Tagged Psychiatry and Psychiatrists

‘Busy Inside,’ a New Documentary, Explores Dissociative Identity Disorder

The condition, formerly called multiple personality disorder, affects a surprising 1 percent of the population.

Twenty-eight-year-old Marshay refers to herself as “the Little One” and says she feels as if she was born six years ago. Her mother knows something really bad must have happened to her when she was very young, although she doesn’t know what happened. When she asks her daughter why she thinks she’s still a small child, Marshay answers, “I don’t remember anything. I don’t want to grow up. I want to stay little.”

Marshay’s brain periodically seeks a safe haven, a persona where she feels immune to some horrific abuse she apparently suffered early in life. She has other identities as well who “come out” when provoked by certain triggering events and she needs these alternate identities to feel safe.

Marshay is one of several people with dissociative identity disorder who are featured in a new documentary called “Busy Inside,” available on public television’s World Channel: America ReFramed. It can be watched free online through April 15. She is among a surprising 1 percent of the population with this psychiatric condition, formerly called multiple personality disorder, which was famously portrayed decades ago in films like “The Three Faces of Eve” and “Sybil.” It mostly affects women.

The new film shows the challenges involved in learning to live with the disorder. Still, most of those affected never seek professional help until and unless their lives become unmanageable.

Karen Marshall, Marshay’s therapist, a licensed social worker, also has the disorder, and told me that 17 different personalities inhabit her psyche and can emerge from time to time. She suffered severe sexual and physical abuse as a young child at the hands of her mother, and said she experienced tremendous relief when she died “and couldn’t hurt me anymore.” She says her own trauma, and the ways she learned to manage it, has helped her be an effective therapist.

Dr. David Spiegel, a Stanford University psychiatrist who gave the disorder its modern name, explained, “We develop our identity in childhood, and if you’re abused by someone who is supposed to love and protect you, you try to detach yourself from” that abusive situation. “In extreme forms, you assume other identities. It becomes a disorder.” The hippocampus, a part of the brain that deals with stress, may shrink and cause an extreme sensitivity to stress hormones, he said.

Early in life when the brain can’t handle something, “it puts it in a little box in the brain,” Ms. Marshall said. Then something else it can’t handle goes into another compartment in the brain, and so forth, resulting in some people developing different personalities, any of which can take over for a time.

A woman in the film named Sarah who has seven or eight identities describes her childhood trauma as being in a freezing cold basement with few clothes on and two men grabbing at her while others stood around laughing. “I can see this happening but I can’t stop it,” she recalls. “The monster keeps coming out, obliterating everything.”

In the documentary, Ms. Marshall encourages Marshay to accept herself as an adult woman with many facets, saying reassuringly, “We all have different roles, and we all wear different masks in a way.”

For those with the disorder, when an alternate identity takes over, the person may lose track of time and have no memory of what the other personality did while it was “out.” Ms. Marshall said one woman she treated had an alternate personality who was a shoplifter and when she reverted to her main identity, had no idea how she had acquired all the things in her apartment.

Dissociative identity disorder is both underdiagnosed and often misdiagnosed as depression or anxiety disorder and consequently mistreated, Dr. Spiegel said. Once affected individuals acknowledge that they have a problem, it takes an average of six years for them to learn what is causing their symptoms if they should seek help, Dr. Spiegel said.

Some people with the disorder never do, and somehow manage to live normal lives until and unless something very stressful causes their alternate identities to take over and disrupt their ability to function. For example, Ms. Marshall told me, one person in the film performed well as a company executive for many years until a family trauma so unnerved her that her identities split, very hostile and disabling personalities emerged and she could no longer do her job.

Dr. Spiegel said some people with the disorder “are afraid of treatment or ambivalent about it; they don’t believe I’m here to help them because, based on their history, they see helpers as potentially harming them.”

Alternate identities can also emerge at the same time, as if the person is two people who oppose one another. The identities develop specialized roles, coming out under certain circumstances, Dr. Spiegel said. For example, one identity may “protect” against another that might be aggressive or harmful. The protective identity may think, “I’m going to stay out while so-and-so is around,” he said. As Ms. Marshall explained, people can have one or two identities that act as gatekeepers, keeping the others inside.

In treatment, by identifying and emphasizing the person’s core values and beliefs, the person’s adult identity that enables them to function normally can learn to take over for identities that are distressing or troublemakers, Ms. Marshall said.

Her approach to treatment does not necessarily try to rid people of their alternate identities unless, of course, that’s what they want to accomplish. Rather, she said, they may learn to use their alternates constructively so they can live a normal life as an adult in society.

Also helpful is learning to recognize circumstances that can prompt a distressing identity to emerge and temporarily replace the adult persona. Ms. Marshall said she has learned, “If I’m tired or sick or stressed, I can end up splitting,” and a childlike personality emerges.

As in post-traumatic stress disorder, people with multiple identities can have flashbacks and experience their abuse all over again. Ms. Marshall said, “I don’t watch shows about child abuse.” In treating dissociative identity disorder, she said, “I try to get the ‘Little Ones,’ who were traumatized, to know they’re safe, that they’re not going to be hurt again.”

