Welcome to our SMI Advisor Town Hall, where we'll be discussing where COVID and SMI intersect, inpatient models of care, and workforce impacts. Next slide, please. The CSS SMI Initiative, otherwise known as SMI Advisor, is a program that's sponsored by the Substance Abuse and Mental Health Administration and funded by initiative implemented by the American Psychiatric Association. Next slide, please. So this will be an interactive session, and I encourage you to submit your own questions. If you look in the bottom right of your control panel, you can see where you can submit questions, and you can submit them at any time, and again, I will work as your moderator to make sure that our two expert panelists are able to get your question and respond. Next slide, please. So I'm going to quickly introduce our two faculty and then explain the format of our town hall and then open it up to questions. So I'll start with Dr. Ipsit Fahiyah. Dr. Fahiyah is a geriatric psychiatrist, clinician, and researcher. He is the Associate Chief of the Division of Geriatric Psychiatry and the Director of Digital Psychiatry Translation at McLean Hospital. He's also Director of the Technology and Aging Laboratory. His research focuses on the use of technology and informatics in the assessment and management of older adults, and currently he oversees clinical and research programs on aging, behavior, and technology. He's published extensively in major international journals and numerous textbooks. He serves on the American Psychiatric Association's Council on Geriatric Psychiatry and the Geriatric Psychiatry Committee of the American Board of Psychiatry and Neurology. He served in the past on the Board of Directors for the American Association for Geriatric Psychiatry, AAGP, as some of you know it, and on the editorial board of five journals, including his current role as social media editor for the American Journal of Geriatric Psychiatry. He has won several prestigious awards in the past, including the AAGP Barry Leibovitz Award and the APA Hartford Geste Award. So we'll hear from Dr. Fahiyah in a second about workforce, COVID, inpatient issues, but I also want to introduce our second speaker and really panelist, Dr. Paul Sommergrad. So Dr. Sommergrad is the Francis S. Arkin Professor and Chairman of the Department of Psychiatry and a Professor of Psychiatry Medicine at Tufts University School of Medicine. He's also the Psychiatrist-in-Chief at Tufts Medical Center. In 2014 to 15, Dr. Sommergrad served as the 141st President of the American Psychiatric Association, and as a past President of the American Association of Chairs of Departments of Psychiatry, he serves as the Secretary for Finance and a member of the Executive Committee of the World Psychiatry Association. He is an international leader in medical psychiatric disorders and care, and Dr. Sommergrad, his research focused on mood disorders, medical psychiatric morbidity, and health system design. He's published extensively with well over 150 publications, book chapters, and other communications. I'll end by saying he is a distinguished fellow of the American Psychiatric Association, a fellow of the American College of Psychiatrists, American College of Physicians, and the Royal College of Physicians in Edinburgh, and has received, of course, numerous rewards and other honors. So thank you so much for joining us. As I think our audience can see, you bring amazing expertise and leadership in different aspects of the field. So I'm going to jump to the next slide and present our format, and then let Dr. Bahia have the first word, and then Dr. Sommergrad. And we'll go next slide, sorry. So again, we heard from each of our presenters, and they're each going to give you a quick overview on what they've seen around workforce, around especially working with patients who are in residential settings, inpatient settings, and COVID. What has been different? What have they adapted to? And then we're going to open it up to questions from everyone, and then we'll end around 12.55 with a final word from our presenter. So I'll quickly let Dr. Bahia have the floor, and then Dr. Sommergrad, and then we'll jump into questions. So thank you both for joining us, and take it away, Dr. Bahia. And we may not need slides anymore, so we're set. Thank you, John. Great to be here, and especially participating on a panel with the two of you. Both people I've known for years and have tremendous respect for. So where do we begin, right? Since we're talking about mental illness and COVID, let's begin at the beginning of COVID, which is two years ago next month. Everything has changed in the world of geriatric psychiatry. So I'll talk a little bit about the journey, because I think it speaks to how a series of unplanned events have landed us at a point where if you had asked us three years ago that if this is where psychiatry in general, but geriatric psychiatry specifically, if it could be here three years from now, I would have said not a chance. So COVID hit, all services shut down for a brief period, and we had to work out quite quickly, as I'm sure most of our audience did, on how to transition to virtual care for the outpatient part. On the inpatient side, things for a little while got highly restrictive, and frankly quite bleak from what everyone described, both staff and patients. This was also the period where the older adult population was being ravaged by that first wave of the pandemic, and even now, disproportionately high rates of fatality from COVID, even after vaccination among older adults. So there's been this, I'd say, tone of precaution and restriction around mental health care for older adults that's driven in large part just by the fact that risk of infection is much likelier to lead to worse outcomes, and I think that has colored how all mental health care has evolved. In terms of inpatient care, it does look a little bit more now like it used to. What's been challenging though is that with every spike, first the original spike, then the mid-summer spike of 2020, then the bleak spike last winter, then Delta, and then Omicron, it has meant that there's a degree of uncertainty where things shut down. Inpatients' units shut down as hospital numbers go high. Sometimes geropsychiatry units have been co-opted to become transitional COVID units. So I think a recent example is that a 30-bed inpatient geropsych unit was converted to a COVID unit elsewhere in the Boston health care environment. What that has meant for us though is that there are... And it's been especially problematic for dementia care because there's already been a shortage of dementia care beds with long wait