

Tony Thrasher, DO, DFAPA, provides a set of questions to include in your discussion with patients:

1. Do you have access to firearms? Risk assessment 

 go beyond this question, as access can be a varied term.

2. Why do you own them? This must be asked without judgment.

3. How do you store them? This is a good time to discuss locks, separate storage, and other important safety options.

4. Lastly, do you understnad the suicide risk firearms pose? 

is the president of the American Association for Emergency Psychiatry (AAEP) and the medical director of crisis services in Milwaukee county, Wisconsin.

These 4 questions can help in your discussion about firearm risk mitigation...

How to Talk to Patients About Firearms 

There is universal confusion around excited delirium syndrome (ExDS): What is it and how should it be treated? The short answer is we do not know the answers, and there are no comprehensive treatment guidelines or formal criteria, according to a panel presenting at the 2021 

American Psychiatric Association (APA) Annual Meeting

Representing the fields ofemergency medicine, psychiatry, psychology, and emergency medical service (EMS), the expert panel consisted of Leslie Zun, MD, MBA; Thom Dunn, PhD; Julie Owen, MD, MBA; and Sarah E. Slocum, MD.

Events in the recent past bring to light the importance of clarifying the differential diagnosis, signs and symptoms, and universal treatment protocols of ExDS, which to date remain unclear.

 dying at the hands of a police officer. In 2019, Elijah McClain, a 23-year-old massage therapist, was placed in a chokehold by law enforcement and sedated by EMS with 500 mg of ketamine, a tactic that is legal in Colorado to control ExDS. By the time he arrived at the hospital, he was brain dead; he died 3 days later.

, but one thing is clear. These and countless other incidents in the public eye have brought to the forefront use of force by police and in emergency settings.

Dunn, a psychologist who is also experienced in EMS, shared a stark example of excited delirium in a hospital setting where an adult male Black patient demonstrated signs of the condition. The presence of police seemed to intensify the patient’s agitation: He sweat profusely, stripped naked, shouted incomprehensibly, and flailed his arms. After multiple attempts to restrain him; police tased him. Emergency staff then administered ketamine; he subsequently died.

 on the matter, stating: “DSM-5 recognizes Delirium, hyperactive type, but the symptoms of this condition differ in many ways from the symptoms typically attributed to excited delirium (eg, superhuman strength, impervious to pain, etc.).”

They further noted that ExDS itself “is too non-specific to meaningfully describe and convey information about a person.” They concluded that 

 should not be used until a clear set of diagnostic criteria are validated.”

The panel concurred: The American Medical Association, the APA, the National Association of Medical Examiners, and the 

s still diverge in their recognition of ExDS.

With all this confusion, the panelist concluded with Slocum’s call for action: “We really need to address this condition as a group and figure out what’s going to be best for that patient.”

1. Council on Psychiatry and the Law. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. American Psychiatric Association. December 2020. Accessed May 13, 2021. 

https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf

2. ACEP Excited Delirium Task Force: White Paper Report on Excited Delirium Syndrome. American College of Emergency Physicians. September 10, 2009. Accessed May 13, 2021. 

https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/ems-and-disaster-preparedness/ems-resources/acep-excited-delirium-white-paper-final-form.pdf

What is excited delirium syndrome and how should it be treated? The short answer is we do not know.

Agree to Disagree: Excited Delirium Syndrome as Volatile as the Term Itself

Psychiatry may be lagging behind other branches of medicine in an important way.

“In the rest of medicine, as you increase the acuity you increase the number of treatments,” Nolan Williams, MD, told the attendees of the 2021 American Psychiatric Association (APA) Annual Meeting, but in psychiatry, “as we increase acuity we actually lose treatment options.”

Williams and his fellow presenters at a panel on rapidly acting medications

 all had the same question: How can psychiatrists design treatments to respond to sudden-onset conditions?

Williams, assistant professor of psychiatry and behavioral sciences at Stanford University Medical Center, described the situation as “emergency room purgatory.” Because of slow-acting treatments and limited hospital capacity, “the whole process of going through the inpatient unit can take several months,” he said. “The only treatment that we have available for these folks is ECT [electroconvulsive therapy.” But ECT is available in only 10% of US hospitals.