Dr. Richard P. Kluft, a psychiatrist in Bala Cynwyd, Pa., focuses therapy for the disorder on providing “good, caring, nurturing, comforting support” that helps patients feel safe. “The mind starts to heal in the face of loving care,” he said. Both he and Dr. Spiegel often use hypnosis to facilitate therapy and teach patients how to calm themselves down with self-hypnosis between sessions.

For patients reluctant to leave behind their “rich inner world,” Dr. Kluft says he welcomes all parts of their personality, helping their various identities learn to empathize with and respect one another.

Ms. Marshall said that as people with multiple identities start to get healthier, “they can look at what they’re feeling and experiencing and then make a different choice. They can learn to use their alternates constructively so they can function in society as an adult person,” which Marshay is gradually learning to do.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Published Feb. 23, 2021Updated Feb. 24, 2021, 5:00 a.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Feb. 23, 2021, 3:48 p.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.

Mental Health Providers Struggle to Meet Pandemic Demand

‘Nobody Has Openings’: Mental Health Providers Struggle to Meet Demand

With anxiety and depression on the rise during the pandemic, it has been challenging for people to get the help they need.

Credit…Jo Zixuan Zhou
Christina Caron

  • Feb. 17, 2021, 5:26 p.m. ET

After Jessica W. was laid off from her job as an executive assistant in November, she began backsliding into the eating disorder that she thought she had overcome.

“I started to not want to eat again,” Jessica, 33, said. “Those thoughts and behaviors — they’re just debilitating and they drain you. It becomes a constant battle with yourself.”

Jessica, whose last name has been withheld to protect her privacy as she searches for a new job, was also struggling with anxiety and depression. So she went online and started searching for mental health providers in Connecticut, where she lives. One of the therapists she called wasn’t accepting new patients. Two of them told Jessica that they didn’t have the right skill sets to help her. Others simply didn’t respond.

“It’s emotionally draining to tell your story,” she said. “You have to be resilient.”

Since the first coronavirus case was confirmed in the United States more than a year ago, the number of people in need of mental health services has surged. But many say that they are languishing on waiting lists, making call after call only to be turned away, with affordable options tough to find. Providers, who have long been in short supply, are stretched thin.

“Never at any time in my practice have I had a five-person waiting list,” said Brooke Huminski, a psychotherapist and licensed independent clinical social worker in Providence, R.I., who specializes in treating people with eating disorders.

Dr. Gregory Scott Brown, the director of an outpatient psychiatry clinic in Austin, Texas, said he recently had to hire an additional nurse practitioner to help care for more patients. “I’m busier than ever and just don’t have room,” he said. “I’m full.”

A rise in demand

According to an American Psychological Association poll of nearly 1,800 psychologists published in November, 74 percent said they were seeing more patients with anxiety disorders compared with before the pandemic, and 60 percent said they were seeing more patients with depressive disorders. Nearly 30 percent said they were seeing more patients overall.

But according to Vaile Wright, the senior director of health care innovation at the A.P.A., this might not capture the full extent of the demand for mental health practitioners because the survey did not ask the therapists whether they had to turn away clients because they were already booked.

“There’s always been more demand for services than there are mental health providers to provide them,” Dr. Wright said. “I think what the pandemic has done is really laid bare that discrepancy.”

Online therapy platforms have seen a rise in demand during the pandemic as well. Mindy Heintskill, the chief growth officer of MDLive, a telehealth provider with more than 62 million members in the United States, said their online therapy and psychiatric care services increased fivefold in 2020 compared with 2019. Nearly half of these patients cited stress and anxiety as the main reasons for scheduling their visits, Ms. Heintskill added.

In August, the Centers for Disease Control and Prevention published a report which concluded that in late June, 40 percent of adults in the United States had been struggling with mental health or substance abuse issues, and rates of depression and anxiety had risen since 2019. In addition, a study of almost 190 million emergency department visits found that visit rates for mental health conditions, suicide attempts, drug overdoses and child abuse and neglect were higher in mid-March through October 2020, than the same period in 2019.

While companies that provide online counseling or psychiatric services like MDLive, Talkspace and BetterHelp have helped to improve access for some, mental health experts have said that these outlets cannot alone address the chronic inequities and provider shortages that were already plaguing the country.

A 2018 study published in the American Journal of Preventive Medicine found that there was an unequal distribution of psychiatrists, psychologists and psychiatric nurse practitioners across the United States, with more pronounced deficiencies in non-metropolitian counties.

‘Every single person I see needs therapy right now’

Ms. Huminski, the psychotherapist in Rhode Island, has tried to accommodate more patients by scheduling people at odd times, but that hasn’t been enough, she said. She can no longer take new clients, in part because her current ones are seeking more sessions than they have in the past. She would offer to make referrals, she added, but “nobody has openings right now.”

