Sep 10, 2020 | Children's Health, COVID-19, Mental Health, Psychiatry, Your Health
As children head back to school—whether in person or virtually—parents may have some concerns about how they will adapt to a new, potentially stressful academic year. Aliza Pressman, PhD, Co-Founding Director and Director of Clinical Programming for the Mount Sinai Parenting Center, answers some of your questions.
How can I address my children’s anxiety about going back to school in person?
Start by making sure that you are calm and not imposing your own anxiety onto the conversation. Your children will pick up on your energy and you want to be focused on their concerns. Also, remember that your anxiety—and your child’s anxiety—is very reasonable at this challenging time. If your child is anxious, don’t try to get rid of that anxiety. Instead, validate their feelings. Tell them that what they are feeling makes sense. Children have been out of school for a long time and for months have been hearing about the importance of staying away from people. Now they’re going to head back into a building full of people. Of course they are nervous.
Once you’ve validated your child’s emotions, explain that you would not send them back to school if you did not think they would be safe. Go over the precautions that the school is taking to protect teachers and students and, for younger children, remind them about what COVID-19 is and what individual measures they can take to keep themselves safe while at school.
Will my child’s learning be affected by having their teachers wear masks?
This is a natural concern. Our facial expressions are part of how we communicate and masks obscure half the face. One way to prepare your child is to practice communicating and reading people’s emotions when they are wearing a mask. Make a game of it. Have everyone at home wear a mask and guess what each person is trying to say by just using body language. Once your kids go back to school, you can reinforce the lessons they are receiving in the classroom; for instance, have them read to you. You’ll probably pick up cues from your children about what they need, and you can adjust accordingly. Remember, kids are incredibly adaptable, more so than adults.
How can I help my child connect with their friends while attending school remotely?
If your child is attending school remotely, they will probably miss spending time with their friends, and interactive screen time is a great way for them to safely connect. Since screen time may be your child’s only opportunity to socialize, you might even want to allow more screen time than you permitted before the pandemic. Just make sure it doesn’t interrupt family mealtime, homework, or replace outdoor activity.
Also, remember that some kids don’t enjoy online interaction. Some children enjoy a more passive interaction like being in the same virtual room as a friend while doing an art project. This allows children to chat with each other without the pressure of an ongoing conversation. As kids get older, they will be able to tell you how they want to connect with their friends. It may be through a video game, taking an exercise class together, or watching a movie together. Or, they may just want to talk on the phone or text.
How do I talk to my child about what is happening in the world?
Before you talk with your child about current events, make sure that you have come to terms with your own state of mind. You don’t want to enter the conversation with the weight of your own feelings. When you are ready to talk, determine what you want to discuss before beginning the conversation. Whether it is COVID-19, social unrest, or something else, begin by asking what they know and what they’re thinking about regarding the topic. You want to be your child’s first resource with any questions and concerns. Be prepared to explain your opinions.
When should I seek professional help?
If you or your child cannot manage to sleep or eat or are feeling out of control, consider seeking the guidance of a mental health professional. It is completely reasonable to feel overwhelmed; this is an enormously stressful time. And, remember, if your child sees that you are willing to seek help, they will know that it is okay for them to do the same.
Updated on Jun 30, 2022 | Psychiatry
Health care workers will likely be facing significant mental health consequences due to COVID-19. Mental health care providers must be prepared to meet the unique challenge of treating them during and after the pandemic.
COVID-19 has taken a tremendous toll on health care workers including doctors, nurses, trainees, students, social workers, and support staff. The trauma and grief of losing patients, the anxiety over potentially exposing family members to the virus, and fears of contracting COVID-19 will likely result in significant mental health consequences. While the full impact will be shown with time, studies on disasters and epidemics suggest that the exposure to suffering, death, and constant stress will lead to post-traumatic stress disorder (PTSD), depression, anxiety, and burnout.
To address this, Mount Sinai has launched the Center for Stress, Resilience, and Personal Growth to provide Mount Sinai staff, faculty, and students with no-cost resilience training, mental health screening, individual coaching, and personalized referrals. Deborah Marin, MD, serves as Director, Jonathan M. DePierro, PhD, serves as Clinical Director, and Craig Katz, MD, serves as Senior Advisor. Below, they discuss the top five things to know about providing psychiatric care to health care workers suffering from mental health issues due to COVID-19.
1. The behavioral health consequences. We have already observed a high level of distress in Mount Sinai’s health care workers—Jonathan Ripp, MD, MPH, Director of Mount Sinai’s Office of Well-Being and Resilience, and his team found that 39 percent of 2,579 workers reported clinically significant symptoms of PTSD, anxiety, and depression. These workers may feel disconnected from a sense of meaning and purpose in their work and personal lives and be excessively self-critical for what they did or did not do during the pandemic. These symptoms can result in “presenteeism” (going to work but not being able to work effectively), absenteeism, irritability, chronic exhaustion, and avoidance of work or work-related issues.