However, psychiatrists might have other options for fast-acting treatments. He shared 

showing that accelerated theta burst repetitive transcranial magnetic stimulation (r-TMS) had positive results for mood disorders, including MDD.

 R-TMS treatment works by stimulating the left dorsolateral prefrontal cortex (DLPFC). In MDD, the DLPFC may be failing to inhibit the subgenual cingulate, and the result of this network failure is cognitive impairment and inwardly directed negative thoughts,” Nolan explained. “By stimulating DLPFC, r-TMS corrects the mood imbalance and restores mood regulation.”

In initial numbers from his study of patients with a treatment-resistant mood disorder (TRD), Nolan found that after 5 days of sessions (10 hourly sessions at 1800 theta-burst pulses per hour), participants improved. On the Montgomery Asberg Depression Rating Scale (MADRS), he found an 80% average reduction of participants MADRS scores.

Another options for fast-acting treatment is ketamine. Charles DeBattista, MD, professor of psychiatry and behavioral sciences at Stanford University, presented evidence for its efficacy for TRD. He noted that ketamine is an anesthetic agent, a μ-opioid agonist, and while its effects on TRD are rapid, making it potentially helpful in psychiatric emergencies. “Often within a couple of hours to a day, patients experience a significant improvement, and the effects were sustained for a week or so,” he said. These effects did decrease after a week, but there is also evidence that repeated injections may lead to 

DeBattista also presented the option of esketamine, which has been fast tracked by the US Food and Drug Administration for treating TRD and acute suicidality in MDD. Multiple studies have found that it rapidly 

New mothers represent another population that might benefit from fast-acting medications. “Maternal mental health is something that’s been an enormous problem forever,” said Samantha Meltzer-Brody, MD, MPH. “Those of us that have the privilege of working with perinatal women are always struck by how debilitating PPD [postpartum depression] can be.” Rapidly acting medications could reduce mortality and morbidity, she said, and allow for more positive interactions between mothers and their newborns.

Although many selective serotonin reuptake inhibitors are approved to treat PPD, she pointed out that their initial effects may not be felt for weeks or even months, and many women’s symptoms do not respond to them. Meltzer-Brody, the Assad Meymandi Distinguished Professor and Chair in the University of North Carolina Department of Psychiatry, also considers an alternative to these medications: neurosteroids like brexanolone.

In a 2018 paper, Meltzer-Brody and her coauthors found brexanolone to be effective for

 Using the HDRS for measurement, the researchers found an average 8- to 10-point reduction in 12 hours, and around an 18-point reduction at 60 hours, the study’s primary endpoint. At day 30, participants average reduction remained, on average, 16 points down from baseline. The paper hypothesized that brexanolone works by increasing γ-aminobutyric acid (GABA) function, which appears to be inhibited during PPD.

With these new options, it seems psychiatry may not lag behind other branches of medicine for long. 

1. Williams N. Developing rapidly acting antidepressants: neurosteroids, dissociative agents (Ketamine Analogues and Psilocybin), and Accelerated Theta Burst r-TMS. Paper presented at: American Psychiatric Association Annual Meeting; May 1-3, 2021; virtual.

2. Nettekoven C, Volz LJ, Kutscha M, et al. Dose-dependent effects of theta burst rTMS on cortical excitability and resting-state connectivity of the human motor system. 

3. Li CT, Chen MH, Juan CH, et al. Efficacy of prefrontal theta-burst stimulation in refractory depression: a randomized sham-controlled study. 

4. Yip AG, George MS, Tendler A, et al. 61% of unmedicated treatment resistant depression patients who did not respond to acute TMS treatment responded after four weeks of twice weekly deep TMS in the Brainsway pivotal trial. 

5. Murrough JW, Perez AM, Pillemer S, et al. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. 

6. Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. 

7. Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). 

8. Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. 

What treatments could handle both psychiatric emergencies and long-standings mental health conditions—in a hurry?  