Even Ms. Huminski’s local hospital, which has an intensive therapy day program where she sometimes refers patients, is fuller than usual. In the past, she said, it would usually take up to four weeks to get in. Now, she added, it’s around four months.

Jennifer Kittler, a clinical psychologist who is also based in Providence, said that she, too, has had almost no availability for new clients over the past 10 months. As her case loads have increased, she’s taking steps to prevent burnout.

“In my case, it has led to my being less willing to extend my hours or schedule — in an effort to prioritize family time and self-care,” said Dr. Kittler, who is working from home while her 12-year-old learns remotely for at least half of the week.

Finding the right team can be even more difficult for patients who require both a psychiatrist and a therapist.

“Every single person I see needs therapy right now,” said Dr. Jessi Gold, a psychiatrist based in St. Louis, Mo., who mostly sees college students and health care workers. “They come back and say, ‘I’ve called 20 people and I don’t know what to do.’”

Bailey, 27, a medical student in New York who did not want to use her last name for privacy reasons, said that last fall she started searching for both a therapist and a psychiatrist who took Medicaid and was “striking out all over the place.”

In November, she spoke to therapists from the Telemedicine platforms BetterHelp and Happier Living, but the cost per session was too much for Bailey to afford long-term. Earlier, she had tried speaking with the therapist at her medical school, but “our personalities just didn’t click,” Bailey said.

She’s currently on several wait lists and is receiving psychiatric prescriptions from her primary care provider.

As for Jessica, who had been searching for a therapist and a psychiatrist in Connecticut, after two weeks of intensive research she finally located an in-network therapist, and recently started seeing an out-of-network psychiatrist.

In many ways, Jessica was more fortunate than most. She still had insurance through her husband’s employer. And she was already well versed in the process of finding mental health providers.

“I have my insurance card ID memorized,” she said. “Like, that’s not normal.”

How to find help if you’re struggling

If you need to see a mental health provider but can’t find one that is taking new patients, don’t just say ‘OK’ and hang up after calling them, Dr. Brown said.

“Ask if they happen to know someone who may be accepting new patients,” he said. “Usually, if I’m not able to help, I can surely point a potential patient in the right direction to a colleague who can.”

If that leads to a dead end, you might try asking a primary care provider for referrals or treatment.

“Some of them do have enough basic training in mental health to be able to help a little bit,” said Dr. Amy Alexander, a psychiatrist who sees students at Stanford University. “Some are even comfortable starting medications for mild to moderate mental health problems.”

If you still can’t find help, try calling local colleges or universities and ask to see a clinician in training. Large academic institutions with outpatient psychiatry departments might also have appointments or provide referrals. Consider also expanding your search to other types of experts. If you were hoping to see a psychologist, a licensed clinical social worker might be a comparable option. Or if you were planning to see an individual provider, think about group therapy options.

Psychology Today maintains a large list of providers that you can filter by location, type of insurance covered, specialty or other criteria. The federal government also has a website where you can search for facilities that treat substance use disorders, addiction and mental illness.

If you’re looking for support groups, check out the resources at the National Alliance on Mental Illness, the National Eating Disorders Association, Alcoholics Anonymous or the Depression and Bipolar Support Alliance.

For those with insurance, an in-network provider will typically be the most affordable option. But if you can’t find someone, check if your plan has out-of-network benefits to help broaden your choice. Online therapy services may also be worth exploring since they can help you speak with someone quickly and in some cases, may reduce out-of-pocket costs.

If you are uninsured, search for providers who offer low- or no-cost options. You may find some who charge fees based on a sliding scale, or interns or postdoctoral fellows at private group practices who may see clients at lower fees, Dr. Kittler said. And government-funded community-based health care centers provide care to patients regardless of ability to pay.

If you have a job, check whether your employer offers certain benefits, like a flexible spending or a health savings account, which allow you to use pretax money for certain medical expenses.

Finally, if you are having serious symptoms that need to be addressed quickly, go to your local emergency room. The doctors there are trained to address mental health crises, Dr. Alexander said.

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).

How Many Are Struggling to Book Appointments With Mental Health Providers Through Pandemic

‘Nobody Has Openings’: Mental Health Providers Struggle to Meet Demand

With anxiety and depression on the rise during the pandemic, it has been challenging for people to get the help they need.

Credit…Jo Zixuan Zhou
Christina Caron

  • Feb. 17, 2021, 5:26 p.m. ET

After Jessica W. was laid off from her job as an executive assistant in November, she began backsliding into the eating disorder that she thought she had overcome.

“I started to not want to eat again,” Jessica, 33, said. “Those thoughts and behaviors — they’re just debilitating and they drain you. It becomes a constant battle with yourself.”

Jessica, whose last name has been withheld to protect her privacy as she searches for a new job, was also struggling with anxiety and depression. So she went online and started searching for mental health providers in Connecticut, where she lives. One of the therapists she called wasn’t accepting new patients. Two of them told Jessica that they didn’t have the right skill sets to help her. Others simply didn’t respond.

“It’s emotionally draining to tell your story,” she said. “You have to be resilient.”

