Telemedicine and COVID-19

Telemedicine technology has been around for a few decades but it was never optimally utilized until the COVID-19 pandemic. Insurance reimbursement was a big barrier in utilizing telemedicine along with other systems barriers. In March 2020, COVID-19 was declared a pandemic by WHO. After this, telemedicine was considered the preferred modality of treatment in the health care industry, and insurance supported the use of this technology. This was a big change for all of us as physicians. We all had to adapt to this new technology within days. This transition had its pros and cons, there was a lot of uncertainty about the usage of telemedicine at that time. When the pandemic started, we were worried if we would be able to continue to safely provide care for our patients or not. With telemedicine as a preferred modality, several of us started working from home. It’s been more than a year now since we have been doing Telemedicine and it has been an interesting experience. Some of us love it and some not so much.

Now most of us are comfortable with this technology and some of us prefer virtual over in-person visits. We never thought that we would be able to build therapeutic rapport and feel connected with patients via telemedicine but I have to say that I feel connected. Research supports this as well. A systematic review by Guaiana and et al published in October 2020 in the Community Mental Health journal showed that the efficacy of Telemedicine and in-person visits were similar (1). Several patients prefer using Telemedicine over in-person visits. There are several advantages of Telemedicine visits. From the patient perspective, 1) They can overcome the geographical barrier and save the transportation cost. 2) They don’t have to worry about bad weather. 3) Several patients are very anxious about waiting in the doctor’s office so they like virtual visits. 4) Mobility is another barrier. As with any technology, there are disadvantages of telemedicine as well. Some patients don’t have access to video technology, some patients are not tech-savvy and it intimidates them to use this platform. As physicians, we see several advantages and disadvantages as well. One of the biggest advantages has been the ability to continue patient care during the COVID- 19 pandemic. Patients’ show rate has been better as compared to in-person visits. Psychiatry is more equipped to do Telemedicine as compared to other specialties where physicals are needed to diagnose and treat patients. With the COVID-19 pandemic, research is showing worsening of mental health so demand for mental health treatment is increasing. Maxime. T et al did a retrospective cohort study on 236379 patients who were COVID survivors. They found out that estimated evidence of neurological and psychiatric diagnosis was 33.62 % in the following 6 months post-COVID (2). 

At this time Telemedicine continues to grow in Psychiatry but we still don’t know what would be the future of Telemedicine once the COVID-19 pandemic is over. Will we as physicians and our patients struggle with virtual “ fatigue” or will we continue to like this? Will this pandemic be over or is COVID- 19 here to stay? Will this be a “ new normal” or not? It is hard to answer these questions at this time. It would be appropriate to have a hybrid model where patients and physicians can have the choice to have either virtual or in-person visits depending on what’s best for the patient. As with any other decision-making in health care, we have to weigh the risks and benefits and make our best decision. 

 References-1.Guaiana, G., Mastrangelo, J., Hendrikx, S. et al. A Systematic Review of the Use of Telepsychiatry in Depression. Community Ment Health J 57, 93–100 (2021). neurological and psychiatric outcomes in 236379 survivors of COVID-19: a retrospective cohort study using electronic health records Maxime Taquet, John R Geddes, Masud Husain, Sierra Luciano, Paul J Harrison 

Ruchita Agrawal MD, FAPA
Board Certified Adult Psychiatrist
Associate Chief Medical Officer Adult Services
Seven Counties Services
708 Magazine Street
Phone no. 5025898926
Assistant Professor U of L

2021 KPMA Annual Meeting

Please join us Friday, September 24th, 2021, at the Louisville Boat Club in Louisville, Kentucky for our annual meeting beginning at 8:00am. Presenters will discuss treating insomnia, novel therapies, current trends in tele psychiatry, methods for dealing with challenging patients, and more!

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Raymond Pary, M.D., VA Hospital, VA Staff Psychiatrist and Steven Lippmann, M.D., Retired PsychiatristLouisville, KY

Schizophrenia has a heterogeneous clinical prodrome and variable outcome. It usually occurs with symptoms of delusions and auditory hallucinations. Sometimes, affective presentations include depression or mania, or less often, catatonia with bradykinesia and mutism. Such presentations are often labeled schizoaffective disorder or catatonia, respectively. Clinical patterns alter over time as do lifetime diagnoses and are unpredictably identified even by accomplished psychiatrists. Agitated and/or violent behavior is occasionally observed.

