The Behavioral Health Hour

It may not be Walter Cronkite with Eisenhower or Barbara Walters with Streisand but in this fireside chat style 2-hour Q&A we tried to go behind the scenes with 5 companies interviewing 7 healthcare innovators around their novel approach to addiction and depression recovery and to changing the path for those with poor housing, food insecurity, PTSD and fall risk from isolation. 5 years ago Ryan Breshears, the chief of behavioral health for Wellstar in Atlanta told me that he didn’t have any luck expanding his unit with financial numbers and data but did eventually win over his board by sharing a patient’s story of recovery (that story here). In this feature program, amazing stories of 6 patients facing immense behavioral health and psychosocial capability are shared – a 28-year-old male with Heroin addiction, a mom of 6 whose youngest has lead poisoning, a 77-year-old widow with dementia and untreated anxiety, a 55-year-old caucasian female, former athlete with schizophrenia and now alcohol addiction, a 60-year-old woman with major depression and 20-year-old confronting PTSD. Their stories, the outcomes and how the health system is trying new models and payment reforms to save money, and lives. Click here to watch the program. Reach out with any questions. -BC

Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States or 18% of the population especially young adults, according to the Anxiety and Depression Association of America, but it is often misunderstood.

Therapist Patrick McGrath, Ph.D. McGrath has treated obsessive compulsive disorder and other forms of anxiety for two decades and says the condition can feel like you’re living in a constant state of “what if this really bad thing happened.”

People often mislabel someone who suffers from anxiety, throwing out words like hypochondriac, antisocial, paranoid or weak, but using these labels so loosely can elevate the person’s anxiety. A hypochondriac, for instance, is someone who lives with the fear that they have a serious medical condition, even though diagnostic tests show there is nothing wrong with them.

Anxiety also has a way of spiraling but the technical term is an “anxiety loop” when the fear of anxiety creates more fear and anxiousness. We’re seeing this now during Covid. “People with anxiety are having a harder time with intrusive thoughts these days – there’s a lot of people afraid of being unwell or passing something on to someone else,” says McGrath. He recommends that people get their information from one good source and to stick to it, rather than risk hearing conflicting things from different sources.

Somatic Syndrome

Someone who is constantly checking symptoms may be called paranoid but may also suffer from what’s called somatic symptom disorder, and the more they check the worse they tend to feel and less reassured they actually become. Calling doctors or looking up symptoms on WebMD at best provide short term relief.

McGrath says people with somatic symptom disorder create symptoms by looking for them and think that “no one cares enough” or takes them seriously, and say “why would I have these symptoms if there wasn’t something wrong with me?” The symptoms are linked–a headache must mean a brain tumor or a scratchy throat must mean throat cancer.

Acknowledgement As Treatment

McGrath says he always starts with a medical diagnostic workup with a person with health anxiety disorder, because otherwise you have nothing to stand on and the patient can argue everything away since a therapist is not a “medical” doctor. The patient thinks “why should I trust you?”

The first level of treatment is response prevention, then layering coping skills.  If you are working with someone with anxiety or if you are parent of a child or teen or colleague dealing with these thoughts, try to help the person break the cycle of safety-seeking behaviors by taking these steps:

• Help them focus on the times that the fear consequence didn’t occur
• Encourage this mantra: “I accept the fact that I have these thoughts, but it doesn’t mean that I have this illness”
• Avoid arguments, because it will just lead to resistance
• Try to say something like, “What you are feeling is real. You’re not crazy. But there may be some influence happening in your head if you’re open to that”
• Help them acknowledge and own the anxiety: “I might feel anxious for the rest of my life but I can learn that it’s not dangerous”

The point is not to teach the person they are not ill, but to teach them that they can handle what they think is going on, to handle the uncertainty. McGrath believes that cognitive behavioral therapy is what works best to help someone with anxiety. Talk therapy doesn’t work, he says, because you need to help change the person’s behaviors.