Since the first coronavirus case was confirmed in the United States more than a year ago, the number of people in need of mental health services has surged. But many say that they are languishing on waiting lists, making call after call only to be turned away, with affordable options tough to find. Providers, who have long been in short supply, are stretched thin.

“Never at any time in my practice have I had a five-person waiting list,” said Brooke Huminski, a psychotherapist and licensed independent clinical social worker in Providence, R.I., who specializes in treating people with eating disorders.

Dr. Gregory Scott Brown, the director of an outpatient psychiatry clinic in Austin, Texas, said he recently had to hire an additional nurse practitioner to help care for more patients. “I’m busier than ever and just don’t have room,” he said. “I’m full.”

A rise in demand

According to an American Psychological Association poll of nearly 1,800 psychologists published in November, 74 percent said they were seeing more patients with anxiety disorders compared with before the pandemic, and 60 percent said they were seeing more patients with depressive disorders. Nearly 30 percent said they were seeing more patients overall.

But according to Vaile Wright, the senior director of health care innovation at the A.P.A., this might not capture the full extent of the demand for mental health practitioners because the survey did not ask the therapists whether they had to turn away clients because they were already booked.

“There’s always been more demand for services than there are mental health providers to provide them,” Dr. Wright said. “I think what the pandemic has done is really laid bare that discrepancy.”

Online therapy platforms have seen a rise in demand during the pandemic as well. Mindy Heintskill, the chief growth officer of MDLive, a telehealth provider with more than 62 million members in the United States, said their online therapy and psychiatric care services increased fivefold in 2020 compared with 2019. Nearly half of these patients cited stress and anxiety as the main reasons for scheduling their visits, Ms. Heintskill added.

In August, the Centers for Disease Control and Prevention published a report which concluded that in late June, 40 percent of adults in the United States had been struggling with mental health or substance abuse issues, and rates of depression and anxiety had risen since 2019. In addition, a study of almost 190 million emergency department visits found that visit rates for mental health conditions, suicide attempts, drug overdoses and child abuse and neglect were higher in mid-March through October 2020, than the same period in 2019.

While companies that provide online counseling or psychiatric services like MDLive, Talkspace and BetterHelp have helped to improve access for some, mental health experts have said that these outlets cannot alone address the chronic inequities and provider shortages that were already plaguing the country.

A 2018 study published in the American Journal of Preventive Medicine found that there was an unequal distribution of psychiatrists, psychologists and psychiatric nurse practitioners across the United States, with more pronounced deficiencies in non-metropolitian counties.

‘Every single person I see needs therapy right now’

Ms. Huminski, the psychotherapist in Rhode Island, has tried to accommodate more patients by scheduling people at odd times, but that hasn’t been enough, she said. She can no longer take new clients, in part because her current ones are seeking more sessions than they have in the past. She would offer to make referrals, she added, but “nobody has openings right now.”

Even Ms. Huminski’s local hospital, which has an intensive therapy day program where she sometimes refers patients, is fuller than usual. In the past, she said, it would usually take up to four weeks to get in. Now, she added, it’s around four months.

Jennifer Kittler, a clinical psychologist who is also based in Providence, said that she, too, has had almost no availability for new clients over the past 10 months. As her case loads have increased, she’s taking steps to prevent burnout.

“In my case, it has led to my being less willing to extend my hours or schedule — in an effort to prioritize family time and self-care,” said Dr. Kittler, who is working from home while her 12-year-old learns remotely for at least half of the week.

Finding the right team can be even more difficult for patients who require both a psychiatrist and a therapist.

“Every single person I see needs therapy right now,” said Dr. Jessi Gold, a psychiatrist based in St. Louis, Mo., who mostly sees college students and health care workers. “They come back and say, ‘I’ve called 20 people and I don’t know what to do.’”

Bailey, 27, a medical student in New York who did not want to use her last name for privacy reasons, said that last fall she started searching for both a therapist and a psychiatrist who took Medicaid and was “striking out all over the place.”

In November, she spoke to therapists from the Telemedicine platforms BetterHelp and Happier Living, but the cost per session was too much for Bailey to afford long-term. Earlier, she had tried speaking with the therapist at her medical school, but “our personalities just didn’t click,” Bailey said.

She’s currently on several wait lists and is receiving psychiatric prescriptions from her primary care provider.

As for Jessica, who had been searching for a therapist and a psychiatrist in Connecticut, after two weeks of intensive research she finally located an in-network therapist, and recently started seeing an out-of-network psychiatrist.

In many ways, Jessica was more fortunate than most. She still had insurance through her husband’s employer. And she was already well versed in the process of finding mental health providers.

“I have my insurance card ID memorized,” she said. “Like, that’s not normal.”

How to find help if you’re struggling

If you need to see a mental health provider but can’t find one that is taking new patients, don’t just say ‘OK’ and hang up after calling them, Dr. Brown said.

“Ask if they happen to know someone who may be accepting new patients,” he said. “Usually, if I’m not able to help, I can surely point a potential patient in the right direction to a colleague who can.”

