The Behavioral Health Hour

Mad man Don Draper made the midday cocktail iconic in the seemingly real-life drama depicting 1960s ad agency life but in 2020 that midday cocktail is taking on a different meaning and pain for many Americans. Rising use of alcohol during the pandemic has reportedly increased incidence not just of ER visits but underlying medical conditions. In a straw poll of 100 adult males who said they are drinking more now than in March, irritable bowel symptoms such as constipation are a growing issue. Our poll is not scientific but 39% of 94 gastroenterologists and internists confirmed this week that the amount of time they spend on virtual visits talking about alcohol’s effects is higher than normal, and referrals to behavioral health counseling are roughly twice the typical rate. The effect of drinking 5x to 7x a week over a 4-month stretch is elevating dehydration, stomach pain and risk of bowel conditions.

“I already refer a lot to mental health since I see a lot of Crohn’s patients,” says Samantha Winston, a nurse practitioner in a GI practice, “but that’s related to depression or intimacy issues.” The alcohol prevalence, she says, is a new problem tied to societal trends like unemployment, anxiety and lack of social interaction.

Harry Aslanian, MD, a professor and endoscopy specialist at Yale New Haven, says he’s noticed an increase in complaints related to constipation due to alcohol, but has not yet diagnosed a patient with IBD due to alcohol use during Covid.

The impact varies by state and gender and even job. 80% of women in healthcare positions in Texas age 25-34 report increasing use vs. 89% of males and females here from education jobs combined. Montana and Missouri have the highest use based on some adult groups while workers in the hospitality industry generally report the highest use, particularly those 35-55 who are supporting families, but generally out of work, according to stats are from TPS Alert.

In April, addiction treatment company Eleanor Health reported an increase in alcohol-related patients but was tackling the issue through telehealth and data about its patients. At the time, chief medical officer Nzinga Harrison, MD, was worried about the stimulus. “We know that the [government’s] Covid stimulus represents additional relapse risk, so we have proactively approached everyone to execute a safety plan,” she said back in April. (story here)

That worry may resurface as the stimulus runs out and people remain out of work, furloughed or underinsured. Gastroenterologists and internists have been actively embracing telehealth to manage patients, according to Joel Brill, MD, board certified in internal medicine and gastroenterology and chief medical officer at Predictive Health. “Question is will we see people return to the ER when the stimulus runs out.” To counter this, Brill believes efforts by patients to report early and for the GI and internist community to collaborate with behavioral health will be important, both for diagnosis and early management of symptoms. 52% of the GIs say they have started to refer patients to telepsych therapists, others say they are contemplating “hiring” a counselor.

All of this further illustrates the connection between the physician and behavioral health, particularly for conditions typically treated by gastroenterologists. Insurers in states like Maryland and New Jersey in recent years have begun to incentivize GI doctors to do more depression screening and management of chronically ill Crohn’s patients. We would anticipate that the Covid pandemic likely accelerates interest in partnerships among GI practices, internists and behavioral health.

 

Science: About 40% of dementia cases may be prevented or delayed by modifying 12 risk factors, researchers reported this year at the Alzheimer’s Association International Conference. Risk factors include excessive alcohol intake, mid-life head injury and exposure to air pollution later in life. It will be interesting to see how advocacy groups, schools and government at the local, state and federal level adjust policies to limit these dementia risks.

Sports: Kevin Love, a power forward for the NBA’s Cleveland Cavaliers, experienced a panic attack in the middle of a game and he wrote about it in his Player Tribune article. Love said he had a hard time figuring out how to talk about his inner struggles without showing “weakness”. Teens in middle school go through this all the time during travel sports games – they hear coaches yelling and see parents in angst. The anxiety spirals into panic. Love’s struggle has been empowering. He now has appointments to see a therapist and collaborates with the NBA to talk about mental health nationally. Ironically, athletes are at a risk of developing mental illness despite their high fitness levels. Many suffer from too much training, what their parents or friends may think, or for Love, what their fans would think. Young athletes and high-paid pros like Love may seem to live very different lives but they live in the same sports culture that pushes winning. Combating stigma in sports will continue to require coaches, parents and teams to be educated on how to support athletes instead of suppressing mental health issues.