What To Do When Thoughts Control

McGrath says intrusive thoughts, images or urges often happen in someone suffering from anxiety. These can be obsessions and even compulsions like in someone dealing with OCD.

“A thought or image or urge is not real and it doesn’t have to be reality,” says McGrath. He advises people suffering from these conditions to do things the things that are uncomfortable because they need to believe they can handle it.

That’s the most important thing is treating anxiety disorder.

For example, take a person who is driving and suddenly has a thought to drive off the road or perhaps a person eating lunch with a friend but a thought pops into their of hurting them. Don’t avoid these thoughts, McGrath warns, because avoiding makes it more scary.  To treat this, McGrath will put the person in that situation. He’ll go driving with them and say, “Okay now drive off the side of the road.”  He says this tactic makes the person realize they won’t actually do the thing they are afraid of. Facing it head on it can be effective at shrinking the thought in their minds.

Confronting Fear

There are some conditions that create frightening images for people with anxiety.

Take post partum OCD. It’s not the same as what’s known as post partum depression for new moms. It’s moreso when a mom is afraid of hurting their newborn while bathing them and an image comes up of the child drowning. McGrath says moms in this situation need to know they can handle this, but telling someone to stop having this thought makes it worse. This is called the paradoxical effect of thought suppression.

PTSD trauma is another condition featuring nightmares and flashbacks. McGrath uses a virtual reality simulator for veterans that puts them directly into the reality of being in war. They watch it over and over again, he says, and while vets don’t enjoy the experience it can work.

“Trying not to think of something makes it bigger,” McGrath says. “As a therapist I think about how do we put people in the situations that they’re afraid of?” -EO

As a respiratory virus, COVID-19 predominately targets the lungs and kidneys but a new study is offering evidence that the virus also invades brain cells and about half of patients report neurological symptoms, including headaches, confusion and delirium. The study has not yet been peer reviewed for publication, but several researchers say it provides compelling evidence that COVID-19 could infect the brain in some patients.

Dr. Akiko Iwasaki, an immunologist at Yale University, led the study documenting brain infection in three ways: in brain tissue from a person who died of COVID-19, in a mouse model and in organoids, which are clusters of brain cells in a lab dish meant to replicate the brain’s three-dimensional structure. Their work shows that the coronavirus acts in a stealthier manner than many other viruses known to infect the brain – it chokes off oxygen to cells in the brain, causing them to die without provoking a typical immune response.

“It’s kind of a silent infection” — Dr. Iwasaki, Yale

The virus has a lot of evasion mechanisms, Iwasaki said. Researchers will need to analyze many more autopsy samples to estimate how common brain infection is and whether it is present in people with a milder presentation of the virus or in so-called long-haulers, those who have lingering symptoms for months, and many of whom have multiple neurological symptoms. 40-60% of hospitalized COVID-19 patients experience neurological and psychiatric symptoms, said Dr. Robert Stevens, a neurologist at Johns Hopkins University. But these symptoms are not necessarily due to brain infection; they may be the result of pervasive inflammation throughout the body.

Paranoia, Anxiety, Depression

More research needs to be done, but this new study highlights even more dangerous, potentially long-term effects of COVID-19. Countless interviews with COVID-19 survivors have shown that many struggle with physical and mental health problems long after the virus has left their body. They suffer from depression, anxiety, even paranoia, as they try to recover and get back to their normal health levels. Many who haven’t contracted the virus or experienced physical symptoms are still struggling with the mental health effects of an ongoing epidemic with no end in sight.

-Ashley Chilton

COVID has proven to be alarming for scientists and researchers who are rushing to find answers so much so that 40% of nearly 4,000 STEM Ph.D. students at the University of Minnesota reported symptoms consistent with generalized anxiety disorder and 37% with major depressive disorder, numbers as much as 19% higher compared with 2019.  Microbiologists, meanwhile, are under stress at the Icahn School of Medicine at Mount Sinai of New York as they discovered that the coronavirus has a rare ability to silence alarms that would normally alert the immune system to mobilize antibodies and virus-killing cells.