If that leads to a dead end, you might try asking a primary care provider for referrals or treatment.

“Some of them do have enough basic training in mental health to be able to help a little bit,” said Dr. Amy Alexander, a psychiatrist who sees students at Stanford University. “Some are even comfortable starting medications for mild to moderate mental health problems.”

If you still can’t find help, try calling local colleges or universities and ask to see a clinician in training. Large academic institutions with outpatient psychiatry departments might also have appointments or provide referrals. Consider also expanding your search to other types of experts. If you were hoping to see a psychologist, a licensed clinical social worker might be a comparable option. Or if you were planning to see an individual provider, think about group therapy options.

Psychology Today maintains a large list of providers that you can filter by location, type of insurance covered, specialty or other criteria. The federal government also has a website where you can search for facilities that treat substance use disorders, addiction and mental illness.

If you’re looking for support groups, check out the resources at the National Alliance on Mental Illness, the National Eating Disorders Association, Alcoholics Anonymous or the Depression and Bipolar Support Alliance.

For those with insurance, an in-network provider will typically be the most affordable option. But if you can’t find someone, check if your plan has out-of-network benefits to help broaden your choice. Online therapy services may also be worth exploring since they can help you speak with someone quickly and in some cases, may reduce out-of-pocket costs.

If you are uninsured, search for providers who offer low- or no-cost options. You may find some who charge fees based on a sliding scale, or interns or postdoctoral fellows at private group practices who may see clients at lower fees, Dr. Kittler said. And government-funded community-based health care centers provide care to patients regardless of ability to pay.

If you have a job, check whether your employer offers certain benefits, like a flexible spending or a health savings account, which allow you to use pretax money for certain medical expenses.

Finally, if you are having serious symptoms that need to be addressed quickly, go to your local emergency room. The doctors there are trained to address mental health crises, Dr. Alexander said.

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).

Doctors, Facing Burnout, Turn to Self-Care

Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.
Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.Credit…Dustin Franz for The New York Times

Doctors, Facing Burnout, Turn to Self-Care

A growing number of programs aim to help doctors, nurses and medical students who are struggling with mental health issues during the pandemic.

Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.Credit…Dustin Franz for The New York Times

  • Jan. 26, 2021, 5:00 a.m. ET

Dr. Michelle Thompson knows a lot about self-care. A family medicine physician in Vienna, Ohio, she specializes in lifestyle and integrative care, using both conventional and alternative therapies to help her patients heal. She also teaches medical personnel how to prevent and treat burnout.

But despite what she recommends to others, taking care of her own emotional well-being hasn’t been easy during the pandemic.

When the pandemic hit in March, Dr. Thompson, 46, who is also chair of medicine for the University of Pittsburgh Medical Center Horizon regional health service, was seeing about 25 patients a day in her office, whom she had to convert to seeing via telemedicine “overnight,” she said.

In April, she joined an eight-week online mind-body skills program run by Dr. James S. Gordon, founder and executive director of The Center for Mind-Body Medicine, which since its founding in 1991 has trained nearly a thousand health care professionals in various self-care measures that they can use in their practices. Dr. Gordon, a psychiatrist, started the skills group earlier this year to help doctors and other health care workers cope with the extra demands and psychological suffering the pandemic has brought. The program included weekly Zoom calls with others on the front lines, along with meditative exercises like drawing pictures, visualizations and guided imagery.

“It allowed me two hours a week to check in with myself and share my experience with other health care professionals who could relate to the overwhelm and intensity of the pandemic,” Dr. Thompson said. “I never realized the power of group support.”

Physician burnout has long been a serious concern in the medical community, with roughly 400 doctors dying by suicide each year in the United States. The issue of pandemic burnout among physicians came to the forefront in the early months of the pandemic following the death of Dr. Lorna M. Breen, who supervised the emergency department at New York-Presbyterian Allen Hospital in Manhattan. Dr. Breen, who had been sick with Covid but working remotely, was later admitted to a psychiatric ward for 10 days. Fearing the professional repercussions of her mental health treatment, she took her own life in April.

“She was overwhelmed with the volume of death and dying, and she could not keep up,” said her brother-in-law, Corey Feist, a lawyer in Charlottesville, Va. “The industry needs a big cultural change.”

Mr. Feist and his wife, Jennifer Feist, Dr. Breen’s sister, have since co-founded the Dr. Lorna Breen Heroes’ Foundation, a nonprofit dedicated to protecting the emotional well-being of health care workers. The Feists also worked with politicians and a cross section of health care industry experts to develop the Dr. Lorna Breen Health Care Provider Protection Act, which aims to reduce and prevent burnout, mental and behavioral health conditions and suicide among health care professionals.