lists, and I think this disruption has meant that it's harder to find a bed. Once one finds a bed, it's harder to find places to discharge people to because assisted living facilities, nursing homes remain shut down. So I think it's that lingering uncertainty and complete breakdown of the traditional workflows around geriatric inpatient care that's been the big negative. In staff terms, we've seen now higher attrition, higher fatigue, the great resignation, we have felt it. The other less bleak side of that coin though is on the outpatient side or the non-inpatient care side, I think it's opened up a whole plethora of opportunities. So for example, the boundary between taking care of someone in an assisted living versus in an outpatient setting, that boundary has disappeared thanks to telemedicine. In our own clinics at McLean Hospital, we've consistently seen 30% more visits now for two years running than we used to before the pandemic because it turns out older people like not having to deal with traffic and weather and parking, who knew? So fewer no-shows, fewer cancellations, a much broader scope of practice. So in the old days, it would be hard to provide services where we are located in Belmont, Massachusetts, to people that lived on areas like Cape Cod or in the Berkshire County, which is two hours of areas, which are very underserved, especially for geriatrics. We found that that notion of geography limiting care has gotten much softer. That's been a big win. We've also found that because so much of life shifted to digital platforms, especially in the early part of the pandemic, people that you would not have imagined learning how to use Zoom are now proficient at it. Not because they want to see me or my colleagues, but because that's where they see their grandchildren, that's where they attend church services, that's where their poker and bingo clubs moved. So I think as life became more digital, adoption became more digital, and so digital care has just become the way forward. I think this is going to be really interesting downstream because we're actively rethinking how the entire ecosystem of mental health care, especially for the heaviest consumers of mental health care, which happen to be primarily older adults with dementia and behavior symptoms. So if you look at who drives up the cost of mental health care, that is disproportionately where cost comes from. So I think as we become more proficient at digitizing care, we will see that this idea of care everywhere, care in home, aging in place, and preemptive care, as well as predictive care, these are all going to be things that start coming into vogue. And if we get this right, and that is a big if, I think we may find that you can reduce cost of care, you can reduce hospitalization, you can have faster disposition, and you can reduce the need for institutionalization. So I think it's been a tough journey, a disruptive one, but assuming that we are kind of approaching a point where this is going to be a more steady reality going forward, I think the opportunity before us is massive. It will require that we learn new skills, we learn a new way of thinking, but we've already begun. So I always hesitate to say I'm optimistic in this day and age, but I think there is a way forward that has kind of made itself apparent, especially over the last three months, that's going to let us provide care for the heaviest consumers in a field that has some of the greatest workforce shortages. So it's an interesting time. Well, that's a wonderful overview, and I think leads to many good questions that I have, and I know our audience well. Now I'll give the floor to Dr. Sommergrad on just some broad initial thoughts on what you've seen in these years. So thank you, John, and thank you, Ipsit, for that wonderful overview. And much of what I have to say is probably going to overlap in some ways with what Ipsit described. So we're now in the beginning of the third year of the COVID pandemic, and that's a long time. Pandemics like wars are highly transformative in human history. That's just if you look at the history of pandemics, they have a profound impact on human society, on social organization, on the adoption and change of technology, and it's in their nature. Hopefully this will be like other large-scale pandemics, which will eventually become more But again, this is a different kind of a virus in many ways, and so there's a lot that we still really don't know about this. I think one of the ways I start by thinking about this is particularly for the serious mentally ill individuals who we interact with and care for, their risk of medical illness and death already is high compared to age-matched controls. Two-thirds of that risk is associated with medical disorders, a third of that risk is associated with death by suicide. But the medical comorbidities and the medical care availability is a very, very substantial issue. In addition, there's a long history of people who have serious mental illness not being taken seriously by both the healthcare system in general, as well as at risk of not being taken seriously by the mental healthcare system. And so consequently, there's certainly many, many, many stories, anecdotal and some data, that suggest that people who have serious mental illness who are medically ill do not necessarily get evaluated or treated as appropriately in various settings, including in medical emergency rooms. Part of this is stigma, part of this is access, part of it is a system issue, part of it is the way we organize our payment systems. Secondly, and I think this was again, one of the things that emerged and I'll talk a little bit about the impact, particularly on inpatient services and the workforce in a minute, the risk of COVID with individuals who have serious mental illness is probably increased in several different ways. One is by greater risk of acquiring COVID, particularly people, you think of it, COVID is a disorder, it's a virus that's spread by respiratory transmission. In the beginning, there was a view of this as primarily being a droplet-based illness. So if you had barriers, you had masks, you had goggles, that would cover most of the transmission. And that probably is still true in the aggregate, but there's certainly evidence for aerosolized transmission and consequently, ventilation, ventilatory systems, situations where people are living close by one another, where there's not a lot of privacy or space, are settings where people are more likely to acquire COVID. Many of those describe situations where individuals with serious mental illness, even outside of the hospital may reside. So homeless shelters, emergency