More than 1.8 million LGBTQ youth seriously consider suicide each year according to The Trevor Project, but the group is using artificial intelligence tools to address the problem. The company created a 24/7 text and chat service and an international social network called TrevorSpace, using hospital admission data and Facebook text and video posts as part of an algorithm to predict and prevent suicide. The algorithm identifies the person who is likely at risk, sends a text with questions such as “How upset are you?” or “Do you have thoughts of suicide?” and then relies on Google’s natural language processing model “ALBERT” to gauge the urgency of response. Trevor dispatches first responders in dire situations while those considered at a high risk for self-harm are bumped up to the top of the queue to speak with a counselor. This doesn’t replace the work of the counselors but enhances the chances of helping someone earlier when every second counts.

“I needed this season…it was supposed to be the one. The one where all that time and effort finally paid off…just like that it’s gone” 

By JACK COTE – Divine Edwards hasn’t played a down of football in nearly 3 years, sidelined two straight seasons after a reoccurring knee meniscus tear and now, with Connecticut high school sports officials cancelling fall football after an announcement September 4^th, an emotional Edwards is wondering what next. “This season was my comeback, to show everyone what I had…my last shot to have a chance at college ball.”

The state’s decision, after months of back and forth debate, is a direct hit to the mental health of high school athletes, particularly seniors, says Jon Evans, a former high school wrestler who’s now a clinical psychologist and CEO for telepsychiatry business, Inovatel, that often counsels youth. Evans worries that athletes will now be entering a second straight season without competition and has already seen evidence of some turning to riskier behaviors to cope.

A new energy had started to blossom throughout the hungry student-athletes here in Connecticut with news at the end of August that officials at the Connecticut Interscholastic Athletic Conference may allow football games. “Yesterday at practice was the first day of pads,” Edwards said. “Everything finally seemed to be normal.”

Brooks McConnell, a senior at Hall High in West Hartford, has been looking forward to leading the charge as a quarterback. “The pandemic is bigger than high school football but I’d say we’re all disappointed and frustrated with the final decision,” McConnell said moments after hearing the news. “I wish they could have had these discussions earlier, instead of making us go back and forth.”

With football cancelled, there is concern about the mental health fallout, not just for athletes but the community that supports high school sports, the pep bands, cheerleaders and alumni. Many have been anxious over the uncertainty about fall sports particularly since many missed out on a spring season. 462 adolescent psychologists polled in May reported a nearly 30% increase in virtual counseling visits with teenagers who were struggling to deal with the lack of competition and social interaction due to Covid cancelling sports in the spring, and a majority of those teens were athletes.

“It’s an athlete’s abyss,” says Mayo Clinic neuropsychologist Paola Sandroni, MD, who believes the mental health rewards of competing and team sport are vital particularly for youngsters.

Edwards said he was “heartbroken” after hearing the CIAC news. He had worked hard after tearing his meniscus in the first game of his sophomore year. “After surgery, I crutched my way to every practice and game. Sometimes I didn’t have a ride to physical therapy and would have to crutch my way there after school.”

Despite the setback, Edwards never stopped working. He took the time to be in the weight room every day and after his knee healed he was in the best shape of his life. “I wish the CIAC knew how much this sport means to me and my teammates. I honestly don’t know what to do now.”

The CIAC had arguably an impossible task.

Simon Gregg, the CIAC’s associate executive director, acknowledged the board’s focus. “The mental health of our student athletes is critical to us right now,” Gregg said in our interview.

Two days before the decision was made, Gregg explained how the CIAC was working with public officials to try and mitigate risk and give a green light for all fall sports.

As a basketball player and cross country runner myself, and trombone player for the football pep band, I emphasized to Gregg the importance of practices, conditioning and team bonding, the mental health benefits. Whether the games would have happened or not, the most significant target should be student-athletes getting the chance to compete with one another, play the sports they love, and make the most of the situation we find ourselves in.