Dr. Thompson teaches medical personnel how to prevent burnout, but learning how to take care of herself during the pandemic has been a challenge.
Dr. Thompson teaches medical personnel how to prevent burnout, but learning how to take care of herself during the pandemic has been a challenge.Credit…Dustin Franz for The New York Times

An October poll of 862 emergency physicians nationwide from the American College of Emergency Physicians and Morning Consult found that 87 percent felt more stressed since the onset of Covid-19, with 72 percent experiencing a greater degree of professional burnout. Concerns about family, friends and their own health were among their chief concerns, along with financial and job security and a lack of personal protective equipment. Yet consistent with a longstanding stigma surrounding physician mental health, 45 percent weren’t comfortable seeking mental health treatment, citing concerns about workplace stigma and fear of professional reprisal.

The American Psychiatric Association, the American Medical Association and other professional groups, have formal statements against punishing doctors who seek mental health treatment. The Americans With Disabilities Act, which prohibits discrimination based on disability, including psychiatric disability, applies to professional licensing bodies. Still, the stigma persists.

A growing number of organizations and programs have taken up the charge to help doctors, nurses, residents, interns and medical students who are struggling with mental health issues.

Columbia University, for example, created CopeColumbia for employees of Columbia University Irving Medical Center. Another program called #FirstRespondersFirst, from the Harvard T.H. Chan School of Public Health, Thrive Global, and the CAA Foundation, recently unveiled its new mental health initiative, designed to provide support to health care workers in the United States and abroad. The Frontline Workers Counseling Project includes some 500 volunteer therapists in the San Francisco Bay Area, while the Physician Support Line, started in late March, is a free, national support line of some 700 volunteer psychiatrists who provide peer support.

A Body Mind Skills group helped Dr. Thompson to take time out for her own needs.Credit…Dustin Franz for The New York Times

“Part of the healing for me is helping other people,” said Dr. Lois Kroplick, a psychiatrist in private practice in Pomona, N.Y., who co-ran a weekly support group for psychiatrists and psychologists at Garnet Health Medical Center, in Middletown, N.Y., and volunteered with the Physician Support Line. During this same period, Dr. Kroplick lost her first grandchild and mother-in-law. “The best way to cope with my own grief was to help others,” she said.

Doctors recognize the growing need for mental health help for others, and for themselves. And as the infection rate continues to climb, many health care workers feel torn between their duty to help patients while also caring for themselves.

Elizabeth M. Goldberg is an associate professor of emergency medicine at Brown University, in Providence, and an emergency room physician. “In March and April there was this sense that you choose either your patients or yourself and it was your expectation to be there,” said Dr. Goldberg, 38, who has three young children. “Many of us wanted to be there, but I did experience fear and anxiety about going to work.”

She attended a free support group for health care workers, which she had never done before. “It was great hearing other people share similar experiences I had of not sleeping well and worrying about our family’s health and talking openly about our anxiety and fear of contracting the illness,” she said.

Kathleen S. Isaac, 32, clinical assistant professor at NYU Langone Health who is also in private practice in New York, created a weekly support group in June for her residents. But not many doctors showed up. Part of that she attributes to time constraints and demanding schedules, but also that many were simply trying to be stoic and power through.

“Asking for help is less stigmatized in the psychological community, but sometimes I think there’s a sense of ‘I’m fine, I know what I’m doing,’” she said. “There’s such a culture of perfectionism, and it’s so competitive that people want to present their best self. It’s harder to admit they’re struggling.”

This applies in her own life, too. She talks to friends and colleagues, exercises, goes to therapy and admits to binge-watching the sitcom “That’s So Raven” to help her unwind.

As for Dr. Thompson, she credits the Body Mind Skills group with helping her change her own self-care routine, checking in with herself hourly. “I ask myself, ‘What do I need? How am I caring for myself in this moment? Do I need a cup of tea? Should I implement some mind-body medicine?’” she said.

This might include soft belly breathing, dancing, mindful eating or just heading outside to get a breath of fresh air. “Maybe I just need to use the restroom and need to make time for simple basic self-care needs,” she said.

“This has been the hardest time of my life, and I am super grounded and really well balanced,” she added. “I am doing OK, but it is constant work and making sure I’m staying aware of my own self.”

Small Number of Covid Patients Develop Severe Psychotic Symptoms

Small Number of Covid Patients Develop Severe Psychotic Symptoms

Most had no history of mental illness and became psychotic weeks after contracting the virus. Cases are expected to remain rare but are being reported worldwide.

Dr. Hisam Goueli treated several psychotic patients who had never had mental health issues before, including a woman who told him she kept visualizing her children being murdered. “It was like she was experiencing a movie,” he said.
Dr. Hisam Goueli treated several psychotic patients who had never had mental health issues before, including a woman who told him she kept visualizing her children being murdered. “It was like she was experiencing a movie,” he said.Credit…Jovelle Tamayo for The New York Times
Pam Belluck

  • Dec. 28, 2020, 12:03 p.m. ET

Almost immediately, Dr. Hisam Goueli could tell that the patient who came to his psychiatric hospital on Long Island this summer was unusual.