rooms, group homes, other settings, may be situations where the risk for transmission is somewhat increased. Secondly, there are challenges in the setting of care. So for example, on inpatient services, and Ipsit described this, that when the pandemic first began, it took a while to help people in the general infectious disease community understand that being on an inpatient service on a psychiatric floor is different than being on an inpatient service on a medical floor, where you may have a single room, or you may have a room with two people in it, and people generally stay in their rooms, they get their meals in their rooms, there may be a capability for reverse negative pressure rooms, so you can prevent greater ventilatory spread of virus. Inpatient psychiatric units contain settings that are really ambulatory within those settings to a large degree, with rare exceptions, people have catatonia, people have certain other conditions. So helping people understand that, and that led, I think, in the beginning across many inpatient services to the reduction in the number of people who could be admitted, because people changed double rooms to single rooms, began to feed people in their rooms, created more isolation for patients, and also a lot of apprehension for caregivers as well. So I think all of those things have now shifted somewhat, I think there's been a relaxation back to more normal, having more full capacity on inpatient services, but people are still masked, people are still wearing goggles or shields, all of that changes the environment of interaction, the comfort zone that people may have, there's still somewhat of a reduction in the kind of group gathering that might allow greater, and there's obviously things like testing and other appropriate forms of treatment. So I think all of those things have made access to inpatient services more challenging, as have the workforce issues. So in many places across the country, we've seen worsening challenges with individuals being boarded in emergency rooms, admitted to medical surgical floors, not being able to be admitted anywhere, not being able to be discharged to state hospitals because they don't have the staff to be able to care for them, group homes, not having the staff to be able to care for them in the geriatric realm, nursing homes and assisted living facilities also being very cautious about, especially for the elderly population. So I think all of those things have changed the flow of, and in many cases, people may have beds, but they don't have staff to care for people in those beds. And I think the other piece to be thinking about here is, as Ipsit reminds us, that COVID is, treats different populations somewhat differently. If you're over the age of 65, your risk is different than if you're under the age of 40, and then there's a group kind of in between. Secondly, there are differences that one has between people who are immunocompromised or have various other medical comorbidities. And then one of the things to think about is that particularly what was called in a JAMA psychiatry article from 2021, schizophrenia spectrum illness, individuals who had what they call schizophrenia spectrum illness in that study had about a 2.7 times greater mortality rate associated with acquiring COVID than age match controls, all of which suggesting that for some patients with psychiatric illness, there may be greater risks. So where does this leave us kind of going forward? And then the other piece, obviously not to forget, is the pediatric mental health crisis, which has been extraordinary. So across the country, there have been inadequate pediatric inpatient beds for kids who are having serious challenges with their mental health. There's been less data to understand what's actually driving this. There's been a set of assumptions that people have had. Well, school's out, therefore. Yeah, but historically, when school is out, inpatient volume goes way down on pediatric psychiatry units. That's why people close them in the summer, because school is out. So is it that school is out or that kids are not having a normal social interaction? So I think the other thing to think about going forward is around all of this is, number one, what's the long-term effect on the workforce of, you know, the wear and tear of all of this? Secondly, how do we continue the incredible changes that have occurred with digital health, which we've seen for the most part on the ambulatory side. And I think that's already now well-established, even to the point where, you know, CMS has now recognized payment for telepsychiatry, including audio telepsychiatry, which is very important for people both with serious mental illness and for the geriatric population, for those who can't quite maneuver Zoom, you know, or other kinds of entities. And then, you know, I think the other piece going forward is also what happens as we begin to get into an environment of, you know, care, early identification with, you know, rapid antigen tests, and then the administration of antivirals, which hopefully will make a big difference along with vaccination. So continued vaccination, continued attention to vaccination. Secondly, we'll be looking at the ventilatory capacity, not just to places like schools, which is so important, but also of group homes and inpatient services. Thirdly, it would be thinking about, you know, particularly within psychiatry, the drug-drug interactions that may be out there, both positive and negative. You know, so there's now, you know, a large trial based out of Brazil suggesting a modest impact for fluvoxamine, which is an SSRI in hospitalization for individuals with COVID that needs replication and expansion to other agents. On the other side, Paxlovid, which is a combination therapy, which includes ritonavir, which is a drug that's used in HIV treatment, has a lot of drug-drug interactions, including with Clozarel. So there's going to need to be familiarity with this going forward. And then I think the other piece, obviously, to think about is what are the workforce issues going to be going forward with the demand for mental health services so high, and with the availability of telepsychiatry so easy in many ways? Is that going to pull people more and more out of the more complex settings where we need them for care of patients with more serious illness? And is that going to leave patients essentially, not abandoned, but with greater difficulty in getting care? So throw it back to you, John. Now, that's a wonderful overview from you, Paul, and thank you from Ipsit, too. It covers the whole spectrum. I think the most pressing question that people