2. How to screen for these conditions. Part of “how to screen” includes “who to screen.” Nurses, nurse practitioners, physicians, and physician assistants have received significant media attention; however, it is clear that support staff are equally if not more affected by the pandemic. An example would be a patient transporter who brings patients to and from diagnostic tests and procedures switching gears to transport hundreds of bodies to the morgue. Our research following 9/11 shows some evidence that these support staff members, who are often members of historically disadvantaged groups, will struggle more with long-term mental health effects due to the pandemic.
When assessing health care workers, important risk factors to consider include pre-pandemic and current social support, level of exposure to pandemic-related human suffering, socioeconomic circumstances, pre-pandemic job burnout, and the presence of secondary stressors following the pandemic, such as job loss or childcare concerns. Patients will often not report a symptom unless asked directly, so it is important to be thorough during screening. The National Center for PTSD maintains a list of common measures of trauma-related symptoms and how to obtain each instrument. The American Psychiatric Association also lists DSM-5-specific measurement tools that can assist in screening. There are also many common self-report screening tools, including the PHQ-9, which indexes depression severity; the PHQ-4, a quick screener for depression and anxiety; and the Primary Care PTSD scale for DSM-5. Many of these tools are available for the public as well, so patients can self-monitor.
3. How to treat these conditions. For PTSD, the gold standard psychotherapies are cognitive-behavioral approaches including cognitive processing therapy and exposure therapy. These interventions involve directly and systematically engaging with traumatic memories and revisiting their meaning in a safe, therapeutic space. There is some evidence that non-trauma focused treatments (such as interpersonal psychotherapy) can be helpful too, particularly for patients who cannot tolerate trauma processing. In addition, paroxetine and sertraline are FDA-approved for PTSD, and VA/DoD clinical practice guidelines indicate that there is “moderate quality” evidence to recommend these as well as fluoxetine and venlafaxine for the monotherapy of PTSD. Some patients may benefit from a combination of evidence-based psychotherapy and medication management with these and possibly other medication classes.
For depression and anxiety, in addition to the range of FDA-approved antidepressants and other medications, cognitive-behavioral therapies, interpersonal psychotherapy, and supportive therapy have a strong and reliable evidence base as first-line treatment or in combination with a medication.
4. How to promote resilience. Resilience can be quick for some people, but for others it might be a slow arc toward recovery and rebuilding their lives. Working with collaborators, researchers at Mount Sinai have identified many behaviors that can enhance resilience following adversity, like that posed by the pandemic. These include individual factors including maintaining an optimistic perspective, building emotional and cognitive flexibility, seeking comfort and connection in spiritual practice, and giving and receiving social support. Further, organizational factors that are important for resilience, particularly in health care workers, include cultivating a sense of belonging, connectedness, and mutual respect in teams.
Let’s take one of these factors, cognitive and emotional flexibility, as an example to explore in more detail. We know that individuals who are resilient are often good at seeing situations from many different perspectives. They can use “cognitive reappraisal” to see a challenging situation or negative thought in more positive or neutral terms. One practical application of this skill is seeing the learning potential and the new colleagues that can come from a changing job role, while also acknowledging the inherent challenges in such a transition. This skill, among others, can be cultivated through individual practice or by speaking to a therapist with expertise in cognitive therapies.
5. What to say to patients. While it is essential to screen and, when needed, treat your patients for COVID-related mental health distress, keep in mind that not everyone is comfortable with formal mental health treatment or can equally access care. It is therefore important to talk with patients about numerous options to promote well-being. These include seeking spiritual or religious support, using a mental health or wellness app, or participating in one or more activities that build social connectedness.
Focusing on strengths can also build a sense of hope and therapeutic connection. One approach from Positive Psychology, known as the positive introduction, involves asking patients to tell you a story about one time they handled a difficult situation in a positive way and were particularly proud of how they navigated it.
Dr. Marin is the George and Marion Sokolik Blumenthal Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, specializing in geriatric psychiatry and Alzheimer’s disease. She also serves as Director of Mount Sinai’s Center for Spirituality and Heath and Director of the Ombuds Office.
May 4, 2020 | Psychiatry
New York City is an epicenter of COVID-19 pandemic in the United States, and the Mount Sinai Health System has spearheaded an array of clinical and organizational innovations to mitigate the crisis. To address the mental health consequences, departments across the Health System collaborated to form a five-tier model of emotional support for all Mount Sinai Health System employees that accounts for the limitations on in-person support in times of social distancing and lock downs. This model is based on the idea that interventions must have a proactive component and should be interconnected and part of a continuum of need. The concept was formulated by Sabina Lim, MD, MPH, Vice President and Chief of Strategy for Behavioral Health for the Mount Sinai Health System, based on recommendations from Craig Katz, MD, Director of Mount Sinai’s Program in Global Mental Health.