Fast-Acting Options for Mood Disorders and Psychiatric Emergencies

“There simply aren’t enough of us,” said Lori Raney, MD, in a scientific session, titled “

Unprecedented Access to Psychiatry: Expand Your Impact to Infinity and Beyond! Collaborative Care, eConsults, and ECHO Models

. The session addressed the vast shortage of psychiatrists and proposed alternative models of care to improve outcomes for more patients.

Speakers discussed the ever-widening gap between the shortage of psychiatrists and the overflowing flood of patients needing care. Shannon Kinnan, MD, a member of the APA Integrated Care Committee, spoke about the gravity of the problem of access to psychiatry. “The severity and the incidence of psychiatric illness continues to climb, which has only been magnified by the pandemic,” said Kinnan, assistant professor at Creighton University School of Medicine, Omaha, Nebraska. She worked in psychiatric services that had a wait list of 350 patients.

Moderated by Ron M. Winchel, MD, assistant clinical professor at Columbia University School of Medicine, Department of Psychiatry, presentations centered around 4 main themes: collaborative/integrated care, psychiatric consults, ECHO models, and eConsults.

Collaborative care, also known as integrated care, is ever evolving, informed by decades of research conducted by the APA, Academy of Psychosomatic Medicine, and other organizations. Kinnan directed participants to APA’s 

 to explore current evidence-base for the model, elements of implementation with detailed examples, lessons learned by those in the trenches, as well as recommendations on how to advance the use of the collaborative care model.

According to Kinnan, the collaborative care model is made up of a patient-centered team that targets the special needs of each patient, looks for solutions, and lays out piece by piece ways to educate primary care physicians (PCP). One core feature of the collaborative model includes encouraging PCPs to use measurement-based care with tools such as Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7).

“The patient’s main points of contact are their PCP and a care manager,” she explained. “The psychiatric consultant then reviews cases in a registry with a care manager and offer guidance to the team on the case.”

The integrated psychiatry model attends to the needs of patients with team-based care and systematic regular caseload reviews, which involves psychiatrists, case managers, PCPs, social workers, and other health care providers. It enables delivery of services to patients at most dire need of psychiatric services.

“It is better than traditional care in the primary care setting,” Kinnan told attendees. “Patients get better, faster. And there’s cost savings as well.”

A consult enables those involved in behavioral health to manage multiple cases and communicate with different allied health professionals, with the goal of extending psychiatric services.

According to Lori Raney, MD, a practicing psychiatrist in Colorado and principal consultant with Health Management Associates, curbside consultation educates PCPs about diagnostic dilemmas and medications, helping them with complex patients.

A consult is an opportunity for psychiatrists to educate and collaborate with the general practitioner, especially important since medical training often involves only 2 weeks of psychiatric training. The consult enables the PCP to understand specific needs of patients and provides diagnostic clarification.

“There are definite approaches you can take,” Raney told attendees. “You want to build the PCP’s confidence in prescribing psychotropic medications and diagnosing behavioral health conditions.”

Psychiatrists can get calls for consults on a variety of issues, Raney explained. “The most prevalent, most common behavioral health conditions we are getting called about often involve anxiety disorders, depression, and substance use disorders . . . And then you’ll see other things, patients with multiple somatic symptom personality disorder traits and pain that play out in the clinic,” said Raney.

Another item on the menu of integrated behavioral health is the electronic mental health consultation (eConsult).

Christopher T. Benetez, MD, associate medical director of the Los Angeles County Department of Mental Health and assistant clinical professor at UCLA David Geffen School of Medicine, has conducted more than 5000 eConsults in the LA County project over the past 5 years.

“An eConsult is an asynchronous consultative, provider-to-provider communication within a shared electronic health record [EHR] or web-based program,” Benetez explained.

The eConsult approach enables PCPs to have remote access to psychiatrists, entering questions into an EHR for quicker response than the bottleneck often found in traditional models of care.

As the second largest health system, LA County occupies more than 4000 square miles with 10.5 million residents, and it is both rural and urban. Psychiatrists are also involved in an array of community partnerships, jails, and courts.