A historical perspective on schizophrenia starts with Emil Kraepelin. In the early 1900s, he attributed degenerative cells in the brain as being responsible for the deteriorating course of illness. The brain pathology is likely genetic and/or related to gene expression, but there are many unanswered questions about the [RP1] role genes have in the neuropathology. Further understanding is needed to understand how the heterogeneous brain connections and circuits contribute to schizophrenia. Diagnoses, now based on subjective clinical symptoms, will in the future hopefully be determined by documentable brain changes. Some amelioration of clinical severity for many patients followed the 1960s advent of administering antipsychotic medications; yet, responses to these drugs is variable.

Sigmund Freud speculated that schizophrenia resulted from disintegration of the ego and separation from reality. Accordingly, the death of the ego produced a loss of self-identity. Unsuccessful attachment to the opposite sex parent and disordered family patterns were thought to contribute to the psychopathology. Paranoid delusions are stress-induced, based on unconscious homosexual impulses. These theories were further elaborated and included the concept of the “schizophrenogenic mother”. Such concepts might have retarded research progress about neurobiology, and there is a dearth of evidence corroborating that mothers actually cause schizophrenic illnesses in their offspring.

Pneumoencephalographic studies reveal that people with schizophrenia have abnormally large brain ventricles. Computerized tomography corroborates this finding. It also suggests that schizophrenia begins in utero as a neurodevelopmental disorder, and that manifestations vary over the life cycle. Ventricular enlargement is not static and appears to exert influence on the illness pathology.

Magnetic resonance brain imaging research among neonates at high risk for schizophrenia reveals that cortical thickness alterations, diminished gray matter volume, and white matter changes occur in the same regions as where pathology is documented in adults with schizophrenia. This supports a neurodevelopmental abnormality. However, structural investigations document non-specific gray and white matter abnormalities that differ among patients and are not diagnostic. 

Positron emission tomography measures blood flow and glucose utilization, depicting abnormalities of brain function. Such investigations evidence deficits in working memory, executive functioning, processing speed, and language production. Imaging studies reveal anatomic abnormalities in the medial frontal cortex, the posterior cingulate cortex, reduced cortical thickness, white matter abnormalities, and enlarged lateral ventricles. The subcortical amygdala, thalamus, hippocampus, and nucleus accumbens are documented to be subnormal in size.

The dopamine hypothesis involving these structures during this illness has undergone refinements over time. In short, the assumption was that hyperactivity of dopamine D2 receptors influence the presence of positive symptoms, while hypofunction of the D1 receptor in the prefrontal cortex may have a role in the negative manifestations of disease. Abnormalities of dopamine may change over different stages of illness and are dependent on other neurochemical systems. These interactive neuronal networks also at least involve glutamate, gamma-aminobutyric acid, and serotonin.

There are progressive alterations in the brains of some patients with schizophrenia. The apparent brain volume changes also might be explained to be imaging artifacts or induced by exposure to antipsychotic pharmaceuticals. The neuropathology leading to hallucinations and delusions remains unexplained. Similar questions apply to the pathological variance among individuals. It is still not established as to whether early detection and treatment mitigate disease progression. Nevertheless, antipsychotic drugs exert a positive influence on the lives of many people with this illness; withdrawing these pharmaceuticals usually yields worsening clinical outcomes for those affected.

Schizophrenia is a disease with genes influencing the development of brain structure and neuronal performance. Alteration of cortical and subcortical structures has pathological consequences for white matter function. These vary between individuals, but abnormalities in neuronal connectivity occurs in many individuals with this illness. Research continues. Antipsychotic medicines generally induce some clinical improvement; yet, there remains no means to cure or fully understand this terrible disease. The neurobiology of schizophrenia is still an enigma.
A Suggested ReadingDelisi, L. The Neurobiology of Schizophrenia. Focus 2020; 18 (4): 368-374

BUTLER HOSPITAL of Rhode Island … plus connections

By Steve Lippmann, M.D.

Well, seems like maybe we are getting over the pandemic. We have lessened coronavirus fears, attenuation of COVID-19 illness severity, and my wife and I are fully vaccinated. Great. With restrictions on travel eased in April 2021, we visited our eldest daughter in Rhode Island. A Brown University emergency medicine faculty member, she was our tour guide; Butler Hospital was among the first things she showed us in Providence. Yes, she took us to the beach, town, medical school, and other affiliated hospitals, too.

Butler Hospital is a very old psychiatric facility and now affiliated with Brown University. What about Butler?