The connection between mental health and sports has deep history and implications that go beyond the pandemic. Athletes can enter an abyss when they get cut from a team, lose playing team, get injured like Edwards, or lose the opportunity to play, compete or enjoy the rewards of team camaraderie or personal sport success, according to Evans.

“Wrestling was vital to me as a youngster – the competitions gave me confidence – I was stronger mentally even in defeat.”

The psychologist is concerned that as more sports seasons are cancelled some may start in on riskier behaviors, like alcohol, drug abuse or eating disorders.

According to the Athlete Mental Health Index, high school athlete mental health dipped drastically from March to May. The index (click here) has chronicled the mental health of 1,362 people including 480 high school athletes in the US since 2010 and this is the first time mental health dipped so low nationally. The index evaluates an athlete’s satisfaction with their sports experience including the level of competition.

With the expected increase in mental health challenges from sports cancellations, several coaches are trying to do their part to help. In New Jersey, football coach Bill Kvaleim started a clothing company called Tackle Depression to promote anti-stigma messages on hats and hoodies. Parents can find a mental health therapist directory, or volunteer, on the “Tackle” website. Many states, including New Jersey, Connecticut and New York, now have new laws requiring Kindergarten to 12th grade schools to teach mental health and provide more support to teens.

But even when sports come back full time, there is a broader question of physical education and its importance in enhancing mental health and reducing the incidence of depression, anxiety and addiction. Susan Matai, who works as an administrator at a high school in New Mexico, says physical education is vital not just via sports teams but for the entire study body, but many schools like hers in Albuquerque lack the resources to put on these programs. At Matai’s school, the only PE available before or after school is organized sports. ‘It is greatly encouraged at this school that students be involved, but there are limits as to how many can be on the teams and there are no other outlets available.”

Programs that can figure out how to provide safe, Covid compliant sports activity will likely be vital particularly if winter sports are also cancelled. Perhaps Divine Edwards workouts during his 2-year injury are a bit of hope. “I still took the time to workout,” he said smiling. “Even got a personal record of 245 on the bench.”

Editor’s Note: Jack Cote is a high school senior at Hall High School in West Hartford. He will tell you he has had his “moment” here as a sophomore but now he is still holding out some hope that he can play a little trombone from the bleachers this fall while his buddies Divine and Brooks march the Warriors down the field for a game-winning drive. One can dream.

-Story contributions from Jack’s dad and The Behavioral Health Hour staff

The coronavirus pandemic has exacerbated pregnancy related risks globally, including in Ecuador, which has one of the two highest rates of adolescent pregnancy in South America. 1 in 5 girls give birth before age 18 in the South American country and now with the pandemic, complications from pregnancy in risky populations – both teens and adults – are exacerbated.

Due to the isolation of Covid, pregnancy is leading to more depression and anxiety than usual as well as less access to care, particularly in rural areas in North, Central and South American countries. This depression elevates the risk of early term birth, brain development and hospitalization, including mortality of child or mother, according to Barry Lachman, MD, a pediatrician who worked for the Parkland Health System in Dallas Texas for 30 years.

Early education and screening for depression are ways some US health systems and health plans are trying to reduce these risks, though Covid has complicated or delayed the ability to conduct these initiatives. Telehealth screening and education are options and will be important systems to put in place.

There is evidence that a mom’s extreme stress can affect fetal brain development. A study published earlier this year in JAMA Pediatrics found differences in fetal brain growth among pregnant women who were psychologically distressed. Stress levels have tripled in women pregnant during the pandemic, according to The Developing Brain Institute at Children’s National Health System in Washington D.C, which first surveyed pregnant women about their stress levels in 2014. 50% reported experiencing moderate to high levels of anxiety this year, up from 18% in 2014, while 35% felt depressed compared to 12% in 2014.

The sample had just 35 patients so researchers suggest a broader study to further understand implications.

Expectant mothers are also likely at an increased risk of getting the COVID-19 virus, according to the Centers of Disease Control, but unlike the Zika virus of 2016, there is no evidence that COVID-19 infection during pregnancy can directly impact the growing fetus.