Policy: Use of telehealth to support children on the autism spectrum has skyrocketed since March, representing around one-third of treatment today in some regions, up from just 5% pre-pandemic. Social worker Katherine Wooten works for a behavioral health company, New Directions, says she’s a “convert” but more data is needed to help determine its value, price and place in treatment . Darren Sush, a behavioral analyst who’s now with the insurer Cigna, is impressed with the progress but now wonders what they can learn from this. “We are looking at what has worked and what hasn’t worked and a number of funding sources.” The Association for Behavioral Health and Wellness is urging the government to collect and analyze data on whether audio-only therapy and counseling are effective as a long-term vehicle for care delivery.

Perspective: Between the COVID pandemic, job losses and nationwide protests in response to centuries of racial injustice, the past few months have exhausted the already significant mental health needs of many Black, Indigenous, and non-Black people of color (BIPOC). Youth are the most impacted. School closures have removed access to therapy for BIPOC youngsters and teens and have added to the stress of remote learning and social isolation. Some schools with smaller populations have been resilient, creating “pods” of teachers and therapists who zoom with families and kids daily, offering a lifeline, summer school, live basketball drills and free meal deliveries. It’s something – but this creativity is difficult in larger schools and communities where BIPOC people are less likely to have advocates. In 2019, 14 million students attended a school with a police officer but no counselor, nurse psychologist, or social worker, according to the Agency for Healthcare Research and Quality. As students return to school this Fall 2020, all students will need immediate support to cope with the events of the past several months or the trauma of the pandemic will outlive the virus itself.

Children with autism can have a higher prevalence of oral health issues due to the nature of their neurodevelopmental condition. Autism-targeted oral health education programs as well as the advent of telehealth can go a long way to addressing the problem and helping parents.

Mom-of-three Pamela Stevens has to leave 2 hours early to get her child to the dentist in Newburgh, New York just because he doesn’t want to go.

“He’ll go see his behavioral therapist because his friends are there and it’s more engaging, but he doesn’t want to go to the dentist. He’s scared, and the visits don’t go well.”

Kevin Donly, a professor of pediatric dentistry at UT Health in San Antonio, says as many as 30% of his patients have behavioral health needs but there are options for parents like Stevens.

Children with autism, ADHD and anxiety all in some way need special accommodations, but the solution depends on the level of severity. “If your kid has a mild form of ADHD it just takes a little more time to explain things. You have to be really patient,” says Donly, who recently served as the president of the American Academy of Pediatric Dentists. “We tend to be quick because kids have a short attention span but kids with behavioral challenges need more time to comprehend.”

Parents should not assume all dentists have expertise in working with kids with behavioral issues. In fact just one in three kids who see a dentist see one who has pediatric training and experience, according to Donly.

Seek dentists who can be creative. Donly’s outpatient practice uses techniques:

• Visual supports
• Low lighting
• Noise-canceling headphones

They schedule extra time for visits, too, since some kids with severe autism might need the operating room for general anesthesia. Dentists should spend a lot of time talking to parents first to help them understand that, in some cases, you can’t really work on the kids safely without anesthesia. If your child has the autism diagnosis the insurance companies tend to accept that as a medical necessity argument for having general anesthesia.

Oral health risk prevention is vital as early as age 1 but very challenging for kids on the spectrum. “We make sure the parents have access to fluoride in the tap and to mix it with their orange juice,” Donly says. “We give them mouth props to open their mouths when they’re brushing and show them techniques to use, because with sensory issues the kids don’t love the sensation of their teeth being brushed.”

Brushing Olympics

Kids don’t have brush in the bathroom. Make it more fun. Stevens says her dentist suggested making a game, having her son try to complete a brushing obstacle course by brushing while walking around each room of the house until he touched each room. “It takes him a good 2 minutes, so it’s perfect! He tries to beat his time.”

At home prevention is vital particularly because there are not enough pediatric dentists in the U.S.