are asking kind of relates to that last point of how do we kind of, in the future, have a mental health workforce to support inpatient units, as you said, Ipsit, or medically complex people with dementia and SMI, when telehealth is expanding and booming, and how do we keep a workforce even motivated for these inpatient roles? I think what's interesting, things are happening. One is it feels as though there's a telehealth startup, a new one every week or two, and then you alluded to this in many places, John, that, and then there are telehealth startups that we heard about six months ago that mysteriously disappear. So I think with so much movement, it will probably take some while for that space to settle. My observation, and I welcome debate on this from the audience and from both of you, is that because it's so easy to get started now, we're kind of seeing a divergence of care for mental health and treatment for mental illness, in that a lot of startups rely on coaches or unlicensed practitioners or interventions that, by design, are meant to be more general and less targeted because the regulatory bar is so much lower. I think what that's doing is that it's making it easier for people that may not have sought mental health care to maybe seek a connection with the world of mental health care. But that's not the same as having better access to mental health treatments, because I think there is, there are tiers of expertise and tiers of needs, and rather than solve the problem of a lack of services at the more specialized tier, what seems to have happened is the creation of a brand new tier, which, yes, it promotes access, which, yes, it makes for an easier entryway. And there's a ceiling there, so I think for people that have more severe depression or bipolar disorder or schizophrenia that may have been under-addressed, and we're starting to see incredible amounts of anxiety, just in all its forms, panic disorder, worse generalized anxiety, things that, you know, relaxation training or CBT or coaching or your general non-form interventions, they can help control up to a point, but that crisis of not having access to that higher level of care for more serious symptoms, I think that's not being resolved. And I think for every person that finds care and gets treated because of tele-services that are not specialized, there's someone that recognizes a need for service that they now can't access, leaving them neither here nor there. So I think that we've created this new tier. It's an important tier. I think it has positive implications for access and equity, but there needs to be a workflow that goes all the way up from, you know, a person in a rural area who now has access to a coach for an app. They get in the door, but then there's a series of doors that they need to pass through to get to where they want to go, and we haven't figured out that entire workflow yet. So I think that's something we're going to have to do. And there is a bottlenecking, I think. So all of us work in tertiary academic medical center environments, and I think we're sort of seeing that bottleneck where it's not possible for us to take on more people. We figured out how to provide care in different settings. We figured out how to reduce the logistical burden, but we haven't yet figured out the scale piece. And I think the scale piece for mental health care has not translated into scale for treatment of serious mental illness and higher needs. That's where the challenge is, and I think that's where we're trying to see what room there is for innovation. It's where some of the more exciting future developments are coming into play. AI gets talked about a lot, and we can spend some time on that. So I think there's ways of technology helping there as well, but it's a very different kind of technology and much less mature than just telemedicine. Yeah, I think, again, I can't disagree with any of that. I think one of the things that COVID has exposed is, I feel at times, and maybe this is just my age getting to me, but I feel at times a little bit like I'm living in a version, and this is not to compare this to the Vietnam War, because obviously that was a very, very different event for a whole host of reasons. But I was in college and medical school during the Vietnam War, and so I remember it pretty clearly. And people used to talk about the home front and the war front, the zone of what was going on in Vietnam and what was going on. And people would go out and they would fight, and people died at incredible rates, both Vietnamese and U.S. soldiers. And then people would come back home and not only would they be disparaged, but people were living their lives as if nothing big was going on. This has been more disruptive than that, but I think within the health care environment in particular, there has been, for the general population, it's a little hard to get really a sense of what it's like for people who are working, whether it's in psychiatric hospitals where there have been substantial outbreaks. I mean, in many psychiatric hospitals, particularly state hospitals across the U.S. and internationally, the first outbreak in Korea was in a mental hospital. One of the two first outbreaks in Korea in 2020 was in a psychiatric hospital. And then the second is really the, so there's a wear, I think, on the health care workforce because they're dealing, you know, whether it's in the most intense areas, particularly in intensive care units, emergency rooms, pulmonary critical care doctors, infectious disease doctors, or it's people who are working on inpatient psychiatry and front lines, you know, where they're in the emergency room, they're on consult services, they're in inpatient psychiatric services, and they're dealing with the impact of this or the threatened impact of this all the time. And I think, you know, one of the things that this has shown is the challenges we have with a payment system, not just for psychiatry, but for all of medical care that's so challenged. So we have hospitals that are full to the brim with patients, but hospitals are losing money. Well, why are they losing money if they're full to the brim? Because they're not able to do those things that are most lucrative and the things that are most lucrative are elective surgeries and other kinds of procedural care. And that's the way the system has been organized. And so consequently, we've had to have appropriately payment to maintain the availability of services. But the workforce in the middle of all of this, I think, is really challenged to to continue. Secondly, I think that there has not been mention in an organized, systematic way to either severe