The patient, a 42-year-old physical therapist and mother of four young children, had never had psychiatric symptoms or any family history of mental illness. Yet there she was, sitting at a table in a beige-walled room at South Oaks Hospital in Amityville, N.Y., sobbing and saying that she kept seeing her children, ages 2 to 10, being gruesomely murdered and that she herself had crafted plans to kill them.

“It was like she was experiencing a movie, like ‘Kill Bill,’” Dr. Goueli, a psychiatrist, said.

The patient described one of her children being run over by a truck and another decapitated. “It’s a horrifying thing that here’s this well-accomplished woman and she’s like ‘I love my kids, and I don’t know why I feel this way that I want to decapitate them,’” he said.

The only notable thing about her medical history was that the woman, who declined to be interviewed but allowed Dr. Goueli to describe her case, had become infected with the coronavirus in the spring. She had experienced only mild physical symptoms from the virus, but, months later, she heard a voice that first told her to kill herself and then told her to kill her children.

At South Oaks, which has an inpatient psychiatric treatment program for Covid-19 patients, Dr. Goueli was unsure whether the coronavirus was connected to the woman’s psychological symptoms. “Maybe this is Covid-related, maybe it’s not,” he recalled thinking.

“But then,” he said, “we saw a second case, a third case and a fourth case, and we’re like ‘There’s something happening.’”

Indeed, doctors are reporting similar cases across the country and around the world. A small number of Covid patients who had never experienced mental health problems are developing severe psychotic symptoms weeks after contracting the coronavirus.

In interviews and scientific articles, doctors described:

A 36-year-old nursing home employee in North Carolina who became so paranoid that she believed her three children would be kidnapped and, to save them, tried to pass them through a fast-food restaurant’s drive-through window.

A 30-year-old construction worker in New York City who became so delusional that he imagined his cousin was going to murder him, and, to protect himself, he tried to strangle his cousin in bed.

A 55-year-old woman in Britain had hallucinations of monkeys and a lion and became convinced a family member had been replaced by an impostor.

Beyond individual reports, a British study of neurological or psychiatric complications in 153 patients hospitalized with Covid-19 found that 10 people had “new-onset psychosis.” Another study identified 10 such patients in one hospital in Spain. And in Covid-related social media groups, medical professionals discuss seeing patients with similar symptoms in the Midwest, Great Plains and elsewhere.

“My guess is any place that is seeing Covid is probably seeing this,” said Dr. Colin Smith at Duke University Medical Center in Durham, who helped treat the North Carolina woman. He and other doctors said their patients were too fragile to be asked whether they wanted to be interviewed for this article, but some, including the North Carolina woman, agreed to have their cases described in scientific papers.

Medical experts say they expect that such extreme psychiatric dysfunction will affect only a small proportion of patients. But the cases are considered examples of another way the Covid-19 disease process can affect mental health and brain function.

Although the coronavirus was initially thought primarily to cause respiratory distress, there is now ample evidence of many other symptoms, including neurological, cognitive and psychological effects, that could emerge even in patients who didn’t develop serious lung, heart or circulatory problems. Such symptoms can be just as debilitating to a person’s ability to function and work, and it’s often unclear how long they will last or how to treat them.

Experts increasingly believe brain-related effects may be linked to the body’s immune system response to the coronavirus and possibly to vascular problems or surges of inflammation caused by the disease process.

“Some of the neurotoxins that are reactions to immune activation can go to the brain, through the blood-brain barrier, and can induce this damage,” said Dr. Vilma Gabbay, a co-director of the Psychiatry Research Institute at Montefiore Einstein in the Bronx.

Brain scans, spinal fluid analyses and other tests didn’t find any brain infection, said Dr. Gabbay, whose hospital has treated two patients with post-Covid psychosis: a 49-year-old man who heard voices and believed he was the devil and a 34-year-old woman who began carrying a knife, disrobing in front of strangers and putting hand sanitizer in her food.

Physically, most of these patients didn’t get very sick from Covid-19, reports indicate. The patients that Dr. Goueli treated experienced no respiratory problems, but they did have subtle neurological symptoms like hand tingling, vertigo, headaches or diminished smell. Then, two weeks to several months later, he said, they “develop this profound psychosis, which is really dangerous and scary to all of the people around them.”

Also striking is that most patients have been in their 30s, 40s and 50s. “It’s very rare for you to develop this type of psychosis in this age range,” Dr. Goueli said, since such symptoms more typically accompany schizophrenia in young people or dementia in older patients. And some patients — like the physical therapist who took herself to the hospital — understood something was wrong, while usually “people with psychosis don’t have an insight that they’ve lost touch with reality.”

Some post-Covid patients who developed psychosis needed weeks of hospitalization in which doctors tried different medications before finding one that helped.

Dr. Robert Yolken, a neurovirology expert at Johns Hopkins University School of Medicine in Baltimore, said that although people might recover physically from Covid-19, in some cases their immune systems, might be unable to shut down or might remain engaged because of “delayed clearance of a small amount of virus.”

Persistent immune activation is also a leading explanation for brain fog and memory problems bedeviling many Covid survivors, and Emily Severance, a schizophrenia expert at Johns Hopkins, said post-Covid cognitive and psychiatric effects might result from “something similar happening in the brain.”