The global pandemic has made pregnancy challenging in other unexpected ways. New mom Sara Littau, 26, of Connecticut, says her due date was square in the middle of the pandemic in April so she wasn’t able to bring her husband to appointments. “I pretty much stopped doing anything outside of the house aside from going for walks around our neighborhood to stay safe,” Littau says.

Post pregnancy challenges are arising as well. The incidence of postpartum depression was already high but with less of a support system able to help due to Covid travel restrictions, the number of new moms suffering from this is increasing. An OBGYN in North Carolina says 65% of moms who delivered during Covid are “having serious postpartum depression,” up from what is usually 20-30%, Pamela Fines, MD, says. Having Facebook or other video connection with family helps, but Dr. Fines says it doesn’t “treat” the depression.

The University of Pittsburgh in Pennsylvania created a remote monitoring program last year that has helped address postpartum. That story by clicking here

Families have had to make accommodations to have relatives meet their new child through a window, glass door or just through a phone screen. “Once we brought our son Nolan home we had originally planned to let visitors come and see our son after a few days, but the pandemic changed that plan completely,” Littau says. “We had visitors come over and see Nolan only through our sliding glass door.”

The delivery of a baby is different now than it was six months ago with new safety guidelines, extra layers of personal protective equipment and everyone wearing masks. Although it looks different, the same compassion and care is going into the delivery as before though telemedicine visits are more prevalent during the 9 month pregnancy to connect parents, families and doctors. Mothers typically need to do a COVID-19 test before being admitted into the hospital for safety measures and no visitors in the hospital.

Littau’s biggest fear was not having her husband in the delivery room but she ended up having an amazing experience at Bristol Hospital. “From the moment we entered my hospital room in the maternity wing it felt like we were in our own little bubble and the coronavirus didn’t exist there. The nurses and doctors did such a great job at making everything feel as normal as possible. I didn’t worry about the virus once while we were in the hospital. I felt safe.”

Parents now must pay close attention to their mental health when they’re in the postpartum phase because even under normal circumstances it’s extremely exhausting to have a newborn but during a pandemic it’s even more so.

Littau is thankful to have her family healthy and safe during the pandemic. “We spend a lot of time outside and together as a family of three. I continue to just look at the bright side of things and I feel blessed to have a happy and healthy baby, at the end of the day that’s really all the matters.”

-Report by Erin O’Donnell

Science: The University of California Irvine Health (UCI) just opened its Newport Beach clinic location, the first to offer a science-based medicine comprehensive model combined with a philosophy of care that makes use of all therapies and disciplines to achieve optimal health. The clinic will consider all aspects of patient mind, body and spirit. Services will uniquely include mindfulness and naturopathic medicine, sports medicine and massage therapy.

Sports: “Tackle Depression” is a non-profit in New Jersey trying to break-the-stigma of mental health with an online clothing store that your teen might enjoy, featuring Adidas snap-back hats and hoodies with anti-stigma messages on them. A high school coach started the clothing company to help athletes and coaches consider the importance of mental health in athletics, including how to look for signs of depression and how words can have a powerful effect on mental health.  Tackle Depression’s website features a mental health directory for the State of NJ and features volunteering opportunities. Founder Bill Kvalheim is a football coach and is diagnosed with depression and anxiety. A new law in New Jersey requires that schools from K-12 teach about mental health.

Policy: Many people on the autism spectrum cannot wear a face-covering due to sensory issues because it causes them great distress.  Robyn Thom, MD and Karen Turner, OTR/L at Harvard Medical School, say trying on different masks to find one that is very comfortable and planning initial outings in low-demand environments that are quiet and calm can help make a person comfortable. Or use an “ear saver” to clip mask loops behind the head instead of around the ears, according to North Carolina’s autism society chapter. In England, the government has an exemption for severe distress and the National Society of Autism provides a downloadable “I am Autistic” card that can be shown to transportation staff, public or British transport police. You do not need to prove you are autistic to be exempt, but for a person on the spectrum it may be comforting.