The eConsult in LA County and other community health hubs are intended for the Safety Net population, defined by the Institute of Medicine (IOM) as “those providers that organize and deliver a significant level of health care and other needed services to uninsured, Medicaid and other vulnerable patients.”1

The eConsult system has optimized health equity by filtering psychiatric expertise to geographically challenged regions and a greater number of residents. “Our Safety Net takes care of over half a million patients a year with > 400 distinct sites; 4000 submitters; 500 specialty reviewers; and > 65 specialty portals,” said Benetez.

The advantages of the system set in place is centralized and coordinated systems and greater access to routine care, as well as patient-centered care and patient education. Limitations include measuring data, reimbursement, and concerns over liability.

Another way to improve access to psychiatric expertise has been through a learning community. Mark Duncan, MD, spoke about one alternative model at the University of Washington (UW).

Duncan is assistant professor at the Department of Psychiatry and director, UW Psychiatry and Addictions Case Conference (UW PACC), a 

 initiative. ECHO stands for Extension for Community Healthcare Outcomes.

 is made up of a didactic and case presentations. “The goal is to increase patient access across the state to effective and evidence based psychiatric, psychological, and addiction care through increasing the knowledge and self-efficacy of all interested health providers within an intentionally supportive virtual community,” said Duncan.

Using a collaborative/educational model, UW PACC is in a position to help guide care across disciplines, including psychology, psychiatry, and primary care. The net result has been to help change practice, build community, and identify providers needing the most assistance.

“It’s a great service because we’re interacting with the provider and asking for quick follow-up questions across many other specialties, so we can get a well-rounded summary of recommendations for people.”

America’s Health Care Safety Net: Intact But Endangered.

 Washington, DC: National Academy Press; 2000.

Collaborative care guides care across disciplines, including psychology, psychiatry, and primary care. The goal is to change practice, build community, and identify health professionals needing the most assistance.

Serving the Needs of the Many: Identifying Strategies for Better Care

Bob Gebbia, CEO of the AFSP, talks about the needed improvement in crisis response systems. 

American Foundation for Suicide Prevention

, which has become the leading suicide prevention nonprofit organization in the United States. He is also a founding member of the National Council for Suicide Prevention, serves on the National Lifeline Advisory Committee, the Executive Committee of the National Action Alliance for Suicide Prevention, and is the past Chair of the Board of Directors of the National Health Council.

There is 1 suicide every 11 minutes... how can crisis response systems help?  

Reforming Crisis Response Care

In the wake of the coronavirus pandemic 2019, physicians and trainees are facing new types of stressors. In a profession where burnout and depression are already commonplace, these additional stressors and traumas can prove overwhelming. Many physicians may need and want to seek psychiatric care but feel unable to do so due to fear of professional repercussions.

The consequences are tragic. The story of 

, MD, the New York City physician who died by suicide at the start of the pandemic is, lamentably, not unique.

 Only a month into 2021, there are already multiple reports of physicians and medical students dying by suicide. Approximately 300 to 400 physicians die by suicide each year, 

Suicide is largely associated with untreated or undertreated psychiatric illness.

, treatment for psychiatric disorders is generally low due to various barriers to care, including inadequate access, self-denial of symptoms, and stigma.

 Physician populations seeking treatment face additional barriers to care. Fear of the 

 if they are known to be receiving psychiatric care can play a major role in their avoidance of care.

Although stigma toward psychiatric conditions in medicine has decreased, it remains a real problem. A recent 

 confirms the fears of those who worry about revealing their illnesses.

 When residency applications disclosed a common psychiatric illness (major depressive disorder), they were at a notable disadvantage when compared to applicants who disclosed non-psychiatric illness (diabetes mellitus type 1). This is just a single example of the many systems within medicine that still perpetuate stigma surrounding psychiatric disorders. Given the very real, often punitive impacts to receiving psychiatric care, it is not surprising that so many physicians chose to stay silent, which can have dire consequences.

 do not ask about mental health conditions, or only ask about current impairment.

 But other states inquire into applicants’ psychiatric history, asking questions related to current functioning and 

 about diagnoses or treatments in the past.