A mental health rounding team volunteering at The Mount Sinai Hospital, from left to right: Marissa Schwartz, NP; Shruti Mutalik, MD; and Rajvee Vora, MD, Vice Chair of Clinical Affairs for the Department of Psychiatry.
The Five Levels
For Level 1 (the most urgent level), immediate mental health crisis response teams (MHCRTs) staffed by more than 50 psychiatrists, psychologists, social workers, counselors, and trainees are assigned to each hospital within the Mount Sinai Health System, connected via a 24/7 call line. They provide assistance for individuals in urgent need of emotional support, and 2) group debriefing and support sessions for units and services in the wake of acute crises (primarily via phone or Zoom).
Level 2 is specifically for front-line health care providers on units and services who are caring for COVID-19 patients—emergency departments, intensive care units, and COVID-19 units. It provides two main sources of proactive emotional support and outreach: 1) “Mental Health Liaisons” for those employees/services directly providing care to COVID patients, and 2) small groups of mental health professionals rounding onsite at all Mount Sinai hospitals several times per week to check in with staff, provide in-person support and encouragement, and provide information about the MHCRTs and Mental Health Liaisons (MHLs).
Level 3 delivers psychosocial support to all employees via Zoom support groups and supportive counseling services. Level 4 contains resources for general guided self-care including Zoom meditation, yoga, and mindfulness activities. Finally, Level 5 focuses on resource navigation—employees can call a central phone line staffed by medical students who can help employees navigate the resources that are available to them. The students are supervised by post-doctoral psychology fellows, who can assist if clinical issues arise.
Mental Health Liaisons
The Mental Health Liaisons (MHLs) program is comprised of more than 100 psychiatrists, psychologists, social workers, and mental health counselors in the Department of Psychiatry and Department of Social Work Services. The teams are assigned to one or more units/services for proactive outreach for employees of all disciplines. They rolled out to 57 units and six emergency departments across the Health System in April. The MHLs serve as the confidential point of contact with individuals via text, email, and phone support Monday-Friday, 9 am-5 pm, as well as regular group debriefing or support sessions. These sessions are primarily virtual, but are also conducted in-person when possible and social distancing is enforced.
“This program is based on the concept of ‘Mental Health PPE’ because we need to be mindful that people need personal protective equipment for their minds as well as their bodies,” said Dr. Lim. Once an employee makes contact with an MHL, the MHLs routinely check in with them again. Support is provided based on principles of psychological first aid, but if an employee is believed to be in need of psychiatric evaluation and/or treatment, the MHL connects them to these services.
The MHL program was expanded in May to include staff in support services, such as environmental services, security, and transport. Various MHL team members have also been assigned to employees who may not be based solely on a unit, such as hospitalists and physician assistants.
Paul Rosenfield, MD, Director of Psychiatry Education and Training at Mount Sinai Morningside/West, volunteering as an MHL with members of the Mount Sinai Morningside nursing staff.
Robert Jaffe, MD, Assistant Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, and Danielle Young, LCSW, Pediatric Intensive Care Unit, and Pediatric ED Social Worker, were the MHL team members assigned to the Hemodialysis and 3 East units at Mount Sinai Queens. “Being able to offer this service to my staff is extraordinary, and paramount to their well-being,” said Anthony Auditore, MNSt, RN, NE-BC, Nurse Manager for the units. “Dr. Jaffe and Danielle have been sensitive to the needs of the staff, flexible to varying situations on the unit, and above all, really allowing the staff to feel that they are not in this alone.”
Ms. Young was immediately struck by the strength and community of the unit. “I have been able to see first-hand how this vicarious trauma plays out, and I want to thank Anthony and his unit for allowing themselves to engage so openly with us during this incredibly challenging time,” she said. “Working as an MHL has been one of the most rewarding experiences I have had as a clinician,” said Dr. Jaffe. “It is an honor to be able to offer groups where staff can safely share their experiences, and we can teach stress reduction strategies.”
“Even just having the iPhone or Zoom meetings, or the deep breathing exercises as a way to take a break and allow time for self-care, really helps us know that we are appreciated and we are all in this fight together,” said Carris Keene, AAS, a registered nurse on Mr. Auditore’s team at Mount Sinai Queens. “Having someone to talk to is truly a game changer.”
Updated on Jun 30, 2022 | COVID-19, Mental Health, Psychiatry, Your Health
The outbreak of COVID-19 is challenging all of us to cope in new ways. For people with depression and anxiety, life can seem overwhelming in normal times. Rachel Yehuda, PhD, Professor of Psychiatry and Neuroscience at the Icahn School of Medicine at Mount Sinai describes ways to deal with the feelings of anxiety and depression during this crisis.