It may hinge on which brain region the immune response affects, Dr. Yolken said, adding, “some people have neurological symptoms, some people psychiatric and many people have a combination.”

From left, Drs. Jonathan Komisar, Brian Kincaid and Colin Smith of Duke University Medical Center, who treated a woman whose sudden psychosis made her paranoid that her children were about to be kidnapped and that cellphones were tracking her.
From left, Drs. Jonathan Komisar, Brian Kincaid and Colin Smith of Duke University Medical Center, who treated a woman whose sudden psychosis made her paranoid that her children were about to be kidnapped and that cellphones were tracking her.Credit…Jeremy M. Lange for The New York Times

Experts don’t know whether genetic makeup or perhaps an undetected predisposition for psychiatric illness put some people at greater risk. Dr. Brian Kincaid, medical director of psychiatric emergency department services at Duke, said the North Carolina woman once had a skin reaction to another virus, which might suggest her immune system responds zealously to viral infections.

Sporadic cases of post-infectious psychosis and mania have occurred with other viruses, including the 1918 flu and the coronaviruses SARS and MERS.

“We think that it’s not unique to Covid,” said Dr. Jonathan Alpert, chairman of psychiatry and behavioral sciences at Albert Einstein College of Medicine, who co-wrote the report on the Montefiore patients. He said studying these cases might help to increase doctors’ understanding of psychosis.

The symptoms have ranged widely, some surprisingly severe for a first psychotic episode, experts said. Dr. Goueli said a 46-year-old pharmacy technician, whose family brought her in after she became fearful that evil spirits had invaded her home, “cried literally for four days” in the hospital.

He said the 30-year-old construction worker, brought to the hospital by the police, became “extremely violent,” dismantling a hospital radiator and using its parts and his shoes to try to break out of a window. He also swung a chair at hospital staff.

How long the psychosis lasted and patients’ response to treatment has varied. The woman in Britain — whose symptoms included paranoia about the color red and terror that nurses were devils who would harm her and a family member — took about 40 days to recover, according to a case report.

The 49-year-old man treated at Montefiore was discharged after several weeks’ hospitalization, but “he was still struggling two months out” and required readmission, Dr. Gabbay said.

The North Carolina woman, who was convinced that cellphones were tracking her and that her partner would steal her pandemic stimulus money, didn’t improve with the first medication, said Dr. Jonathan Komisar at Duke, who said doctors initially thought her symptoms reflected bipolar disorder. “When we began to realize that maybe this isn’t going resolve immediately,” he said, she was given an antipsychotic, risperidone and discharged in a week.

The physical therapist who planned to murder her children had more difficulty. “Every day, she was getting worse,” Dr. Goueli said. “We tried probably eight different medicines,” including antidepressants, antipsychotics and lithium. “She was so ill that we were considering electroconvulsive therapy for her because nothing was working.”

About two weeks into her hospitalization, she couldn’t remember what her 2-year-old looked like. Calls with family were heartbreaking because “‘You could hear one in the background saying ‘When is Mom coming home?’” Dr. Goueli said. “That brought her a lot of shame because she was like, ‘I can’t be around my kids and here they are loving me.’”

Ultimately, risperidone proved effective and after four weeks, she returned home to her family, “95 percent perfect,” he said.

“We don’t know what the natural course of this is,” Dr. Goueli said. “Does this eventually go away? Do people get better? How long does that normally take? And are you then more prone to have other psychiatric issues as a result? There are just so many unanswered questions.”

Depression in Childhood Tied to Physical Illnesses in Young Adulthood

Depression in Childhood Tied to Physical Illnesses in Young Adulthood

Youths with depression had elevated risks of liver disease, thyroid illness and other problems in their 20s.

Nicholas Bakalar

  • Dec. 14, 2020, 5:15 p.m. ET

Children and adolescents diagnosed with depression may be at increased risk for physical diseases and premature death as young adults, researchers report.

For a study published in JAMA Psychiatry, researchers used Swedish health registries to track a group of 1,487,964 children, of whom 37,185 were diagnosed with depression between ages 5 and 19. The investigators followed the group until they ranged in age from 17 to 31.

Of 69 physical diseases they were able to track, people with depression had a higher risk for 66 of them, even after controlling for other psychiatric illnesses.

For example, compared to their peers who were not depressed, they had eight times the risk of sleep disorders, more than three times the risk of liver disease, and nearly five times the risk of thyroid illness.

Boys had higher risks than girls for most diseases, but both boys and girls with depression had a rate of all-cause mortality six times as high as those without depression. Their rate of suicide was 14 times as high, and deaths from natural causes more than twice as high, as their peers who were not depressed.

“Our observational study can’t address whether this is causal,” said the lead author, Marica Leone, a Ph.D. student at the Karolinska Institute in Stockholm. “We need further research to determine that. But physicians need to look for other diseases, and not just psychiatric disorders, that flow from youth depression.”