 Furthermore, disclosure of treatable and common conditions such as anxiety or depression may result in a 

 Physicians working in states with more in-depth questions about psychiatric diagnoses are 20% less likely to seek treatment.

 This silence can lead to deadly consequences, quite literally putting the physicians’ life in jeopardy.

 despite current attempts to improve trainee wellness.

 now make explicit efforts to ensure mental wellbeing of their students.

 When students enter medical school the administration does its due diligence by providing links to resources for 

 and advising students to seek help when needed.

 Regrettably, even now after all of these positive changes, 

medical students are still 3 times more likely than their peers to die by suicide

 report having suicidal thoughts in the past 2 weeks.

The process of seeking help for a psychiatric issue can be daunting for anyone. For potential patients, there are often guides online providing step-by-step information about what the process of seeking help looks like. Unfortunately, this process can be different for those in the medical profession. They learn about psychiatric care through rumors or whisper networks. Fear motivates most to stay quiet, and this silence continues after medical school. 

 of physicians have found that almost 50% believe they met DSM criteria for a psychiatric diagnosis but refuse to seek treatment, largely due to concerns relating to stigma and repercussions of licensing boards.

 released in October 2020 showed that many physicians still do not feel comfortable seeking mental health treatment, even in light of the additional stress of COVID-19. More than half (57%) reported concerns for their jobs if they were to seek help, and 73% believed that there was still significant stigma in the workplace towards those with psychiatric disorders, stating that this stigma played a role in their avoidance of the care they believed they needed.

It is clear that the current system leads physicians and trainees to avoid 

 While the system may prevent some from seeking care, the benefits from seeking treatment do outweigh these risks in a majority of cases. Last year, hundreds of physicians spoke out on social media about their own pathways to treatment, many stating that they wished they had sought treatment earlier.

 These testimonials prove that although seeking treatment for a psychiatric condition may be more professionally burdensome than it should be, it does not end careers—for most. In fact, by seeking treatment many of these physicians stated that it improved their ability as physicians.

Physicians should never be penalized for seeking help. Nonetheless, while we work to further improve the system it is important that medical training also includes education about how and when to get treatment. Both trainees and their supervisors should understand this process. Physicians who do not need to seek psychiatric help are often not aware of these processes and their implications; however, trainees are all taught about the importance of reporting physicians who appeared impaired. Providing clear information on how to seek treatment and demystifying concerns surrounding the professional impacts of treatment allows individuals to seek help early, rather than creating a situation where we must wait to catch our colleagues at their lowest points before they submit to treatment.

There is no doubt that more physicians would seek psychiatric care if non-punitive, non-stigmatizing policies were in place. Fortunately, 

many are already working towards policy improvements

 The medical licensing board questionnaires remain 

 found there have been changes in questions related to mental health, especially after it was evident that many of these intrusive questions violated the ADA.

 Additionally, the Dr Lorna Breen Health Care Provider Protection Act (

) has been introduced in the House and the Senate and is supported by 

Even if we cannot remove all aspects of these problems today, we can advocate for systemic change that supports physicians and trainees, such as the Dr Lorna Breen Act, by contacting our 

 to show our support. Through awareness of the process, those who need help will feel able to regain some control of their situation; this knowledge can empower physicians and trainees to feel comfortable to seek treatment as soon as they realize they need it.

currently pursuing an MD/PhD in Neuroscience at Wayne State University

is a third-year medical student at Wayne State University School of Medicine.

1. Knoll C, Watkins A, Rothfeld M. ‘I couldn’t do anything’: the virus and an ER doctor’s suicide. 

https://www.nytimes.com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.html

2. Anderson P. Physicians experience highest suicide rate of any profession. 

https://www.medscape.com/viewarticle/896257?src=soc_fb_share#vp_1

3. Dong M, Zhou F, Xu S, et al. Prevalence of suicide‐related behaviors among physicians: A systematic review and meta‐analysis. 

4. National Institute of Mental Health. Mental Illness. Accessed February 1, 2021. 

https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

5. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. 

More than half of physicians believe that seeking psychiatric care would jeopardize their employment. What can be done? 

Psychiatric Emergencies