By 2030, the American Academy of Pediatric Dentists says there may be enough pediatric dentists to replace those who will retire but Donly sees a bigger problem. “In the state of Texas, for example, it’s very rural and so if you drive out to El Paso there just aren’t enough. So although we may technically have enough to replace, we don’t.” When he talks to lawmakers he points out that there are 10 times more pediatricians than pediatric dentists.

“It’s a distribution problem because it’s not easy to get pediatric dentists out into more rural towns.”

At present, there are only 7,000 pediatric dentists in the entire country vs. 80,000 pediatricians, so a lot of kids go to a dentist without pediatric expertise, without an understanding of autism. “We do our best to train general dentists to see these kids but it’s a challenge.”

Telehealth

In 2020, several insurers began to embrace teledentistry as an option to help during the Covid pandemic and this should expand into the future. Anthem partnered with Teledentistry and Dentaquest partnered with MouthWatch to provide virtual dental check ups in Alabama, Massachusetts, Oregon, and Washington. Teledent offers live video conferencing and file and photo sharing capabilities to help patients receive dental care from home.

This trend can help improve access but may be a valuable way to help children on the spectrum who have sensory issues and don’t do well at the dental office but are accustomed to iPADs and virtual learning. It has potential, says autism specialist Tammy Flores, who believes that with more adoption of virtual therapy for kids on the spectrum there is a “natural connection” to having the oral health check-in done virtually too. “At a minimum the hygienist can take some pictures, check the teeth, have a brushing contest with the kid and then, if needed, the child comes in – this could be really impactful in reducing the number of cavities and gum disease.”

There continue to be a host of ways to head off suicide or talk to a mental health counselor. 988 is now the new number to call to head off a suicide and thank goodness – it’s a heck of a lot easier to remember than the previous 800 number that few used! Hotlines continue to try to hire staff. Didi Hirsh, which operates mental health centers in LA, had 1,800 calls into its hotline in March, up from 22 usually. Crisis centers that are kind of urgent care meets ER have popped up in several cities: Baycare, a health system in Tampa Bay, is readying to create a mental health ER type center funded by private donations, including from pro sports teams. In Missouri,  Greene County commissioners partnered with Burrell Behavioral Health to build a 24-hour crisis center for mental health and addiction in February. Jail and ER avoidance was the goal, says Tom Prater.

But often there’s just no time in crisis and with Covid, access the old fashion way is often best. Nurses Cayce Branyon and Emily Shiflet have a nurse-led triage company, 1st Call Triage, that handles much more than mental health but both acknowledge the volume of calls involving some sort of mental health issue continue to go up. The duo have Carolina roots and took a glass-half-full approach this spring, rounding up 20-some thought leaders for a virtual summit on healthcare after Covid. I give them credit. They were on one hand trying to run their relatively new business, on the other trying to elevate the conversation. I was humbled when they invited me to talk mental health. We wrapped about emerging solutions to the mental health crisis and while I may have gotten on my soap box, hopefully the conversation is helpful.

The interviews are all free to access. You can register by clicking here: https://1stcalltriage.com/summit/

Financial stress has a way of forcing us to change behavior and, well, this is a doozy: 61% of college students will forgo school this year according to our random poll of 417 incoming freshman and sophomores and more than a third of those “taking a break” report plans to try and ‘start up digital businesses’, namely apps, many partnering with fellow classmates and old friends. “I was basically told by my parents that the $45,000 a year for a few virtual classes wasn’t in the cards, which I get – so me and my friends created this app to help parents find home-school teachers this year,” says Wiley Platt, 19, who was due to be a freshman at Illinois. Educators are worried that the break will mean lower enrollment in future or a change in what college becomes. “There’s something about the social experience, the gathering, the teamwork, learning how to think and be on your own that is inevitably lost,” says Norma Saunders, an English adjunct in the New Jersey public university school system.

Read full report on our Mood Monitor.

Nearly half of children maltreated during childhood ended up with depression, addiction or both according to a University of Texas research study. Emotional abuse, rape, sexual assault, the death of a loved one, being the victim of a crime or accident, and catastrophic natural disasters are all examples of traumatic events that may have an impact on addiction. Check out our research page here under “Addiction” for a new resource for families on understanding how trauma affects the brain and the link to substance use.

Science: The national suicide rate had been steadily increasing over the past 2 decades and has increased during the pandemic, but scientists are looking into how primary and specialty care settings can identify early signs to help doctors, nurses, teachers, families and others. The National Institute of Mental Health has a 5-year plan to try and define what’s happening in the brain that might be triggering suicide thoughts.

Sports: The 137^th edition of Harvard-Yale will have to wait until 2021 because the Ivy League cancelled fall competitions. Due to the COVID pandemic, team sports activities are being cancelled at all levels and student-athletes are experiencing mental health issues at 3x the typical level. A recent report from researchers at the University of Wisconsin’s School of Medicine and Public Health found that 68% of student-athletes reported symptoms of depression in May 2020.

Policy:   Lawmakers in North Carolina are pushing legislation that would increase the number of social workers, counselors and psychologists in schools starting in the fall. Another bill would require every school to have a permanent, full-time nurse on duty. School mental health officials expect a greater number of students, teachers and other staff members will return to campuses needing their services. One potential solution to fill the gap if hiring is difficult is using telepsych companies to provide remote interaction for students. One secondary school principal in Carolina, Martin Flanders, said, “It’s not ideal but it’s not going to be easy to hire therapists…we are looking at all options, including a virtual solution”

Perspective: There are some common misconceptions about people with mental illness. I know in my own family we struggled with that with a grandmother with Alzheimer’s and my own mom who battled depression – the path from figuring out why and then how to help can be long and painful, but taking time to talk to youngsters in particular about what mental illness is and isn’t can be impactful. According to research poll we did of physicians, therapists and consumers, the 6 most common misconceptions are (1)  people with mental illness want attention, (2) medications for mental illness are dangerous, (3) mental health is only an issue for people who sick from something else, (4) getting help for mental illness is easy, (5) mental illness can be cured with food and fitness alone and (6) therapy traumatizes people more than it is helpful.

There’s limited consensus on how and when to re-open schools, healthcare facilities, camps and mental health clinics, but there is consensus that re-opening needs to happen safely, and soon. Here are some recent statistics and developments in how schools, camps and the mental health community are beginning to open up services during the coronavirus:

• Akron Children’s Hospital in Ohio has announced the launch of an outpatient clinic to treat children and youth up to the age of 18 with substance use disorders. The new clinic will complement an existing program at Akron Children’s that treats patients with other diagnoses who also have a substance use disorder.
• In Pennsylvania, behavioral health services are reopening under Gov. Tom Wolf’s plan. Masks required, although telehealth remains to be preferred method.
• In Georgia, an opioid treatment center called The Athens Clinic is still postponing face-to-face counseling but is still open during regular hours for getting ‘extra take-home medication’ or receiving ‘Naloxone’.
• In Kansas City, Missouri, non-for-profit behavioral health agency CommCare says their call center has seen a dramatic uptick in calls, particularly in April as the COVID-19 restrictions began to feel relentless for many. Spokesman Keith Davenport says the county’s 24/7 crisis hotline is receiving almost 400 calls per week.
• Online therapy company Talkspace reports a 65 percent jump in new patients since mid-February.
• In Connecticut, school buildings remain closed and summer nears, so there’s growing debate about how to offer physical activity for kids to help with social-emotional and physical development. Re-entry guidelines for camps are very complicated given the point of ‘play’ and the difficulty monitoring kids as they compete and move. One camp is planning small groups of 10 kids to be with a single coach for a 90-minute period on ‘sunshine’ days only, playing games that limit contact, but gets kids running, competing.
• Julia Hoffman, PsyD, says there’s a 10-25 year reduction in life expectancy for those with severe mental disorders, but believes digital behavioral health is growing in value. She believes this will be the newer standard of care. “Thank goodness we walked into this crisis with 15 years experience,” says Hoffman, who heads up strategy for Livongo. Trina Histon, who helps Kaiser Permanente with prevention and wellness, says the wide use of smart phones nationally (about 70-80% of citizens with some access) is vital to accelerating services.