The hospital was founded in 1884 as one of the earliest mental health facilities in this country. It is a huge institution sitting on a surprisingly massive, yet attractive campus that houses numerous buildings, a park-like environment, and even a two-century old farmhouse. Besides the expected many in-patient facilities for psychiatry and addiction medicine, it also hosts a day hospital, and services for social work, a wide variety of offices for other out-patient medical specialties, research facilities, and legal aspects, that include a courthouse. A network of campus roads and parking lots link the numerous buildings.Butler is a base for Brown University’s Psychiatry Department and remains a famous, award-winning mental health hospital. The focus is on psychiatry, addiction medicine, research, and movement disorders, like Parkinson’s disease. They serve adolescents and adults; children, too, had been included, but kids these days go to another affiliated facility. The hospital campus also has a psychiatry emergency evaluation and treatment center with close ties to Brown’s two main Emergency Medicine Departments. Butler Hospital also has an interesting history.

One prominent story is about Dr. William Halsted. He was a famous, early leader in aseptic surgery, use of anesthesia during operations, and numerous innovative surgical techniques. Dr. Halsted was admitted as a patient to the Butler Hospital because of his being addicted to cocaine. At Butler, physicians back then prescribed opiates to attenuate cocaine drug withdrawal, as was the accepted medical practice in those days. Thus, Dr. Halsted got “switched” from cocaine dependance to became opiate addicted; hard to imagine now adays … sad, but true.

Together with the Oxford internist, Sir William Osler, Dr. William Halsted was one of the founders of Johns Hopkins Medical School. It offered excellent, up-to-date physician education. Here now follows a Louisville connection.

Back in those days American medical schools were generally not up to European scientific standards. They were unregulated, often proprietary, and without academic requirements, faculty, or credentialing. Our own Louisvillian, Abraham Flexner was part of a movement that evaluated all American medical schools, closed them, and only allowed reopening only if they met the Johns Hopkins role model for educating new doctors. That included having faculty on-staff in all specialties, providing clinical care to patients, while actually teaching medical students. This reform greatly improved US medical training. Oh, Abraham Flexner Way, a road named in his honor, is in Louisville, running between Jewish Hospital and the University of Louisville of School of Medicine.

By the way, Johns Hopkins Medical School was originally conceived in the 1890s to be built with a big economic donation of railroad stock shares. It was to be a public hospital without race or other restrictions for patient admissions. However, a stock market decline left insufficient funds. The donor’s daughters agreed to help fund the new school, but IF and ONLY if women students were to be admitted under the same criteria as men. The administrators initially refused, but short on money, they finally agreed. Johns Hopkins was then established offering a top-quality medical education as the national role model for all US medical schools to copy. Hopkins also helped begin the concept of admitting women to study medicine in this country. So be it.                                                                

COVID-19: Medical Issues and Responses

by Robert Frierson, M.D. & Steven Lippmann, M.D.

The SARS-CoV-2 virus emerged causing a worldwide pandemic in 2019. Many people in Louisville and the rest of Kentucky were infected during 2020 by its illness, called COVID-19. The population was worried and that bothered the healthcare community, including doctors. Robert Frierson decided in 2020 to formally poll his local physician colleagues about their concerns and hear what they suggested doing about it. 

Doctor’s feared exposure to the virus, transmitting COVID-19 to family members, and/or getting sick themselves; that emerged as one of the initial issues. There was disappointment by all healthcare personnel and the general public about insufficient supplies of personal protective equipment (PPE), even of facial masks or routine gowns. It seemed that we were not response-prepared for this type of viral contagion. Physicians were concerned about diminished ability to be in close clinical contact with patients nor with other medical personnel; families were blocked from visiting relatives, even during emergencies or terminal situations. Patients were even more upset by these separations, and these factors had a negative impact on hospital and clinic staff resilience and morale.

Rates of addiction and psychiatric presentations escalated along with affective illness and overdoses; many people with somatic conditions, fearful of COVID-19, also avoided medical contacts and were suffering from increased and untreated pathology. Societal apprehension concentrated on problems of quarantining with social distancing, along with concerns about employment, education, and unstable or inadequate life-style.

Questioning then focused on what to do about these issues. Doctors reported that talk-time with colleagues and extra consideration in dealing with healthcare personnel was beneficial. Maximizing social connectedness and advocacy in all spheres possible was helpful. They also focused more on enjoying support from the wider community at their “front-line” efforts and took gratification from providing effective healthcare. Also helpful was avoiding overly subscribing to COVID-19 news reporting. Caring for oneself was another benefit: assuring good rest, diet, exercise, balance with family time, and related matters. These responses lead to more satisfaction throughout the medical community and everyone, despite a continued pandemic. Hopefully, it facilitates effective administration of optimal health care for the remainder of the COVID-19 pandemic.