Stress levels are high for everybody these days. For people who are already dealing with anxiety and depression, what advice would you give?
Many mental health providers are seeing their patients through telehealth. Should you not be able get to an appointment in person, your provider will likely be available to talk to you by phone or by online chat services like Zoom or Skype. It’s very important that while we isolate ourselves physically, we don’t isolate ourselves from the world or from people. If you can’t talk to your provider, make sure you are talking regularly to somebody, whether it’s a family member or a friend. I encourage people to talk by phone, video call, Skype—or to reach out through social media.
The more we’re in touch with the idea that we’re all in the same boat, the less anxious we may become. Many people with depression and anxiety feel that no one understands them, and this increases the isolation. Right now, a lot more of us are feeling isolated, so we are experiencing feelings that some people struggle with all the time.
Anxiety and depression are heightened by the feeling that no one can understand. But right now, we’re all going through the same thing and this provides an opportunity to really connect with each other as we realize that we’re part of a greater culture and humanity. I see an opportunity for healing, because more people will be able to empathize. Staying connected on social media and seeing what everyone else is going through may help people not feel so isolated.
I imagine being on social media can be a double-edged sword. How do you gauge when you’re exposing yourself to too much social media?
You certainly have to strike a balance. But I think the problem isn’t so much too much social media, but negative social media. It’s a matter of choosing your friends wisely, and choosing what you engage in. Sometimes we engage with people who trigger us with their negativity or politics that we don’t agree with.
But if you have friends who are posting important news information, humorous things, or positive items, this can be a great way to stay connected. It’s a good distraction from all the uncertainty and can be a pleasant way to spend some time. The positives of social media should be used to their fullest. Some people are sharing life-affirming stories about how people are helping each other. My rabbi posted a short, 20-second prayer that you could recite while washing your hands, while being mindful that your actions are helping to protect other people. It can be a time to be inspired and connected to all the positives of humanity when we pull together.
Of course if you have friends who are posting things that you find upsetting, blocking or unfriending those people may help you feel in control at a time when you are controlling much less than normal. And that can be healthy. We have the power to mute negative messages.
What warning signs should you look for regarding anxiety and depression?
If you’ve gone a while without bathing, if you’re not eating, or not caring about getting dressed in the morning, letting the house get messy and out of control, then you should be getting outside help or trying to talk to someone. If you have thoughts that keep coming into your head that you can’t get rid of about becoming infected, or feeling everything around you is unsafe, that is also a sign that you might be getting very anxious. Even though there is truth to the idea that things on the outside might not be currently safe, social isolation, self-quarantine, and taking precautions should make you feel in control. If you can’t feel in control or feel your actions aren’t effective in increasing your safety, that is a warning sign.
We are in a real emergency. So it’s appropriate to have rational plans about worst case scenarios. What will I do if I get a fever or a cough? Do I have enough cough syrup in the house? Do I have a thermometer? These are reasonable thoughts to have, and formulating a plan for those things should provide reassurance. But if they do not, it’s time to reach out to someone.
Mental health is being conducted on hotlines and many medical institutions have been preparing to deliver care like this for quite a while now. This is the day we’ve been preparing for—where people in need can have a reassuring voice on the end of the line that can walk them through their fears and anxieties.
Updated on Jun 30, 2022 | Psychiatry
At the Department of Psychiatry’s March 31 Grand Rounds, Craig Katz, MD, discussed the history of epidemics and the effects on mental health, as well as new COVID-19 data from China.
Craig Katz, MD, Clinical Professor of Psychiatry and Global Health, is the founder and director of Mount Sinai’s Global Mental Health Program. He organized the psychiatric response to 9/11 in New York City through an organization he co-founded, Disaster Psychiatry Outreach, including founding and directing the World Trade Center Mental Health Screening and Treatment Program for 9/11 responders. He has also been deeply involved in researching the mental health toll of child separation at Immigration and Customs Enforcement centers, showing the extent of mental health disorders in detained children.
In his grand rounds talk from Tuesday, March 31, Dr. Katz reviews the impact of prior epidemics on humanity and mental health and discusses common human reactions to infectious outbreaks, factors that influence people’s reactions to them, and how to apply these historical lessons in your own practice. He also covers recently published data on the mental health repercussions of health care workers following COVID-19 in China. His presentation provides us with a bird’s eye perspective on the challenge we are currently facing, and highlights our role in this crisis as mental health care providers. Watch the lecture >
Living through the COVID-19 pandemic can cause stress, anxiety, and depression, not to mention feelings of loneliness and isolation. But when we are under orders to stay at home, it is hard to get help for these issues. Fortunately, telepsychiatry—psychiatry appointments held by phone or video session—are becoming more and more common and enable you to speak with a psychiatrist while maintaining social distancing.