In a sign of the times, San Francisco’s Department of Public Health is collaborating with licensed physicians to distribute “limited quantities” of alcohol, marijuana, and tobacco to addicts in quarantine under the city’s program for housing homeless people in hotels. Private funding will be used. The idea behind this is to have homeless people dealing with alcohol and tobacco use “in these hotels” to protect the health of people who might otherwise need hospital care for life threatening alcohol withdrawal. The administration of the drugs is a “harm-reduction technique” aimed at helping people complete quarantine without having to rely on taxpayer money, according to San Francisco’s DPH. There are an estimated 700 people living on the streets in housing and more rooms are being prepared, especially for those over age 60. During a screening process, the city is offering support to patients “before they enter quarantine” to try to get any substance abuse issues under control.

Homeless healthcare issues have been a challenge nationally, particularly for hospitals. One hospital, St. Francis in Connecticut, said they sometimes have ‘homeless patients’ at their hospital for multiple weeks, in one case more than 35 days, former case management director Lynn Veith noted. “There’s no payer–we are the payer.” These issues are exacerbated during a healthcare and economic crisis, thus the San Francisco response.

In 2018, we profiled a homeless patient in a story that highlighted many of these challenges. Click here for that story.

Wigs for people undergoing cancer treatment are big business, costing upwards of $5,000-a-piece and supported by a national network of non-profits, retail salons and annual fundraisers, but the coronavirus has halted the industry, leaving some small start-ups and non-profits to close and patients, in some cases, left without a custom wig.

Non-profit Locks of Love donates 400 wigs a year but donations are down 25%.

Pantene Beautiful Lengths relies on funds raised from the Relay for Life program “but we’re already cancelling these,” a spokesman confirmed. They made 1,200 real wigs for Chicago cancer patients in 2019, all from Relay funding.

In Omaha, Fresh Hair salon for people with cancer to get the right wig fit is closed “until further notice,” says Fiona Ford, herself a cancer survivor.

Wigs for Kids in Ohio partners with area salons who give people discounts on hair cut donations. “I have 20-30 cuts a week just for this,” says Pam Kleary. But the salon, and others in nearby, are closed. Part of the reason people come to the salons is hairdressers like Kleary know just the right hair length wig makers need.

Not all operations have ceased. Headcovers Unlimited is filling orders from Texas but telling people “to be patient” as the supply chain has slowed. A Dana Farber Cancer Institute customer rep says they are “taking calls” but fundraising from a cancelled bicycle challenge raising $40 million annually will drop. Several women whose daughters underwent treatment for Leukemia ride in the event and created the Pink Wig Gang. They wear pink wigs during the ride and, since 2009, have raised $90,000 for real-hair wigs.

A bounceback seems likely but more important and more costly and will require more help from non-profits and fundraising events. For one, most people are avoiding doctors, particularly primary care offices where hidden symptoms of cancer can be detected. “Leukemia symptoms like bruising don’t always show up so with [primary care physician] visits down there have been fewer physicals, which means fewer CBCs ordered—reducing the likelihood that a physician could catch an abnormal blood count,” says Susan Buchanan, who was an adult Leukemia physician assistant during the 2009 economic downturn. The number of people able to give to wig charities is likely to diminish and the number of people without insurance will drop. Anthem, one of the largest healthcare insurers, estimates around 30% of its members are losing insurance and going to Medicaid or state health plan exchanges. Some of these don’t cover the cost of wigs.

Real hair for cancer patients is more costly vs. synthetic, but also much more popular, a consumer poll of women with cancer found. It can be colored, permed, cut and blow-dried just like normal but it must be re-styled after each shampoo, so most women using wigs have been left without a place to get their hair done. “I know I’m home with just my family but you get used to having your hair done,” says Natalie Filler, a 25-year breast cancer survivor.  Makes you feel normal, less depressed, she says. “It’s not just a wig. It’s hope.”

-Report contribution by Jack Cote, a high school junior studying journalism