psychiatric illness or, you know, the pediatric mental health crisis, I think, is a particularly clear exemplar of this, you know, where where there's been some data that's come out of CDC, you know, about suicide rates, emergency room visits, et cetera, you know, some of which goes across against, you know, kind of standing narratives that are out in the culture. But we have not looked at this in any kind of systematic way and we need a much more systematic attention to, you know, data and the populations that we're responsible for. And then I think what Ipsit describes is absolutely correct. It's wonderful that people are more open to talk about mental health and mental well-being, not all emotional stress, mental concerns, anguish is a psychiatric disorder. Some of it is, you know, it's it's emotional life. It's real. It's real life. It's suffering. Some of it crosses over into the realm of disorder to the extent that we have a pathway in the teleworld and the digital world for non-regulated care. It's much easier to do that without having to worry about, you know, do I meet an FDA criteria here or am I offering medical care, you know, without, you know, am I creating a liability issue? Is there a licensure issue? You know, what do we do about the fact that patients move around the country and we no long, you know, we're out of the emergency regulations which allowed us to care for patients when they were across the country because all the state licensing issues got got suspended because of the crisis. And now we're back to where we were before. And depending on where the patient is, you may or may not be able to care for them in another state. So there's a lot that we're really going to have to pick up the pieces around going forward on this. And that's going to take some period of time. I have one more workforce question has come in and some passing at our questions, really saying any examples of what your hospital or system has done to try to give staff extra support? Again, we've said it's stressful. There's been a lot of uncertainty. Is there anything hospital systems can be doing to support staff more, should be doing, or you think are just they're not doing and they need to? Yeah, so one of the things that we did was we stood up an emotional support service for our own staff that basically ran without additional funding on the basically the the backs of our existing caregivers. You know, we had people would we produced, you know, webinars, 20 videos, written material. We stood up a direct support line. We stood up a direct referral line, whether those have been enough for people. But that certainly was something that that we did. We have had group meetings with various affected groups as well as individual meetings, as well as some of the standing health and wellness things that we do for our staff and personnel. But I think if we look at it across a large workforce like any of our systems have, I think that that's hard to say that that's enough. On the other hand, it's not clear that traditional EAP is going to make a difference or or any of those things. I think some of this is also a recognition at a cultural and social level that we've been through a crisis. You know, ordinarily when cultures go through crises like this, there are you know, I remember in the very early days of the pandemic, I said to one of my colleagues at the hospital, I said, someday there are going to be walls and hospitals with the names of people who died delivering care during COVID. You know, they're probably in the U.S., depends on the numbers you look at, thirty five hundred health care providers who have died in the service of individuals. That's a lot of people. That's a lot of people. We're going to need to and there are firefighters and there are police that are in the same category. There are teachers in the same category. There are grocery store workers and retail workers who are in the same. We're going to need to find some way as a culture to come together in a way that's not conflictual to be able to celebrate their sacrifice and their service, remember their suffering and and their sacrifice and be able to memorialize it in a way that's beyond simply just, you know, we're off to the next set of activities. Those are good points. Sorry, I was just going to say that's that's such a critical point, Paul, that I think there is an element of just unaddressed grief and trauma culture wide. Nine hundred thousand deaths as of early last week. Right. It's it's grief is just in the air and losses in the air and not just death of people that succumb to covid, but loss of a way of life, loss of a norm, loss of expectation. And I think that one reason it's been so traumatic for younger folks is that it's the loss of a projected future and that the reality they thought they were growing into may not the reality, not be the reality that they're heading for. One thing that we ended up doing is sort of an ad hoc service that has stuck around is just straight support groups for anyone that wants to talk about how covid has affected them. This started out as a very concise thing. It started out as a support group for caregivers of dementia patients enrolled in our clinical trials. So it started out as a very conscript thing that has since just grown and grown. Powerful anecdotes have emerged from it that we're now thinking of how to systematize. I think I think the way of the future, as it relates to both growing needs and workforce shortages, is that group therapy is is in focus. Telemedicine has made the delivery and the creation of group therapy services easier than it's ever been. I think very concretely within our system. That's what we've honed in on. There's financial implications, too, because it's one of a relatively small number of ways of increasing access and scaling up psychiatric services without increasing overhead and without getting into workforce shortages as well. Now, group therapy is not a secret. It's been around for decades. But I think really dissecting it into which parts work, why they work, how it can be more effective. We may be heading towards a way of very precision based group therapy, some of which has existed in the research realm, but has not translated into clinical services. And I think we're starting to do that. So to your question, John, or to the audience question about what are our services, I think one concrete answer is that we are really paying close attention to what we're doing our services. I think one concrete answer is that we are really paying close attention to how we can build up specifically group psychotherapy services in number, but also in focus and in skills training. Yeah, I think that's a good. Yeah, yeah. And the second piece, which is more personal than system wide. And this may be a bias for me because I've worked with older adults that tend to be temperamentally, I think, just a little mellower. I found myself unafraid to expose a little bit of vulnerability to my patients. Now, this may not be something that you should try at home as they say, because it depends on who, but it would be unexpected. I would meet someone in session. I would ask them how they were doing. And they were saying the key question here, Doc, is how you're doing, because you've got two kids in school and I don't. So I think as psychiatrists, there are rules, right? And there's classical traditions about maintaining firm boundaries and important rules. We must reinforce them. But every now and then, if an exception is made, it can be incredibly powerful. I won't hesitate to declare that empathy from my patients may have been, in some ways, the biggest barrier to personal burnout that I've experienced over the course of the pandemic. I think don't let all of your patients know how you're feeling. But if you have good rapport and it may be clinically appropriate, I think patients are able to give tremendous empathy. And this is different from other crises in that, yes, we are the doctors and they are the patients, but we're all experiencing this giant disruption together, right? It would actually be, I would say, facetious to assume that we are protected from it in ways that our patients may not be. I think we're just as vulnerable. And it's surprising how well people respond to just acknowledging that simple fact that your life is being overturned by this. But honestly, so is mine. Yeah, I think it's an extremely powerful point, both on the group therapy as well as on the fact that this is a global, national phenomenon. And when you were talking about the impact that this has had, if you think about it, it's upended the developmental pathways, the normative developmental pathways and expectations almost for every group. For young children, they didn't see grandparents. They may not have seen aunts and uncles for a period of time. They weren't able to go to school. They weren't able to go to preschool. They lost social relationships. For kids in schools, similarly, for people who are young people who are in their 20s and maybe mid to late 20s or early 30s, the ability to go out and to do things in the world has been somewhat more impaired. Although their risk level is different than people who are older. For older individuals, who knows if it's ever gonna come back to being normal. If you're 80 years old or above or 70 years old and above, are you gonna travel through the world the way you might have before until this is really in a very different state? So I think the enormity of this makes it almost impossible to grasp. And then when people are, when a culture is grieving, if you look at excess mortality, it's over a million people in the United States. Excess mortality, which is probably a better measure, is over a million people in the United States. That means we've lost one in 330 individuals in this country. These are enormous numbers of disruptions that have occurred during this period of time. And how do we deal with that when we're so busy fighting with each other? We're externalizing so much of this. And I think it affects our workforce and it affects particularly, I mean, individuals with serious mental illness. What happens when they can't see their parents who may be caretakers for them or who have been involved in their care as advocates? What happens for geriatric patients who can't see relatives and friends who would otherwise come to visit them? FaceTime on a phone is not the same as being with somebody in person. Oh, and that's one of our next questions. For your inpatient units or services residential, what is the threshold to let visitors come back to have family meetings? We know how important these are in people's recovery, especially in inpatient-like facilities. How are you guys managing that or seeing that evolving? When is it okay versus not okay? It changes on the case numbers and the case positivity rates. I think when we've had spikes, in the early days of the pandemic, there were no visitors at all, and that was brutal. I think now things have changed and there's more PPE and a better understanding of safety requirements and a variant that seems to be a little less dangerous in terms of fatalities. So at the moment, one person is allowed. I think as numbers go down, those regulations are restricted. Or they're slowed down. But really, it has fluctuated quite a bit over time. I would say that the more restrictive it is, the worse it is for the patients. I think it tangibly impacts their outcomes on the unit. Yeah, and it also depends on which state you're in. So every state, by and large, in the United States at least, healthcare's regulated at a state level much more than it is at a federal level. It's a traditional state function. So departments of public, CDC can provide some general guidance. There may be, obviously, FDA and CDC approve certain kinds of drugs and therapeutics. But from the standpoint of day-to-day decisions, X state has a mask mandate, Y state doesn't. X state's Department of Public Health says you can have one visitor or no visitors or these are the criteria. Departments of Mental Health may be separate from Departments of Public Health or they may be conjoined. And they provide guidance as well. And so in many ways, what we are doing is, it's not an individual entity decision. It's really a public health decision that we then have to implement. So it's gonna probably keep changing a little bit as our public health regulation hopefully finds a uniform place. Related to that question, some people said clearly when COVID restrictions are more severe, it's harder to interact directly with patients. We may have patients in quasi-isolation kind of on inpatient units. Has there been anything that you guys have seen that can help people have a better experience on an inpatient unit when we're kind of having to do all these restriction protocols and distance? I think nothing other than recognizing that this is different and hard and that it should be a topic for discussion as patients wanna talk about that if they do wanna talk about it. Obviously you don't wanna impose it on them assuming that it's an issue or problem for them. But if it is, to talk about it. And again, you need to acculturate patients who are coming into the hospital. These are our rules. This may be different than the last time you were in the hospital. We have to do certain things differently. It's not about you. It's about the rules of how we have to operate. This is not being done in a punitive way. It's being done for your protection and other people's protection. And then find them. Not everybody's gonna feel comfortable with that. We've tried to enhance the group therapy and activities offerings on the inpatient unit. It hasn't always been successful because there's been short staffing to begin with. And then even when you get something going, you never know who's going to get exposed somewhere and then be out on quarantine. So it hasn't necessarily always worked smoothly. But trying to make up for the lack of visitors and the lack of outside contact by enhancing the therapeutic offerings on the unit has been in theory the approach. But quite flawed practically if we're being fully transparent because so many moving parts. This is a related question. It says some of my patients or people have had now concerns about the psychiatric impact of catching COVID or kind of long COVID or have been reports of developing psychosis after COVID exposure. How are you educating families, patients and coworkers even on the mental health implications of COVID? I think for, so it's a very important question because there are now, we're now starting to see six or eight month post infection data starting to emerge and they're not great. There was one study that found that the incidence rate of a neuropsychiatric symptom, a single neuropsych symptom, six months after being hospitalized with COVID was 91%. So 91% of people that were hospitalized for COVID had a neuropsych symptom of some form at the six month period. For those that had had a neuropsych symptom when they had COVID, that rate was even higher. And there's been some evidence to suggest that for people that experience confusion or delirium, there may be a heightened risk of dementia. So world experts on this, like Sharon Inouye have written in publications like Nature outlining mechanisms why they're afraid that neuropsychiatric symptoms of COVID infection may be setting us up for an epidemic of cognitive or neuropsych impairment three, four years down the line. So I think that's actually the democracy sword here that are we in fact heading into a massive mental illness crisis? We're in a mental health crisis now, but is there a mental illness crisis coming? Especially in people that have recovered from COVID. Too soon to have an answer to that. But I like many others have had family members that have experienced the infection. And this is now not a clinical recommendation. It's just educated suggestion, if you will, that there is a suite of interventions that are believed to be protective for the brain. Antioxidants, vitamin B12, folic acid, exercise, bright sunlight, all of the things that we would recommend to keep good brain health, maybe a little more important in the context of if you've recovered from COVID. I think those are under the principle of do no harm. Those tend to be relatively safe recommendations and that we should all be, like you said, eating our vegetables and exercising and sleeping well. So I think a lot of brain health recommendations are heightened in importance, but it's too soon to say whether there can be any concrete recommendations beyond that other than just wait and watch and don't be afraid of seeking care. Paul, you may have a broader purview on that because- Yeah, I mean, there's a large study which both our hospital and our colleague hospitals in Boston are involved with, which is the post-acute COVID syndrome study. It's in collaboration with NYU. It's funded by the NIH. And it's a very important study because there's so much that we simply don't know here. To what degree are some variants, if any, neurotrophic? What is the correlation, if any, between loss in taste and smell and evidence of central nervous system involvement? Is this an inflammatory response in the brain? Is it a direct infection of the brain? Again, different kinds of limited data that's out there. That's certainly one. Secondly are just the general impacts of other types of symptoms that people have, shortness of breath, fatigue. There are individuals obviously who've had more severe illness. And like with other forms of delirium and ICU, people who are very ill often have post-ICU related syndromes and there are, of course, historically have been many, many post-viral syndromes. I mean, just look at what just came out a month ago about multiple sclerosis, that a strong longitudinal correlation with prior Epstein-Barr virus infection, even though Epstein-Barr virus infection is extraordinarily common, 95% of people have Epstein-Barr virus infection, but for individuals who develop multiple sclerosis, the longitudinal, temporal and other data now strongly suggest that that's a trigger for the development of this. We know in the 1918 so-called Spanish flu pandemic, there was a whole post-infectious syndrome of people having kind of encephalitis lethargica, or people were, the movie Awakenings with Oliver Sacks looks at some of those individuals, some who are hospitalized for a long period of time. So it would not be surprising to know that in a, and also we don't know what the impact is gonna be of antivirals. We don't know what the impact is gonna be of vitamins like vitamin B12 or vitamin D, or obviously the impact of vaccination, which we hope will reduce the likelihood of this, or what happens with variants that may be less potentially neurotropic. And again, I don't think there's clear evidence that any of the viruses are necessarily neurotropic, but there are certainly concerns out there. So I think, again, to the general point is I don't, and let me just say this as broadly as I can. I don't think we have had the level of data gathering, science, policy, or attention to the various levels of the mental health issues, whether it's the post COVID syndromes, or it's the impact on people with serious mental illness, or it's the workforce, or it's the broader mental health crisis that Ipsit is describing. We have not had the level of data and attention to this we need. We have been assuming, because we know something about what makes people happy or sad, that we kind of know what's what here, and we don't. And we really, really, really need a much broader collection of data and policy and analytics to attend to this on the one side. On the other side, I think we need, we have collective grieving, and maybe it's hard to grieve until we have a sense that this is over. But there's tremendous pain and suffering that's across the country, and certainly the world. And so that's the mental health side of this that I think is so much broader than even the SMI side, as important as that is. No, but they're both definitely related, as you guys have pointed out, and we have to be addressing each. One just fascinating comment in response to a prior question, someone's saying their state hospital basically was told not to have visitors, and now the legislation is challenging it in that state, and the hospital staff was told, you guys have to make up the rules, that the legislator doesn't want to help you. So it's interesting seeing sometimes individual hospitals being told, there's a conflict among different regulatory bodies, you guys have to pick these visitor policies. I imagine these things will keep happening, right? It's at some point we're gonna be asked also to help make decisions about how open arguments are. And also remember, there are complicated legal and human rights issues. So individuals, particularly if they're involuntarily hospitalized or committed either by adjudication by a judge or hospitalized from out of an emergency room, whatever, are in an unusual legal condition. We don't normally treat people involuntarily or restrain them from going about their daily activities. So many states and many, both nationally and locally, have rules about visitors are important for people's human rights. And so balancing these things has been very, very tricky, and it has required a lot of discussion with regulatory agencies. And different states, again, are gonna have different rules about this. Now that makes sense. So I think maybe I'll, if you each wanna give a 30 second final comment, then I have some slides to share so our audience can learn more. But again, maybe a 30 second, any big takeaway or reaching our hundreds of people listening right now, any message, not that you've already said so many wonderful things, but any parting words. I'll start, maybe just the same order, Dr. Vahia first. Right, well, that would be appropriate here because I think Paul should have the last word on this. I'd say that it's, you know, in addition to all of the anxiety around the pandemic itself, I think there's a layer of anxiety around the fact that there is an uncertain time and one filled with change and disruption ahead of us. And I think that if we've learned anything, it's that the people on the front lines probably understand the nuances of the mental health impact of COVID better than anyone. That would mean most of the people in our audience today. And I think we should change our stance towards advocacy and leadership around figuring out what happens here. And, you know, this is addressed to the APA as a whole. I think the APA should be guiding and leading us towards understanding technology, understanding how to cope with grief. I think the extraordinary intellectual capital within its membership should be leveraged to, I think, steer this. And it's time for the organization to pull its weight on the global level because we need it. I would say just that we need to be able to continue this dialogue, number one, to remember that individuals who have serious mental illness are at particularly serious risk and need to be cared for and thought about in a very careful and thoughtful way, you know, recognizing both, you know, the potential impact of any, you know, psychiatric illness they have, as well as the potential risks associated with the care and, you know, management of COVID in those individuals. You know, I'd say more broadly, I think that we need more data, as I said, and I think we need more implementation science around, you know, what is gonna work and what isn't. And then finally, I think we need some recognition of our collective grief. You know, today I believe is the anniversary of the young pulmonary doctor in Wuhan who first kind of went public with what they were seeing and then died today, I think two years ago today, you know, from COVID, an early fatality, an early healthcare fatality. Maybe that's a good moment for all of us to, you know, step back and remember, you know, the burden that all of us have been sharing as healthcare providers, as physicians, as nurses, as, you know, pulmonary therapists, but also for the general public as well. No, I think, thank you both for those words. It's certainly been a collective effort, right? From everyone, from our patients to peer specialists, to social workers, to nurse practitioners, to therapists, psychologists, it's huge. These are team efforts, it's still ongoing, but as I appreciate both of you sharing your insights about what we're seeing this evolving one, helping us all kind of answer questions I know that we're all having. So maybe again, I'll quickly share some slides to tell our audience about new things coming up. Again, I want to of course thank both of our speakers for sharing their time. So we'll quickly go to the next slide. So I said, the SMI Advisor Program actually has a mobile app. We have access to our large library of resources, of videos, of webinars, screening assessments for mental health. It's completely free. You can download it at smiadvisor.org slash app. And we'll go next slide. So SMI Advisor, of course we offer webinars, meetings like this. We also have a consult service. You can submit a free and confidential consult at any time. To our experts, you can log on and have an account. Again, there's no cost, it's confidential. You can bring up questions about anything from psychopharmacology to therapy, recovery, support, family engagement, and more. So feel free to submit a consult. Our experts are there and ready for you. And next slide. So of course there's many SAMHSA initiatives that offer wonderful information. SMI Advisor is just one of the many SAMHSA initiatives. We encourage you to look across the whole range of them for help about broad range of mental health supports ranging from addiction to implementation. And of course, SMI Advisor being one of those evidence-based practice centers. Next slide. And final thing, we have upcoming webinars. So next one is called Engage or Enrange, De-escalation Strategies for Mental Health Crisis Part Two. If you missed part one, it's actually online right now. It's a webinar. This will be on February 17th with Mark Feagan and Brian Bean. So again, you can look for that and education on smiadvisor.org has a pretty robust video library of all those right now. Next slide. And with that, we'll conclude. So thank you everyone. Thank you, Dr. Bahia. Thank you, Dr. Samajad. Bye.

COVID

serious mental illness

inpatient models of care

geriatric psychiatry

virtual care

telemedicine

access to care

underserved areas

mental health

healthcare workers