 

Project Angel Food in California provides over 2,000 meals a week during the pandemic to the frail elderly and people with serious illnesses, such as heart disease, or those coming out of surgery like a bypass, up from 1,600 meals a week in 2019. God’s Love We Deliver, a New York non-profit, also reports a record number of home deliveries since March. But their outreach doesn’t simply end at delivering meals.

“We aren’t Amazon or UPS”, says Project Angel Food’s Executive Director Richard Ayoub.

Volunteers also engage with recipients, ask them how they are doing, and then report anything problematic they see, like uneaten meals. That 5-minute connection is vital, Ayoub says, as 60% of Project Angel’s clients may not see anyone else that day. The homebound older woman with osteoarthritis, or the man dealing with a serious heart condition and both struggling with depression and anxiety – these can be lonely, at-risk populations. But with organizations like Project Angel Food, the meal delivery can act as an opener to something just as important: conversation.

Additionally, depression is common in those with heart disease and those coming out of cardiac surgery and can often leads to dehydration, which raises the risk of falls in the home.

Support for these home based initiatives was growing nationally even before the pandemic, coming not just from traditional federal and state funding, but also from health insurers and hospital systems realizing that “food is medicine”.  L.A. Care Health Plan, for example, which provides healthcare coverage for Los Angeles county residents, funded a refrigerated van and partial salary for a nutritionist for Project Angel Foods as part of an effort to provide meals tailored to those with chronic conditions such as HIV/AIDS, heart or kidney disease, and uncontrolled diabetes.

And while the value of the pre-meal companionship may be hard to quantify today, it is likely to be an increasingly relevant measure of the potential of these programs to limit costs like hospitalizations or falls or mortality.

In one landmark study, the continued presence of depression after heart surgery recovery increased the risk of death to 17 percent within 6 months after a heart attack vs. 3 percent in heart attack patients who didn’t have depression. During recovery from cardiac surgery, depression can intensify pain, worsen fatigue and sluggishness, or cause a person to withdraw into social isolation, says Leo Puzuelo, MD, who’s a physician in the Cleveland Clinic department of psychiatry. Patients who have had a cardiac event and have untreated depression after surgery also have increased morbidity and mortality.

Even the youth market’s experience with heart health and depression is relevant. A reported 29% of athletes developed eating disorders during their 7th to 11th grade year in one study, citing the pressures of remaining in top shape to ensure a scholarship. But from this disorder emerged complications, like lost weight which led to dangerously low heart rates and hospitalization in several cases. Average length of stay in a hospital is close to 3 weeks for these patients, our study found. A new model has been developed that combines virtual counseling and online support groups from companies like Talkspace combined with tailored healthy meals.

The connection between heart disease and depression is not just a US phenomenon. African and South American countries report high incidence of the diseases. Mortality due to ischemic heart disease increased in Ecuador, for example, from 2001-2016, and it is estimated that at least a quarter of those who died also suffered depression that started after their diagnosis. “It increases morbidity and mortality risk across genders, particularly when the person lacks a support system and education and access to counseling,” says Yvonne Swyth, a counselor for heart patients in Florida.

Centers dedicated to being efficient in a potential suicide and handling high-risk mental health situations are popping up in a number of US cities. They are funded typically from a combination of corporate, hospital, university and sometimes government funds, and they are designed to give police a better place to bring people who are in a crisis and free up crowded hospital ERs. In Springfield Missouri, Greene County commissioners and the leader of Burrell Behavioral Health created a 24-hour crisis center for mental health and addiction in February 2020 . Jail and ER avoidance is the goal, says Tom Prater, a co-chair of the Healthy Living Alliance’s Mental Health and Substance Use Task Force. In Tampa Florida, the CEO for health system Baycare is pushing a similar model. A local pro sports team may even support it. In this 20-minute podcast, we talk about these new models, where they fit and triaging these high-risk situations: