Psychiatric Mental Health Nurse Practitioner (PMHNP) Certificate Blog

While scrolling through social media, I saw an advertisement for a man selling solar-powered dryers for the low price of $49.95. When people would send him a check for the amount, he would mail a clothesline back to them. They got what he advertised, but they thought they would get something else.

This led me to think about how easy it is to misunderstand the meaning of what you may believe to be straightforward communication as a provider to a patient and how patients need to know what to do if they are in crisis, so they do not fall into a communication black hole that they must dig themselves out of.

As a psychiatric mental health nurse practitioner student, I have seen how quickly a provider can become overwhelmed with tasks and miss the boat on being there for a patient when they are most needed if they do not have clear communication or a plan in place.   I have learned that I can incorporate printouts and phone calls into my daily practice to help patients' anxiety levels be manageable so they can make informed decisions when they may not be thinking clearly due to a flair in mental health symptoms.

Moraco et al., 2023 suggest providing a printout for patients that includes their next appointment, what medications they are taking, how to take the medicines, and who to contact if they have an adverse effect. When a person is in crisis, their mind may be overloaded, and having simple, written instructions can help them feel empowered to navigate a scary time. Wampold & Flückiger 2023, go so far as to state that a simple phone call for a mental health provider liaison to check in on a person to remind them of upcoming appointments can serve as an intervention. 

A short phone call can make all the difference to a patient’s day if they are dealing with a distressing situation that they might otherwise have to seek emergency assistance for if they are not getting the help they desperately need. Sometimes hearing a friendly, caring voice can make all the difference in a patient's life who is struggling with mental illness. For future providers, the best way to do this is to communicate straightforwardly and to clarify any questions patients have before they have a problem. This way, they can be proactive instead of being reactive in providing care for their patients in crisis.

References:

Moraco, N., Lipworth, A. D., Lei, Y., Bassell, L., Harper, M., Collins, E., & Keitz, S. (2023). Finding New Meaning in the Practice of Medicine: A Quality Improvement Project Evaluating the Remote Communication Liaison Program during the Initial COVID Pandemic Surge. Journal of Palliative Medicine.

Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: Conceptualization, evidence and clinical applications. World Psychiatry, 22(1), 25-41.

Children and Adolescents spend a lot of time watching screens, including smartphones, tablets, gaming consoles, TVs, and computers. On average, children ages 8 - 12 in the United States spend 4 6 hours a day watching or using screens, and teens spend up to 9 hours. While screens can entertain, teach, and keep children occupied, too much use may lead to problems.

Have you ever heard the phrase - “you have to put the oxygen mask on yourself before you try to save anyone else”? Guess what, it is true. Self-care is one of the most important things that we can incorporate into our daily lives. What is the best way to do this? There is no one correct answer. We are all unique-do what makes yourself feel better. In the next few paragraphs, you will read some of the things that help me most!

5/2021

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Feeling the effects of the COVID 19 stress or blues? Do you ever feel overwhelmed and stressed? Is there so much going on with home life, school, kids and work that you feel like you never have time for yourself. Me too! You are not alone! Forget the stigma! We all have needs, especially when it comes to our mental health. Have you ever heard the phrase-“you have to put the oxygen mask on yourself before you try to save anyone else”? Guess what, it is true. Self-care is one of the most important things that we can incorporate into our daily lives. What is the best way to do this? There is no one correct answer. We are all unique-do what makes yourself feel better. In the next few paragraphs you will read some of the things that help me most!

Exercise releases endorphins that make us feel better. There is a vast array of what is considered exercise. Exercise can be walking, running, dancing, or even lifting weights. The goal of exercise is to stop being sedentary and raise your heart rate. This movement not only has physical benefits but benefits your mental health as well. Try taking a walk, especially when
you are feeling stressed. These are the times when it is most beneficial for us, even if we do not feel like doing it.

Have you heard of the term “mindfulness”? The basic concept of mindfulness is to be present. It sounds easy but think about all of the things that you’ve done, that you don’t remember, or all of the conversations you have had and can’t recall what they were about. Being mindful is not always easy. Through meditation, you are guided in how to be present. If this sounds like too much, know that one of the key concepts of mindfulness is forgiveness and acceptance that we are human, and we are bound to have trouble with these tasks.

In addition, you should try to get some rest. Sleep restores our mental functioning. Many people have trouble falling asleep and/or staying asleep. There are some easy quick fixes that you can do to help fix this problem. Routine is very important when it comes to sleeping. You should try to go to bed at the same time each night (or as close as you can) and have the same routine in waking as well. You should avoid caffeine after lunch. Also, you shouldn’t eat large meals or consume alcohol before bedtime. As far as your bedroom, it should be dark, cool and comfortable with no electronics. These small changes can help improve your sleep quality and
quantity.

Lastly, give yourself a break. We are all human, and nobody is perfect. So, smile, laugh and do something that brings you joy. Your mental health should be your priority! And, don’t forget that in this day and age, there is an app or website for everything. Check these out if you want more help- Headspace.com, Calm.com and Fitnessblender.com

Family is the basic unit of the society and plays an important role in every person’s life. When a member of the family, especially your mother goes through physical or emotional difficulties, it affects the children. I was born as the oldest child to my parents, who were married in their young twenties. My mother was a homemaker her whole life, while my father worked as a contractor. I had a younger brother and sister. My mom was a young energetic woman in her twenties. Her whole life turned upside down, with the dead of my young brother at the age of four, in an electrocution accident. 

3/15/2022

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Grief is a common feeling for humans. When we lose someone that is dear to us, we grieve for a few months and the pain gradually eases as we accept the loss. Each person experience grief differently. For some, they find purpose to life and decides to move on with the reality. But for some, it could result in “unresolved grief” or “complicated grief”, that lasts a long time and it could turn into depression. The signs and symptoms of complicated grief include continued disbelief in the death of the loved one, or emotional numbness over the loss, inability to accept the death, feeling preoccupied with the loved one or how they died, intense sorrow and emotional pain, sometimes including bitterness or anger, blaming oneself for the death, wishing to die to be with the loved one, feeling alone, detached from others, or distrustful of others since the death, feeling that life is meaningless or empty without the loved one, loss of identity or purpose in life, feeling like part of themselves died with the loved one. The loss of a child is not easy for the mother, as she works through the emotions of foreseeing that child grow up and do the things she expected him/her to do. It has been a long thirty-six years for her, trying to cope with the loss of her child. Bereaving parents could utilize the services of bereavement counselling or support groups. In the case of my mother, she was greatly disadvantaged due to the era when this happened and being in a different culture. The culture of Indian society, where mental illness or sadness got overlooked, due to taboos associated with mental illnesses, and the lack of appropriate psychotherapeutic options, and the lack of importance given to mental illness resulted in not getting help for her unresolved grief for years. There is heavy stigma associated with mental illness within some of these communities or cultures, where mental illness is thought to be punishment from god for person’s past life or karma.

A change in health condition of one family member affects the equilibrium of the entire family, which in my mom’s case affected the time spent with me and my sister and her productivity, since she spent a lot of time in hospital with multiple health problems. For the initial several years, she didn’t receive any medical, professional or psychiatric treatments, for her “unresolved grief”. I definitely feel like she could have utilized some cognitive psychotherapy, grief counselling or even pharmacological management to aid with her “unresolved grief”. Cultural or religious engagement or support groups are another option to relieve the unrelieved grief of losing her son. Family engagement or reunions can help heal the emotional damage caused over the years of stressful life situations.

Family plays a major role in the life of any individual. Not one person lives in isolation and is a part of the bigger community, one way or another. Life brings in several stressful situations that result in various physical and emotional disturbances in people’s life, “unresolved grief” and depression being one among the many. With the help of family and community engagement, the practitioner can help the patient get appropriate medical attention and reduce their suffering, also create awareness among family and community regarding mental illness and the importance of treatment.

You can get more information about unresolved grief and the various services available at

• https://eddinscounseling.com/grief-counseling/
• https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/depression-and-complicatedgrief.html
• https://www.cancer.org/treatment/end-of-life-care/grief-and-loss/grieving-process.html

Part of my clinical experience as a student involved participating in a support group for people who are struggling with drug or behavioral dependencies. It was Carol’s first time at the meeting, and she shared her story with us. Without revealing all the details, she talked about her use of heroin and how it had taken over her life for many years. She was now 90 days clean with the help of suboxone, a type of medication-assisted treatment for opioid use. She was now residing in a sober-living house and was required to attend 12-step meetings.

1/25/22
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Part of my clinical experience as a student involved participating in a support group for people who are struggling with drug or behavioral dependencies. It was Carol’s first time at the meeting, and she shared her story with us. Without revealing all the details, 
she talked about her use of heroin and how it had taken over her life for many years.  She was now 90 days clean with the help of suboxone, a type of medication assisted treatment for opioid use. She was now residing in a sober-living house and was required to attend 12-step meetings. When the owner of the house learned that she was on MAT, the conversation went like this. You need to attend the meetings, but you will not be able to share your story because of the negative attitudes about being sober with the use of MAT.

Wait… Was this true? In an article written in Addiction Professional (2018), Narcotics Anonymous describes that it does not express opinions on issues outside of its focus, such as MAT. However, it goes on to describe “clean” as being free from all drugs. Individuals on MAT are encouraged to attend meetings but not actively participate. “This mindset is damaging to individuals, at a time when they could benefit greatly from a fully supportive community of peers in recovery who would reward them for their progress in stopping their heroin or prescription opioid use” (Enos, 2018).

How Could this be… She wasn’t using heroin off the street, homeless, or stealing for her drug use. She wanted to change her life and become healthier but needed some time to deal with the physical symptoms of not using while she worked on herself with therapy. Let’s look at some research related to MAT and how it has been proven to be beneficial. “Most patients with opioid use disorder, including those who have already achieved abstinence through medically supervised withdrawal or other means, require long-term treatment to prevent relapse” (Saxon et al, 2021, para.1). First-line treatment includes pharmacotherapy with an opioid agonist or antagonist and psychosocial treatment. Dr. Stephen Stahl who has pioneered the successful use of MAT discusses that the relapse rate for opioid detoxification and abstinence is greater than 90%. “Despite the availability of psychopharmacology treatments, few with opioid addiction receive them” (Stahl, 2018, p. 115).

Why is this important? Opioid abuse, addiction, and overdose continues to be an epidemic throughout the world. According to the World Health Organization and the social stigma related to medication assisted treatment (MAT) National Institute on Drug Abuse, only 10% of those with an opioid dependence are being treated (Stahl, 2018). Keeping silent in support groups, is it helpful? So, should we as health care professionals or other members or society, encourage or even require support groups  that believe that MAT is not true sobriety? The founding president of SMART Recovery, which is an alternative support group to 12-Step based groups, states “encouraging people not to reveal such information (in a setting where they otherwise are expected to be honest) can be psychologically damaging” (Enos, 2018, para. 22). A physician, Joe Gerstein, also facilitates SMART recovery meetings and talks about his experiences with SMART recovery. “I have never heard a discouraging word about appropriately prescribed medications” (Enos, 2018, para. 24).
So, what is SMART recovery? Self. Management. And. Recovery. Training.
SMART is a global community of mutual-support groups. Participants help one another resolve problems with any addiction. Participants find and develop the power within themselves to change and lead fulfilling and balanced lives guided by our science based and sensible 4-Point Program (SMART Recovery, n.d.). 
SMART Recovery:

•  Each phase is achieved through the principles of cognitive-behavioral therapy, which focuses on changing behaviors related to addiction.
•  Does NOT base its program on a 12-step model, higher power, or spiritual principles. 
•  Does NOT give participants labels such as addict or alcoholic. 
•  SMART Recovery describes alcoholism as a behavioral issue which can be corrected and isn’t a person’s identity. 
•  Encourages people to NOT see themselves as powerless and at the mercy of the condition but empowered to overcome the problematic behaviors (American Addiction Centers, n.d.).
•  Has groups for families and friends

In Conclusion, there is help out there for people and families who are suffering with the devastating effects of dependencies. You’re not alone and you don’t have to be SILENT. More information and where to connect with an online or local group can be found at 
www.smartrecovery.org.

By: Cathy Ensworth, AGNP-C 
Saginaw Valley State University PMHNP student
 
References
American Addiction Centers. (n.d.). How does SMART recovery work? Retrieved April 4, 2021, from https://www.alcohol.org/aftercare/support-groups/smart-recovery/ 
Enos, G.A. (n.d.). Medication patients may find chilly reception in NA’s rooms. Addiction Professional. Retrieved April 4, 2021, from 
https://www.psychcongress.com/article/medication-patients-may-find-chilly-reception-nasrooms
Saxon, A., Strain, E., & Peavy, M. (2021). Approach to treating opioid use disorder. UpToDate. Retrieved April 3, 2021, from 
https://www.uptodate.com/contents/approach-to-treating-opioid-usedisorder search=MAT&source=search_result&selectedTitle=2~38&usage_type=default&display_rank=2
SMART Recovery (n.d.). Retrieved April 4, 2021, from https://www.smartrecovery.org/ Stahl, S., (2018). Antagonist treatment is just as effective as replacement therapy for opioid addiction but neither is used often enough. CNS Spectrums, 23(2), 113-116. doi:10.1017/S1092852918000858

Dr. Mark Tarnopolsky (2016) stated, “If there were a drug that could do for human health everything that exercise can, it would likely be the most valuable pharmaceutical ever developed.”1 The benefits of exercise are widely known – increased strength, endurance, cardiovascular health, better balance, better mobility, reduced risk of chronic conditions and many more.2 Additionally, there are no concerning side effects associated of non-pharmacologic interventions, like exercise, for symptom management.

1/3/2022
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Dr. Mark Tarnopolsky (2016) stated, “If there were a drug that could do for human health everything that exercise can, it would likely be the most valuable pharmaceutical ever developed.”1 The benefits of exercise are widely known –increased strength, endurance, cardiovascular health, better balance, better mobility, reduced risk of chronic conditions and many more.2 Additionally, there are no concerning side effects associated of non-pharmacologic interventions, like exercise, for symptom management. Yet despite these know benefits, statistics from 2018 show that only about 53% of adults met the CDC’s Physical Activity Guidelines for aerobic physical activity and only about 23% met the guidelines for both aerobic and muscle-strengthening activity.3

Exercise is also arguably, the most under-utilized non-pharmacologic intervention for treatment of symptoms associated with mental health conditions. Improved focus and attention, improved memory, better mood, improved sleep quality and increased energy/motivation are some of the mental health benefits associated with participation in regular in exercise. In fact, some of the benefits of exercise are immediate and occur soon after a single exercise session. Increase levels of neurotransmitters serotonin, dopamine, and norepinephrine are noted immediately after exercise which improves mood. A deficit of dopamine, norepinephrine and serotonin are associated with symptoms of depressive disorders and anxiety. Additionally, exercise also contributes to release of an endogenous opioid and an endogenous cannabinoid which are believed to underlie the commonly known “runners high” and are involved in pain modulation, and stress and anxiety reduction.

Long term benefits of exercise, which result from consistent participation in an exercise program include increased volume of cells and protection of the cells in specific areas of the brain which contributes to improved long-term memory and better and focus, reduced risk of natural cognitive decline and neurodegenerative disorders, and long–lasting increases in neurotransmitters which are associated with improved mood.

How long and how often must one exercise to achieve the benefits noted above? The general recommendation is for individuals to exercise at a moderate intensity for 30 minutes most days of the week. The 30 minute goal can be divided into 10 minutes sessions if individuals struggle to complete all 30 minutes at one time. A national initiative led by the CDC, Active People, Healthy Nation, is an effort to help 27 million Americans become more physically active by 2027.4 If you are just getting started on an exercise program, it is important to start at a lower intensity that is and increase the intensity as tolerated. However, the most important factor when you are just starting is to pick activities that you enjoy doing to increase likelihood of long-term adherence to the exercise program. Also, identifying opportunities to increase incidental daily activity – parking out further in parking lots, taking stairs, rather than elevators, exercise while watching television/during commercials, walking during lunch break while at work - can help individuals to achieve more daily physical activity. 

References
1. Oaklander, M. (2016, September 12). The New Science of Exercise. Time.
2. Center for Disease Control and Prevention. (2021, March 30). Health Benefits of Physical Activity for Adults. Retrieved April 4, 2021, from https://www.cdc.gov/physicalactivity/basics/adults/health-benefits-of-physicalactivity-for-adults.html
3. Center for Disease Control and Prevention. (2021, March 1). Exercise or Physical Activity. Retrieved April 4, 2021, from https://www.cdc.gov/nchs/fastats/exercise.htm
4. Centers for Disease Control and Prevention. (2021, February 19). Active People, Healthy Nation. Retrieved April 4, 2021, from https://www.cdc.gov/physicalactivity/activepeoplehealthynation/ index.html

I was counseling a 19-year-old male who was feeling very disorganized and unmotivated. He was often late turning in assignments and would begin many projects but finished few. He told me he felt ill-prepared to leave home and take responsibility for himself. He was considering dropping out of college after the first year because he didn’t know what he wanted to study. He was experiencing communication problems with his girl friend who told him she was tired of reminding him what he needed to do and she felt he was not listening to her.

 11/15/2021

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ADHD: Techniques to Help with Daily Living
By Theresa Carrier-Torrealba
I was counseling a 19-year-old male who was feeling very disorganized and unmotivated. He was often late turning in assignments and would begin many projects but finished few. He told me he felt illprepared to leave home and take responsibility for himself. He was considering dropping out of college after the first year because he didn’t know what he wanted to study. He was experiencing communication problems with his girl friend who told him she was tired of reminding him what he needed to do and she felt he was not listening to her. 

He had been newly diagnosed with attention deficit hyperactivity disorder and was struggling with time management and organization. We discussed what he felt were priorities in his life and then brainstormed together techniques that would help him achieve his goals. 

We started with the basics, a planner, which he bought but then lost. Instead, a dry erase calendar was attached to the wall near the exit door. When he forgot to look at the calendar, his keys were attached to a hook placed below the calendar and all he had to do was raise his eyes and see what was scheduled for the day. He used colored dry erase markers to make events stand out. A great article to share with clients on planners for ADHD is The Best ADHD Planner? One That Actually Gets Used.

Part of one session was spent setting up online bill pay with his bank and demonstrating how to put reminders in his phone. He began to embrace technology to help him remember things. To avoid being late for class or work, he set an alarm on his phone for the time he must leave home by, to avoid being late. He felt his bedroom was “a big mess” and we discussed ways to organize his space. He began to set a timer for daily15-minute cleaning binge. A good resource on organization of all types is Lisa Woodruff, 
founder of Organize 365, she created a 100-day Home Organization Program and Sunday Basket Workshop on Paper Organization. She also has a free handout: Clean Up and Get Organized in One Weekend.

We discussed communication styles, and I sent him the article Don't Just Talk, Communicate. Which he found helpful. He identified with many things the author, Kathleen Nadeau, PH.D. wrote about, for example clamming up instead of talking about his feelings. The solution, write down thoughts and feelings before an important conversation or write a letter to the person instead. We also talked about the book The Five Love Languages by Gary Chapman. This gave him ideas he could use to better demonstrate his feelings for others by being aware of their love language/s. 

There are many creative ways to help clients with ADHD achieve better functionality in life. It is fun to help clients identify problem areas in their life and work with them to overcome those challenges. Seeing their confidence grow is a great reward.

As a society, we have all been impacted by the Covid-19 pandemic in one way or another, however children are more vulnerable to developing emotional distress, behavior changes, impaired functioning and long-term mental health consequences after experiencing a natural disaster based on their age and critical period of development. 4,5,6,7 It has been documented mental health related emergency department visits among children less than 18 years old have significantly increased in the United States during 2020.5 Therefore, as healthcare providers, it is paramount to assess the social, emotional, and mental health well-being of the children we care for during this crisis. However, before we can assess, we must be able to identify and have a clear understanding of what some of those burdens might be that have affected children during this crisis.

10/12/2021

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Assessing the Mental Health Impact on Children <18 years old During the Covid Pandemic
As a society, we have all been impacted by the Covid-19 pandemic in one way or another, however children are more vulnerable to developing emotional distress, behavior changes, impaired functioning and long-term mental health consequences after experiencing a natural disaster based on their age and critical period of development. 4,5,6,7 It has been documented mental health related emergency department visits among children less than 18 years old have significantly increased in the United States during 2020.5 Therefore, as healthcare providers, it is paramount to assess the social, emotional, and mental health well-being of the children we care for during this crisis. However, before we can assess, we must be able to identify and have a clear understanding of what some of those burdens might be that have affected children during this crisis.

Emotional, Mental, Social, and Physical Burdens Children May Experience During the Pandemic

• Social isolation
•  Fear and uncertainty
• Emotional distress
• Anxiety and worry
• Disruption of daily schedules and routines
• Increased risk of poor socioeconomic status (lack of food, inadequate housing, poor mental health support, lack of access to resources e.g., internet for remote learning, etc.) due parental job loss
• Exposure to domestic violence
• Possible child maltreatment, neglect or abuse
• Grief or bereavement of death of a loved one due to Covid
• Guilt
• Fear of loved one or they themselves becoming infected with Covid
• Sleeping and eating difficulties
• Depression
• Feeling lack of security and safety
• Missing out on significant life events (birthdays, vacations, graduation, schooling etc.)
• Poor coping strategies
• Post-traumatic stress reaction or traumatic grief
• Increase substance or alcohol use
• Suicidal ideation
  These factors represent a handful of topics children may be confronted with since Covid began and are of the 
  utmost importance for providers to be aware of when caring for this vulnerable population.

Mental Health Assessment Screening Tools for Children During Coronavirus 

After understanding potential concerns, it is important to assess the emotional and mental health well-being of the child using screening tools. The University of Michigan has developed a Coronavirus child/adolescent mental health questionnaire 8 to help identify mental health issues children and parents may be facing during the Covid crisis. This checklist quickly identifies mental health issues the child and caregiver may be experiencing during this difficult time and pin points those problem areas to allow the practitioner to focus on areas of concern. In a recent non-systematic review of literature on the mental health impact of children during the coronavirus, researchers investigated 51 articles that used a variety of mental health screening tools specific to children and adolescents, to assess anxiety, depression, and post traumatic symptoms. 4 The majority of screening tools noted in this article are considered universal and can be easily incorporated into a child’s plan of care to help assist healthcare providers in identifying potential mental health issues.

What Practitioners Can Do to Help Mitigate Mental Health Issues for Children/Adolescents During Covid?

First, it is imperative we continually monitor children’s mental health during every patient encounter, whether that be during face-to-face visits or telehealth visits, to assess the emotional well-being of the children we care for. The following briefly outlines what we can do as practitioners to help aid children and their parents during this time:

• Start the conversation. Providing information and prioritizing communication based on children’s age and developmental stage about Covid-19 is an essential component of any universal, community-led response to the pandemic.3,4,6
• Next, it is essential to involve parents and provide them with as much information and resources as possible to help them protect their child’s mental health well-being during this crisis. There is a plethora of resources available on-line we can direct parents based on their child’s age and developmental stage. 

Below, is an example of two of those resources.

• The Centers for Disease Control and Prevention have developed age-appropriate resources to help support caregivers start the conversation with their children about the Covid crisis.
  • Talking with children about Coronavirus 1 and
  • COVID-19 Parental Resources Kit 2

Lastly, early intervention is key to help mitigate the short- and long-term mental health effects our children may encounter during this Covid-19 crisis. Let’s start the conversation now!

References
[1] Centers for Disease Control and Prevention. (May, 2020). Talking with children about coronavirus disease 2019. U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/daily-lifecoping/talking-with-children.html
[2] Centers for Disease Control and Prevention. (December, 2020). COVID-19 parental resources kit: ensuring children and young people’s social, emotional, and mental well-being. U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/parental-resource-kit/index.html
[3] Dalton, L., Rapa, E., & Stein, A. (2020). Protecting the psychological health of children through effective communication about COVID-19. The Lancet Child & Adolescent Health, 4(5), 346-347. Retrieved from https://www.thelancet.com/action/showPdf?pii=S2352-4642%2820%2930097-3 
[4] de Miranda, D. M., da Silva Athanasio, B., de Sena Oliveira, A. C., & Silva, A. C. S. (2020). How is COVID-19 pandemic impacting mental health of children and adolescents?. International Journal of Disaster Risk Reduction, 101845. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481176/pdf/main.pdf
[5] Leeb, R. T., Bitsko, R. H., Radhakrishnan, L., Martinez, P., Njai, R., & Holland, K. M. (2020). Mental Health–Related 
Emergency Department Visits Among Children Aged< 18 Years During the COVID-19 Pandemic—United States, January 1–October 17, 2020. Morbidity and Mortality Weekly Report, 69(45), 1675. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660659/?report=classic
[6] Pfefferbaum, B., Jacobs, A. K., Griffin, N., & Houston, J. B. (2015). Children’s disaster reactions: The influence of exposure and personal characteristics. Current Psychiatry Reports, 17(7), 56. Retrieved from https://doi.org/10.1007/s11920-015-0598-5
[7] Shah, K., Mann, S., Singh, R., Bangar, R., & Kulkarni, R. (2020). Impact of COVID-19 on the mental health of children and adolescents. Cureus, 12(8), e10051. https://doi.org/10.7759/cureus.10051
[8] University of Michigan. (2021). Covid-specific issues and screening. Retrieved from  https://medicine.umich.edu/dept/psychiatry/michigan-psychiatry-resources-covid-19/healthcare-providers/covid-19-mental-health toolkit/youth-patients/children/covid-specific-issues-screening

Do you find yourself frustrated when deciding the best approach to guide mental health patients who present with possible cannabis use disorder (CUD)?  Do you lack confidence that what you tell them is based on sound scientific evidence?  With legalization of marijuana/cannabis in many states, one quickly becomes aware of the prevalence of its use among patients receiving mental health care.  A review of the literature tells us that we still have a lot to learn about the health effects of cannabis and who might be most likely to suffer negative effects from its use.

4/04/21

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Do you find yourself frustrated when deciding the best approach to guide mental health patients who present with possible cannabis use disorder (CUD)? Do you lack confidence that what you tell them is based on sound scientific evidence? With legalization of marijuana/cannabis in many states, one quickly becomes aware of the prevalence of its use among patients receiving mental health care. A review of the literature tells us that we still have a lot to learn about the health effects of cannabis and who might be most likely to suffer negative effects from its use.

What we know now:

• Cannabis contains more than 100 cannabinoids, with tetrahydrocannabinol (THC) being its main psychoactive agent. Adjustments to production techniques have resulted in substantial increases in the levels of THC in cannabis products, sometimes as much as 20% to 25%. This equates to being up to four times the THC levels in cannabis in the 1980s. [2,3,4]
• Even more troublesome are the cannabis concentrates or synthetic cannabinoid products that can contain up to 80% to 90% THC. Such concentrates are used in Marijuana dab pens. High THC content has been identified as a risk factor for adverse mental health outcomes and dependence on cannabis. [2,3]
• Another cannabinoid, cannabidiol (CBD) may attenuate some of THC’s adverse effects. However, researchers have concluded that high doses of CBD are required to inhibit the effects of even low doses of THC. [2,3]
• Most common cannabis products today contain high THC and lower CBD levels of potency. [2,3]
• Cannabis can be addictive and the risk of developing CUD is currently believed to be approximately 9% for adult users and increases to 17% for adolescent users. [3,5]
• The complexities associated with an individual’s response to cannabis use, coupled with the large variety of cannabis products, result in clinical effects that can range from euphoria and relaxation to panic, anxiety, or even psychosis. [3]
• People with mental illness, including schizophrenia, mood and anxiety disorders, are especially vulnerable to seeking the “short-term rewards” from cannabis use, not realizing that current data supports potential harms to patients with psychotic and mood disorders over beneficial effects. [3]

How to move forward:

In my opinion, a strong therapeutic alliance between the clinician and mental health patient is paramount to having an honest and open discussion about cannabis use. There is no “one size fits all” answer on how to approach the subject with a patient. We all have our experiences that influence our opinions on this subject; but, be careful not to let that come across as being judgmental towards the patient. It is okay to make the patient aware that more research is needed to determine the likelihood of harm versus benefit for cannabis use. In the meantime, the clinician must stay current on their knowledge of what the research suggests, and apply that knowledge to each individual case. In researching this topic, I found a number of informative articles that you will find referenced below. Two stood out as being especially useful. The first is an article available through PubMed Central, “Cannabis and Mental Illness: A Review”. It’s a nice summary that presents recent research related to this topic. The second is a patient handout “MARIJUANA”, that was developed with a grant from the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

References:
1. CDC: Centers for Disease Control and Prevention (Web Page). Marijuana and Public Health: What are the health effects of marijuana? https://www.cdc.gov/marijuana/index.htm
2. Fischer, B., Russell, C., Sabioni, P., Brink, W., Foll, B., Hall, W., Rehm, J., & Room, R.: Lowerrisk cannabis use guidelines: A comprehensive update of evidence and recommendations. The American journal of public health 2017; 107(8):e1-e12. doi:10.2105/AJPH.2017.303818
3. Lowe, D., Sasiadek, J., Coles, A., & George, T.: Cannabis and mental illness: A review. Eur Arch Psychiatry Clin Neurosci 2019. Author manuscript; available in PMC 2020 February 01:e1-e23. doi:10.1007/s00406-018-0970-7.
4. Stoner, S. A.: Effects of marijuana on mental health: Bipolar disorder. Alcohol and Drug Abuse Institute: University of Washington 2017. https://adai.uw.edu/pubs/pdf/2017mjbipolar.pdf
5. Williams, A. R. & Hill, K. P.: Cannabis and the current state of treatment for cannabis use disorder. Focus 2019; 17(2):98-103. doi:10.1176/appi.focus20180038.

The Center for Rural Behavioral Health & Addiction Studies will periodically partner with other programs at SVSU to offer training opportunities for the students and professionals who are aspiring to learn new skills. One such program took place this past month when we held our NADA (National Acupuncture Detoxification Association) acupuncture training. This event was a 3 day class that allowed 34 of our PMHNP students to gain the necessary knowledge and training to become certified in auricular acupuncture. This particular form of acupuncture allows health providers to use a simple, safe and standardized ear acupuncture protocol to treat addictions, behavioral health, trauma and disaster relief. The CRBHAS parntered with Kimberly Kile to teach this class. Kimberly has extensive experience working with Substance Abuse and MAT (medication for addiction treatment). She has been teaching NADA classes since 2012. The class participants not only learned about this form of treatment, they had the opportunity to practice acupuncture with each other, and were given the supplies necessary to complete the NADA protocols so they can become certified Acupuncture Detoxification Specialists.

The class was also given a presentation by our team member Dr. Miriam Adams, who stated "I use it on patients with mood disorders (depression, anxiety, PTSD), I use it on patients who would like to stop a behavior, such as smoking cigarettes/vaping, using substances such as marijuana and alcohol, nail biting and compulsive overeating. There is, of course scientific documentation of why this is useful, but has to do with altering the brain chemistry. I have seen patients make significant changes, and it has been very beneficial for them. Many of them have had ongoing sessions, and have enjoyed the way it has helped them to relax, to calm, to practice their mindfulness skills and to experience times that a non-pharmacologic intervention can be helpful. 

I use the acupuncture on patients between 8-10 visits. They don't usually come to my office only for the acupuncture, but some have! Each person has reported that it has helped."

For more information on this type of acupuncture, visit the National Acupuncture Detoxification Association's website at https://acudetox.com/.

The Psychiatric Mental Health Nurse Practitioner program at SVSU is proud of its current and past students.  There are numerous success stories that come from our program.  One such story is highlighted in the following interview with alumni Gladys Kimeli.

Please tell us about yourself.

My name is Gladys Kimeli. I am a board-certified family and psychiatric mental health nurse practitioner. I completed my PMHNP certificate from SVSU in August 2020 after graduating with a master’s degree in nursing with a specialization in family nurse practitioner in May 2017 from Indiana State University. I was then offered a full-time NP position at Jafferany psychiatric services in Saginaw, MI where I have been working for the last 2 years.  Currently, I am in transition to moving to our new practice, State Street Behavioral services, which is located here in Saginaw MI. I love working with my patients and it’s been my passion to help people in need.

Why did you choose a PMHNP certificate instead of other types of graduate certificates?

In the medical field there are many different and important job titles. For me I chose a PMHNP certificate because I had been already working in a psychiatric office, which gave me a sense of fulfillment and purpose. It solidified my interest in mental health and I wanted to continue providing effective care for my patients with complex psychiatric and physical needs.  

Why did you decide to pursue the PMHNP certificate through SVSU?

I decided to pursue the PHMNP certificate through SVSU because first, I wanted to support a local university. Secondly, SVSU’s program focused on equipping nurse practitioners with the tools to care for a rural population who are impacted by mental conditions and substance use disorder. SVSU’s program is designed to prepare nurse practitioners to deliver integrated mental care with physical care in addition to substance use, which is much needed in our communities.

After completing the program, what advice would you give to others that are considering the PMHNP certificate?

Being certified as a PMHNP is very rewarding. I would advise them that their position in the healthcare field means they are able to help others and at the same time find fulfillment in caring for patients. Also working with mental health patients comes with its own distinct set of challenges. It is by no means an easy profession to pursue, but those that are dedicated can find tremendous rewards in the field.

How has gaining this certification affected your professional career?

Gaining a PHMNP certification has affected my professional career greatly.  It opened a door for me to see the needs in our community. There are many patients out there that are looking for psychiatric care, yet they are told by many psychiatric offices they have waiting list for couple months. This patient doesn’t have months to wait to be seen. Having learned more about mental health, my husband and I felt compelled to open a behavioral clinic: States Street Behavioral Services to cater to the needs of our vulnerable population.

Is there anything in particular that SVSU’s program offered or did that has enhanced your ability to perform in your career?

SVSU program did enhance my mental health knowledge and confidence in caring for complex psychiatric illness. In the current mental health model, care is often delivered in a “split model,” meaning that medication providers such as myself before PMHNP certification see patients, sometimes briefly for medication management and psychotherapists such as psychologists and licensed clinical social workers provide psychotherapy. I now find it difficult to provide psychopharmacologic treatment without including at least some psychotherapy. I was once counseled by a mentor to make every interaction with a patient therapeutic by providing respectful, engaged treatment, and I try to bring this to every patient I see. I am grateful to have learned about motivational interviewing, psychotherapy, addiction, and psychopharmacology at SVSU to strive to provide the best care to my patients.  

How would you describe the PMHNP program at SVSU to other people?

The PMHNP program at SVSU is a place for anyone. The staff and professors are very knowledgeable and friendly. SVSU is committed to the success of their students. SVSU offers a rigorous curriculum and one of the first Psychiatric-Mental Health Nurse Practitioner (Lifespan) specialties in Mid-Michigan. SVSU’s program teaches how to use advanced clinical judgment and practice to assess, diagnose, plan, implement, intervene, manage and evaluate holistic plans of care – including treatment with psychotropic medications; individual, group and family psychotherapy; crisis intervention; case management and consultation.  SVSU provides low faculty-to-student ratios, mentoring and personalized attention. I am proud to be a SVSU alumni.

Events of the past year have certainly been one for the history books. We watched as life, as we knew it, changed swiftly and dramatically. We saw schools and businesses close; panic buying result in toilet paper and food shortages; social media consumption widen; and watched as debates soared about mask-wearing and loss of freedoms, related to safety measures implemented to slow the spread of the novel coronavirus (COVID-19).  These last 13 months have certainly brought major challenges to individuals, businesses, healthcare systems and public health policies, around the world.

Significant social and economic changes have resulted in job insecurity or loss, financial instability, the transition of both occupational and educational formats to a home-based environment, isolation and the development of new or worsening mental-health conditions, such as anxiety, depression, substance misuse and suicidal thoughts. Last summer, a report from the Centers for Disease Control (CDC) revealed that 2 in 5 residents of the United States reported struggling with mental or behavioral health issues associated with COVID-194.

Regardless of whether or not you have an active substance use disorder (SUD) or are in recovery; stress, grief and fear related to COVID-19, along with disruptions in routines, isolation, and a lack of support, in conjunction with the above-mentioned changes, are all risk factors that can lead to substance use or relapse, as a method to temporarily escape from the pain of reality. Even more worrisome is information coming out about how substance use increases the risk of complications associated with COVID-19.

Emerging research suggests that people with substance use disorder (SUD), particularly opioid use disorder (OUD), and those who are African American are at a higher risk of contracting COVID-19, being hospitalized and dying as a result of their infection. The reasons for increased risk of adverse events are complex, but involves having a weakened immune system, as a result of substance use; a compromised cardiovascular and respiratory system, from damage and inflammation related to both reduced blood oxygen levels associated with opioid use and inhalation of substances; and changes in the brain and vascular system, including vessel narrowing, which can cause high blood pressure6. Despite the abundance of evidence available regarding the negative consequences of substance use, it is clear that this information has done little to deter use.

Data from an August 2020 report by the CDC showed that approximately 13.3% of people had increased or started using substances to cope with their stress or emotions related to COVID-191. In fact, sales of both alcohol and marijuana have increased since the start of the pandemic. Nielson, a global leader in retail measurement services, reported that in-store alcohol sales were up 54% in late March 2020, while online alcohol sales had increased by almost 500% the following month3. Sadly, increased reliance on substance use as a coping mechanism increases the risk for overdose and death.

The highest number of overdose deaths ever recorded in a 12-month period of time, 81,0000, occurred in the United States between May 2019-2020; largely related to synthetic opioids, such as illegally manufactured fentanyl, suggesting an overdose acceleration during the pandemic2.  It’s possible that some of these deaths may have been related to concerns about obtaining addiction care, during the pandemic, causing substance users to dread going to medical settings where COVID infection risk was elevated, as well as, fears that they would not receive treatment for acute intoxication due to overburdened emergency rooms and staff.  Furthermore, even pre-COVID-19, difficulties existed in gaining access to and maintaining adherence with treatment, for people with both mental health conditions and/or substance use disorder; the pandemic only making matters worse. These difficulties exist due to a serious lack of mental health and substance use education and awareness in this country, along with poor public policies and significant financial barriers to receiving treatment; a shortage of treatment centers and properly trained providers, social stigma and bias against individuals with behavioral health and substance use conditions, as well as, racial barriers that limit access to care for black, indigenous and people of color (BIPOC).  Until the marginalization of people with these conditions is stopped and public policies are put in place to increase access to behavioral health and addiction treatment services, the number of casualties will continue to rise.

It can’t be all doom and gloom, though, right? Understanding the road blocks before us, how can we help support individuals with mental health and substance use disorders right now? First, clinicians should evaluate every patient for new or worsening mental health or substance use disorders. If identified, emotional support should be offered, with an emphasis on the fact that the individual is not alone and that they have a treatable condition. Supporting the patient and letting them know that you are there for them and willing to help, can make a difference in their willingness to accept treatment. At the start of the pandemic, federal agencies implemented policies which helped opioid treatment programs (OTP) distribute take-home doses of both methadone and buprenorphine, thus increasing access to substance use treatment medications, as well as, expanding access to telemedicine for treatment and counseling services5. Additionally, support group meetings, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) moved online.  As these options provide treatment avenues and support for people with mental health disorders and SUD, their use should be recommended and encouraged by both clinicians and family members supporting loved ones with these conditions. Moreover, clinicians have an obligation to stay on top of new developments that can impact ways they deliver care; and should familiarize themselves with community programs, especially those accommodating people with limited resources or who lack insurance, so that they have a variety of support and treatment programs available to offer to their patient population. Clinicians treating people with SUD should encourage harm-reduction techniques for those individuals whom abstinence isn’t the goal, such as needle-exchange programs, to reduce the risk of acquiring hepatitis C or human immunodeficiency virus (HIV). Additionally, providers working in OTP, should emphasize realistic expectations and avoid criticizing individuals for “slip-ups”; praising small steps and encouraging abstinence behaviors. Most importantly, life-saving medication (Narcan) should be prescribed to anyone with an opioid use disorder, with instructions on use.

Uncertainty still exists in terms of when life may start to resemble the world we knew, over a year ago. In some ways; though, life will never be the same again, as people have said good-bye to their savings, businesses, health (following chronic changes associated with COVID infection), friends and loved-ones. Stress, related to the pandemic, is contributing to mental health and addiction issues across the nation. Addiction hides, and may not be immediately obvious; thriving in secret and progressing rapidly, especially when isolated. If you or someone you know is experiencing increased substance use and cravings, or has relapsed, please contact your provider or call the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 24/7, 365-day-a-year treatment referral hotline at 1-800-662-4357 to reach out for assistance in locating mental health or addiction services near you.

Resources

Centers for Disease Control. (2020, August 14). Mental health, substance use,
Centers for Disease Control. (2020, December 17). Overdose deaths accelerating
and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020.

https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm?s_cid=mm6932a1_w

during COVID-19. Retrieved from

https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html

Christensen, T. (2020, July 1). COVID-19 pandemic brings new concerns about
Stephenson, J. (2020). CDC report reveals “Considerably Elevated” mental
excessive drinking. https://www.heart.org/en/news/2020/07/01/covid-19-pandemic-brings-new-concerns-about-excessive-drinking

health toll from COVID-19 stresses. JAMA Health Forum.

doi:10.1001/jamahealthforum.2020.1078

Office of National Drug Control Policy. (2020, June). Covid-19 fact sheet. file:///C:/Users/juju_/AppData/Local/Microsoft/Windows/INetCache/IE/3F HKPL51/ONDCP%20COVID%20Fachsheet%202.0_FINAL.pdf
Volkow, N. (2020, October 5). New evidence on substance use disorders and
COVID-19 susceptibility. Nora’s Blog. https://www.drugabuse.gov/about-nida/noras-blog/2020/10/new-evidence-substance-use-disorders-covid-19-susceptibility

As flu viruses and the virus that causes COVID-19 can spread this season, getting a flu vaccine is more important than ever. Here are five reasons why you should:

1. Helps Keep You Healthy
Flu can cause signs and symptoms; such as fever, cough, and body aches, that can keep a healthy person home from work, school, and errands for a few days to a week or more.

The best way to prevent seasonal flu is to get vaccinated every year. Flu vaccination helps prevent millions of illnesses and flu-related doctor visits each year. CDC estimates that influenza vaccination during the 2019–2020 influenza season prevented 7.52 million illnesses, 3.69 million medical visits, 105,000 hospitalizations, and 6,300 deaths associated with influenza.(1)(3)

2. Beat the Bug
Flu vaccination can reduce doctor visits due to flu. Several studies have shown flu vaccination can reduce the severity of illness in people who get vaccinated but still get sick. And during seasons when the flu vaccine viruses are similar to circulating flu viruses, flu vaccine was shown to reduce the risk of having to go to the doctor with flu by 40% to 60%.(2)

3. Care for Each Other
You may think of flu vaccine only as a way to protect yourself from flu. But getting vaccinated also may protect the people around you. Many people in the U.S. are at higher risk of getting very sick from flu because of their age, or because they have one or more of certain health conditions, like asthma, diabetes, or heart disease. Also, some people in your family or community may not be able to get vaccinated due to their age (children younger than 6 months, for example).(4) They rely on you to help prevent the spread of disease. When you get a flu shot, you help protect them.

Help CDC promote flu vaccination in conversations with friends, family, and neighbors, and post to followers on social media using resources available in this year’s #SleeveUp to #FightFlu digital media toolkit.

4. Help the Health Care System
Getting a flu vaccine is more important than ever during the 2020-2021 season. A flu vaccine this season can help protect you and the people around you from flu, reduce the burden of flu on our health care systems during the COVID-19 pandemic, and save medical resources for the care of COVID-19 patients.

Since health care workers are needed to care for people sick with COVID-19 and may care for or live with people at high risk for influenza-related complications, it is especially important for them to get vaccinated.(5)

5. It’s Not Too Late
National Influenza Vaccination Week (December 6-12) is focused on highlighting the importance of influenza vaccination. It’s not too late for anyone 6 months and older to get a flu vaccine. Laboratory-confirmed flu activity is low now, according to the Weekly U.S. Influenza Surveillance Report (or FluView).

CDC has worked with vaccine manufacturers to have extra flu vaccine available this flu season. Manufacturers have distributed 197.4 million doses of flu vaccine this season so far. Use the VaccineFinder to find yours.

Resources

Flu Vaccine Benefits
2020-21 Flu Season
About Flu
National Influenza Vaccination Week
Flu Vaccines Work
Vaccine Finder

References

https://www.cdc.gov/flu/business/promoting-vaccines-workplace.htm
https://www.cdc.gov/flu/prevent/vaccine-benefits.htm
https://www.cdc.gov/flu/about/burden-averted/2019-2020.htm
https://www.cdc.gov/flu/prevent/vaccinations.htm
https://www.cdc.gov/flu/professionals/healthcareworkers.htm

Apr 10, 2020

____________________________

My experience with Body Dysmorphic Disorder (BDD)
I am an adult NP and a student at Saginaw Valley State University pursuing a post graduate certification in psychiatric mental health. My experience with Body Dysmorphic Disorder started when my son was 22 years old and was in college. He was having issues with anxiety and depression and one day while walking with him in Ann Arbor he shared his story about body dysmorphic disorder with me.

My son who was an attractive, 6-foot-tall male explained to me his despair and horror that he had perceived physical flaws that were causing him an immense amount of sadness and stress. He said he had been hesitant to share his story because he was embarrassed and thought he would sound like he was vain. He had been meeting with a psychologist while in college but had been doing research of his own and he explained to me that he believed he had something called Body Dysmorphic Disorder. He said he was spending hours and hours every day focusing on his perceived defects. He spent his time doing investigation on the internet to see if he was as abnormal as he believed he was and also looking in the mirror multiple times a day, horrified at his reflection. His illness was causing him much distress and was interfering with his ability to live his life successfully.

I was devastated, I had never heard of Body Dysmorphic Disorder. How could my beautiful, brilliant boy see himself in such a way, why couldn’t he see himself the way I did? I just couldn’t understand it, I couldn’t put my arms around it. I started by trying to help him see how perfect he was but my complements and intent to change his negative view of himself didn’t help. My son has worked hard to get better and has received therapy which included cognitive behavioral therapy, group therapy, exposure therapy as well as psychopharmacologic treatment which has resulted in much improvement. That was five years ago. During this time I have become more educated about Body Dysmorphic Disorder which I believe helps me to be a better mom and better support person for my son. As far as his progress, I’m happy to say he is doing much better though he still has occasions when his preoccupation with his perceived flaws overtakes him and causes him distress.

What is Body Dysmorphic Disorder?
Body Dysmorphic disorder is listed in the DSM 5 under the heading of Obsessive Compulsive and Related disorders. In the DSM5, BDD is defined as a disorder where the individual who has it believes that he or she is unattractive and even hideous with one or more specific areas that they see as being flawed or deformed. To fill the diagnostic criteria, the individual at some point performs repetitive behaviors (compulsions) related to the flaw (obsession).

These repetitive behaviors can be something like mirror checking or grooming the specific area of concern which could take up hours of the individual’s day. The individual feels that performing the behaviors will decrease anxiety but if the anxiety is slightly decreased the relief doesn’t last. The DSM 5 also evaluates specifiers related to a patient’s insight or understanding of his or her illness. In the book Understanding Body Dysmorphic Disorder, An Essential Guide, by Katherine A Phillips M.D., she states that sometimes individuals describe the need to perform the compulsive behavior like an “itch that needs to be scratched.” These repetitive behaviors lead to impairment in social, occupational and other areas of function.

Some Facts about Body Dysmorphic Disorder:

• BDD occurs slightly more frequently in females than males: 2.5% vs. 2.2%
• Mean onset age: 16–17
• Median onset age: 15
• Most common onset age: 12–13
• Environment: BDD is sometimes associated with childhood neglect and abuse
• Suicidal behavior: more predictive if onset prior to age 18
• Genetic: BDD is more prevalent in those who have a relative with OCD
• Gender differences: Males are more likely to have genital preoccupation and females are more likely to have eating disorders in addition to BDD (DSM5, 2013, 244)

High Economic and Health Cost of Body Dysmorphic Disorder:

• High economic cost explained by excessive medical care including medical and psychiatric hospitalizations as well as medical and surgical evaluation sought out to obtain unnecessary cosmetic procedure
• Decreased work productivity and job loss due to time spent on obsessions and compulsions
• Highest cost of all is suicide and 25% of the population that has Body Dysmorphic Disorder have attempted suicide. Dr. Phillips stated that approximately 80% of the people with Body Dysmorphic Disorder who had participated in her research had experienced suicidal thoughts (Phillips, 2009, 109)

Screening tools for the clinician:

• Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS) — 12 item scale. This scale gives a score that reflects the severity of the patient’s BDD.
• Body Dysmorphic Disorder (BDDQ) for adults — This tool screens for BDD but does not definitively diagnose BDD.
• The Brown Assessment of Beliefs Scale (BABS) — 7 item scale. This scale was designed to assess a patient’s conviction and insight related to their beliefs, and in the case of BDD, beliefs about their perceived physical flaw or defect.

Medical Treatments for BDD:

• Multiple studies have shown that SRIs are effective for treatment of Body Dysmorphic Disorder.
• In the study done in 2002 by Phillips, Albertini and Rasmussen it was concluded that fluoxetine was safe and more effective than a placebo in treatment of Body Dysmorphic disorder. (Phillips, Albertini and Rasmussen, 2002)
• A study done in 2016 which looked at relapse prevention in BDD, found that prolonged treatment with the SSRI escitalopram caused continued improvement of symptoms as well as delayed time to relapse. (Phillips, Keshaviah, Dougherty, Stout, Menard, & Wilhelm, 2016)
• Phillips recommends the use of any of the SSRIs as first line treatment for BDD. (Phillips, 2009)
• Phillips also states that SSRI dosage needs to be individualized with BDD and she has found that higher doses are typical with BDD.(Phillips, 2009)
• If the SSRIs fail the tricyclic antidepressants clomipramine and desipramine have been studied with BDD but due to high rate of side effects Phillips states they should not be the clinicians first choice. (Phillips, 2009)
• Phillips states that SSRI should be continued for 12–16 weeks prior to giving up and changing to a different medication with possible need to continue increasing to maximum dose. (Phillips, 2009)
• Phillips states that pharmacotherapy with SRI should be continued for at least 1–2 years to prevent relapse. (Phillips, 2009)
• Augmenting agents suggested by Phillips are: buspirone, levetiracetam, clomipramine, venlafaxine, bupropion, neuroleptics such as ziprasidone, olanzapine, risperidone, methylphenidate, lithium and benzodiazepines. (Phillips, 2009)

Cognitive Behavioral Therapy for BDD:

• Cognitive Restructuring: This is used to help the client develop healthier thoughts related to their appearance.
• Exposure: The exposure aspect is that the client exposes themselves to people to see if they react to their perceived ugliness the way they expect them too.
• Ritual Response Prevention: With this therapy the client works to decrease and eventually stop the ritualistic behavior such as looking at themselves in the mirror.
• Perceptual (mirror) Retraining: This method instructs the client to look at their entire body and objectively describing themselves in a holistic fashion not just focusing on one perceived flawed area. (Phillips, 2009, 190–192)

Insight Oriented Psychotherapy for BDD:
This has not been proven to be effective as a stand alone treatment for BDD but can lead to better self understanding and self awareness which can be helpful. (Phillips, 2009,228)

Supportive Psychotherapy for BDD:
This therapy is also not recommended as a stand alone therapy with BDD but this type of therapy offers to the patient understanding and emotional support which could help them to deal with their struggles with BDD. (Phillips, 2009, 228)

Couples and Family therapy for BDD:
Also not recommended as first choice for therapy but may help therapist to gain some insight from family as well as to provide some understanding to family about client’s struggles with BDD.(Phillips, 2009,229)

Group Therapy for BDD:
This type of therapy allows the client to work in a group rather than individually and Phillips suggests that with the BDD population Group CBT is the most effective type of Group Therapy.(Phillips, 2009, 229)

BDD Support Organizations:

• International OCD Foundation (IOCDF)
• Body Dysmorphic Disorder Foundation

References:
American Psychiatric Association: Diagnostic and Statistical Manual of Mental disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

Hollander E, Allen A, Kwon J, et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry. 1999;56(11):1033–1039. doi:10.1001/archpsyc.56.11.1033

Hong, K., Nezgovorova, V., & Hollander, E. (2018). New perspectives in the treatment of body dysmorphic disorder. F1000Research, 7, 361. https://doi.org/10.12688/f1000research.13700.1

Phillips, K.A.,(2009)Understanding body dysmorphic disorder: an essential guide. New York, New York: Oxford University Press.

Phillips K.A., Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry. 2002;59(4):381–388. doi:10.1001/archpsyc.59.4.381

Phillips, K. A., Keshaviah, A., Dougherty, D. D., Stout, R. L., Menard, W., & Wilhelm, S. (2016). Pharmacotherapy Relapse Prevention in Body Dysmorphic Disorder: A Double-Blind, Placebo-Controlled Trial. The American journal of psychiatry, 173(9), 887–895. https://doi.org/10.1176/appi.ajp.2016.15091243

Apr. 5, 2020
____________________________

Think back to a time when you experienced physical pain (ex: removed a sliver from your finger; bit your lip; hit your head on a cupboard). What were the emotions you felt? Whenever I encounter pain, I naturally experience distress, anger, and frustration – all negative emotions. I like to think that these emotions are, in a sense, a “safeguard” to help me (and all of us) avoid future potentially painful events as much as possible. After all, one of our basic human instincts is to preserve life. Self-harm, or the hurting of oneself on purpose (via cutting, burning, hitting, punching, etc.), is most prevalent among adolescents - around 17% have engaged in at least one episode. It is a tactic used to relieve negative emotions, such as sadness, anxiety, anger, guilt, emptiness, and self-disgust.

Wait. If physical pain naturally leads to negative emotions, but self-harm helps many teens relieve negative emotions, what is going on? To answer this question, we have to take a look inside the brain at what happens when someone self-harms. In a recent article in Psychology Today, author Terri Apter, Ph.D., explains that the sense of relief generated during self-harm stems from the activity of the amygdala, an area of the brain responsible for producing emotions. Rather than activation of the amygdala from physical pain (resulting in common emotions of anger, frustration, etc.), in some adolescents, self-harm results in a reduction of amygdala activity – thus, relief of negative emotions. Another explanation for self-harm involves the stress hormone, cortisol. This hormone naturally increases during moments of stress, but also during these times the body releases endorphins to help cope with stress and feel better. Cortisol levels are actually lower in self-harming adolescents, therefore, self-harm increases cortisol and endorphin levels and provides a sense of “feeling” to teens who feel empty.

Understanding the physiologic brain changes behind self-harm helps us to make sense of why certain strategies help adolescents cope. Let’s talk about what some of these strategies may be. Psychology Today suggests one tactic is to increase levels of “good stress” through activities such as physical exercise or learning a new hobby. Teens can also try other tactics, such as taking a cold shower, chewing something with a strong flavor (peppermint), journaling, or cuddling a pet when they feel an urge to self-harm.
Learning this information has been a game-changer for me, especially as a nurse practitioner working in mental health. My previous thought was that teens self-harmed as an attention-seeking technique…I was quite wrong. Learning that there are actual physiologic changes in the brain during self-harm has increased my understanding and empathy toward those who struggle with it. I hope it has for you, too. If you know someone who participates in self-harm, whether it is a friend, family member, or patient, I encourage you to think about the science behind their behavior and encourage them to use a safer, healthier skill when they get an urge to self-harm.

References

1. National Alliance on Mental Illness. (n.d). Self-harm. In National Alliance on Mental Illness. Retrieved from https://www.nami.org/learnmore/mental-health-conditions/related-conditions/self-harm
2. DeAngelis, T. (2015). Who self-injures? Monitor on Psychology, 46, 60.
3. Smith, M., Segal, J., Robertson, L., & Shubin, J. (2019). Cutting and self-harm. In HelpGuide: Your trusted guide to mental health & wellness. Retrieved from https://www.helpguide.org/articles/anxiety/cutting-and-self-harm.htm
4. Apter, T. (2020). The pain paradox. Psychology Today, 50-52

In this challenging time of COVID-19, many out-patient substance use disorder (SUD) treatment centers are converting services to telehealth or limiting services.  With Face to face interaction, a key element of recovery support, it is imperative to ensure that patients have meaningful virtual experiences with their healthcare providers.  As many find themselves working from home, they are wanting and needing to treat their patients with substance use disorder (SUD), they find themselves utilizing either the telephone or video conferencing to reach out to their patients. During this time of social isolation, how do we reach out and keep our patients engaged in treatment to who are struggling with addiction and in recovery?

Social isolation is often difficult for those who have SUD and are in recovery. Addiction can be a lonely disease which leads to social isolation.  Social support is imperative for a person recovering from SUD as social isolation is a risk factor for relapse.  The COVID-19 pandemic has resulted in executive orders from many states that mandate social distancing and only allowing direct contact with those whom people currently live at the same address to reduce the disease transmission and flatten the curve.  Social distancing can be especially difficult for individuals in recovery as much of their social interaction comes from appointments, meetings, and peer-support groups. 

In order to address social isolation, those in recovery are encouraged to reach out to others or join a recovery group. Here, they meet other individuals who have went through similar circumstances. Reaching out and being a part of a group that has the same recovery goals makes one feel supported and cared for. The goal of being in a recovery group is to have the ability to feel and be open with those who have found themselves in similar situations. Recovery groups provide a safe place where feelings of fear, joy, substance use, and recovery can be shared and judgements are left behind.  In this time of need, individuals in recovery need a safe place that feelings can be shared and be surrounded by people who understand their point of view, because they are in recovery themselves. With the COVID-19 pandemic, patient’s in recovery have reduced access to health care and recovery services and this can be challenging time for them. 

In our community, Peer 360 is a local support group for individuals seeking therapy for SUD. Their vision is to create an environment where recovery from substances, such as alcohol and opioids is understood, embraced, and appreciated, while all who seek help will have access to support, care, and resources to achieve lifelong sobriety and a healthier life. In keeping with their vision, Peer 360 has moved from face-to-face meetings to an online format to reach those still in need. They have two meetings per day, one is at noon and the other at 6pm. Recovery coaches remain available to their patients via phone.

In addition, The Grace Project (Gaining Recovery in Addiction for Community Elders), located within the Bay Community Health Clinic provides a multidisciplinary team to meet the healthcare needs including, medication assisted treatment (MAT) to individuals with SUD. Our clinic has moved to online services, as well. Our patients connect telephonically or via video conferencing with providers to continue care and treatment. The providers at The Grace Project include a psychiatric nurse practitioner, family nurse practitioner, social worker, peer recovery coach, case manager, pharmacist, dietician, and occupational therapist. This provides us an opportunity to visually see them via a phone or tablet, while assessing mental and emotional status. It also provides an opportunity to ask, if they have enough food and toiletries in their home. We have the manpower, if needed, our team could drop off food.

During the telehealth visit, prescriptions are refilled as needed.  Outside of their scheduled telehealth visits, a member of the interdisciplinary team calls to check-in on the patients on a daily to weekly basis, based on the patient’s needs.  Providing our patients and community with these services will help combat the social isolation that may be felt during these trying times. It is important to maintain a therapeutic relationship, and through online means, we embrace the need we all have for human connection.

7/13/20

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The novel Coronavirus 2019 disease (COVID-19) pandemic has required healthcare providers to limit in-person patient visits and interactions to help decrease the spread of the virus.  This is especially challenging for patients with substance use disorder (SUD), in particular those with opioid use disorder (OUD) who are receiving medication assisted treatment (MAT).  This is due to the fact that prescriptions for agonist maintenance are limited in duration or administered at an Opioid Treatment Programs (OTP). 

Several regulatory bodies have responded to the COVID-19 pandemic in attempt to flatten the curve with social distancing while still allowing patients with OUD to receive the care they need.  The Centers for Disease Control (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA) have released guidance for healthcare providers to assist patient’s with SUD during this pandemic and social distancing.  The CDC endorses using telehealth for patient’s healthcare needs during the pandemic.  This past March, SAMHSA announced that blanket exceptions could be made by states and that OUD patients could receive 14-28 medication doses to take home based on the patient’s treatment stability.  This exception is in effect only while the United States public health emergency is in effect.     In addition to established patients, SAMHSA allows new patients to be prescribed buprenorphine via a telehealth visit and waived the exam in-person.  However, an in-person initial exam is still required for methadone treatment. 

During the pandemic, The Drug Enforcement Agency (DEA) has allowed for delivery and administration of controlled substances used to treat OUD.  The DEA's exception allows staff from OTP’s, law enforcement, and the National Guard to make door step deliveries of take-home medications in particular methadone.  The medications can be delivered to a patient’s approved lockbox at the patient’s home which allows for social distancing to help prevent the spread of COVID-19.  SAMHSA has guidance afor OTP’s for delivery of medication if a patient is positive for COVID-19 to allow patients to receive their medication without leaving their home.

All of these aforementioned changes have allowed for the use of telehealth to be incorporated into SUD treatment and eliminated some of the barriers associated in-person visits and prescribing controlled substances.  Healthcare providers use their clinical judgement to identify patients who can use telehealth.  Some patients may require higher level of care and not be able to be managed without in-person visits.  Patients with SUD and comorbidities including the elderly, immunocompromised, and pregnancy are at increased risk for complications from COVID-19. 

By utilizing telehealth healthcare providers can safely communicate with patients about their healthcare needs.  There are a variety of options for a virtual visit including mobile apps, video conferencing, and phone calls and texting.  Seeing patients virtually decreases the spread of the virus to both the public and healthcare workers and decreases the use of personal protective equipment (PPE) that is in limited supply.  There are a variety of virtual technology that can be used to assist a healthcare provider with assessment of the patient virtually including an electronic stethoscope, blood pressure cuff, and oxygen sensor.  Patients can also access group support via telehealth.  Many recovery support groups have quickly converted to virtual meetings and encourage attendance.

Patients are encouraged to check with their health insurance provider for access to telehealth services and coverage.  Many of the health insurers are giving patients and healthcare providers incentive to use telehealth.  In addition, The Federal Communications Commission has provided funding for healthcare providers.  Two hundred million dollars was appropriated by Congress to help healthcare providers establish a telehealth service.  The COVID-19 Telehealth Program will fund telecommunication and information services as well as devices to connect patients to their healthcare providers.

Disclosures: The author reports no conflicts of interest concerning the subject matter of this article.

References

Centers for Disease Control (CDC).  Corona Disease 2019. Retrieved from:   https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-resources.html

Federal Communications Commission.  COVID-19 Telehealth Program.   Retrieved from: https://www.fcc.gov/covid-19-telehealth-program

Prevoznik, T.  U. S. Department of Justice, Drug Enforcement Administration.  DEA Qualifying Practitioners, DEA Qualifying Other Practitioners.  Retrieved from: https://www.samhsa.gov/sites/default/files/dea-samhsa-buprenorphine-telemedicine.pdf

SAMHSA. Opioid Treatment Program (OTP) Guidance. Retrieved from: www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf.

6/15/20

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I never thought about working with patients who struggled with substance use disorders- not once. But a door had opened, and life had taught me that unexpected journeys were often the intended path. So, I stepped tentatively across the threshold. As a family nurse practitioner, I am committed to passionate work. If I can’t be all in, I will find a place I can be. If the passion didn’t come, no harm done. There would be another opportunity.

But come it did, and before too long the humanity and melancholy beauty of the patients won my heart. With empathy and the art and science of advanced practice nursing, I became a channel of hope and healing as I learned to treat substance use disorders with medication and a caring relationship. I had my limits: I could not touch the companion that so many walked with-- a co-occurring disorder. Substance use disorders and mental illnesses are often closely intertwined. But my training hadn’t equipped me to treat mental illnesses. Some patients wished aloud that they could have both problems treated in our clinic. Another door was cracking open.

I discovered that the need for mental health providers is a great and complex problem. There is a marked shortage in psychiatrists nation-wide and psychiatrists are an aging population: 60% are greater than 55 years old. The problem is acutely felt in rural areas as most psychiatrists practice in more populated areas. 60% of counties in the US do not have even one psychiatrist. Urban areas also bear a heavy burden because 45% of psychiatrists don’t take private insurance or Medicaid. The impact of these disparities is felt far beyond the patient. A compelling JAMA infographic shows how It affects society as a whole; the disease burden of mental health disorders is greater than any other disease including heart disease and cancer. Tragically, only 5% of healthcare spending is for mental health disorders.

Psychiatric Mental Health Nurse Practitioners (PMHNP) are well suited to meet all of these disparities. Nurse Practitioners have historically met the needs of the poor and underserved. By training a large number of PMHNPs and allowing them to practice to the full extent of their license, the shortages can begin to be addressed. PMHNPs can work in traditional practice models such as community mental health and private practices. They can also branch out in new ways bringing services right to the patient. They can be imbedded in primary practices with an integrated practice model. PMHNPs can also use telemedicine platforms to virtually meet their patients at home wherever the patient is. This provides mental health access into any county and overcomes the transportation difficulties that patients often face.

As a family nurse practitioner completing my PMHNP certification, I am passionate about helping my patients attain their optimal health in all areas of health. Who knew that all the non-pharmacologic interventions that make a healthy mind also make health body? As I diagnose and treat mental health conditions, I prescribe medications without forgetting all the things that work so well without side effects: mindfulness meditation, counseling, yoga, tai chi and other forms of exercise, rest, and a healthy diet. As a PMHNP, I can help fill the gaping need with a holistic approach that embodies respect and dignity of all. My patients are not divided into mental, spiritual, and physical parts with a piecemeal approach to care. FNPs that have added PMHNP to the credentials are uniquely and holistically suited to meet the needs of those afflicted with mental health issues and walk along side them to their best life.

You may have never thought about becoming a psychiatric mental health nurse practitioner—not once. But one in five have a mental health disorder and at best, 50% get treatment. Consider this your open door to a need that reaches into every area of healthcare and society. If you follow the need, you too just might find your passion.

Harrar, S. (2020). Inside America's psychiatrist shortage. Retrieved April 10, 2020, from https://www.psycom.net/inside-americas-psychiatrist-shortage/ Levine, D. (2018). What's the answer to the shortage of mental health care providers? Retrieved from https://health.usnews.com/health-care/patient-advice/articles/2018-05-25/whats-the-answer-to-the-shortage-of-mental-health-care-providers Weiner, S. (2018). Addressing the escalating psychiatrist shortage. Retrieved from https://www.aamc.org/news-insights/addressing-escalating-psychiatrist-shortage

6/4/20

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Dear university community,

Like many of you, I have watched the death of George Floyd at the hands of a Minneapolis police officer and the community reactions across the country. I have struggled to find the words to express my feelings. I am appalled at his death and the deaths and mistreatment of other people of color due to racism and hatred. As a former police officer, as a former professor of criminal justice, as a university president, and as a human being, it angers me.

Let me be clear: racism has no place at our university. It cannot and will not be tolerated. We can and must do more on our campus and in our communities to create justice and equity for all, and especially for those who have been disenfranchised.

These issues are deeply personal to me and have guided my life’s work. The late Martin Luther King Jr. said that “a riot is the language of the unheard.” Growing up in a diverse, working-class neighborhood in Detroit, I watched the famed 1967 riots outside our family’s living room window. To this day, the scenes are etched into my memory. The dry cleaning business that sponsored my Little League baseball team was among those vandalized. I watched as the fabric of my neighborhood was shredded. Those silenced voices unleashed in a scream. We see that again today.

Not too long thereafter, I chose to pursue a career in law enforcement. I joined the Detroit Police Department. In 1967, the city had only about 50 African-American police officers. Fifty in a city of more than 1.5 million people. It is no wonder why the cries of the oppressed went unheard. More than 50 years later, the wounds exposed in 1967 are still not fully healed in our community. In my most discouraging moments, I wonder if they have healed at all.

I know what it means to work in a community whose residents feel that the application of law and order is anything but equal. When the police arrive in their neighborhood, the residents do not feel “protected” or “served,” they feel fear. That fear is justified by too many examples of mistreatment and worse. When I joined SVSU to teach criminal justice, it was because I wanted to prepare men and women for the challenges of law enforcement and to teach them that everyone deserves justice. This justice was denied to George Floyd and too many others like him.

We have worked hard to create an inclusive environment and a culture at SVSU where diversity training and education are available and encouraged, and where there is zero tolerance for racism and discrimination. We must do more. We cannot be bystanders. We cannot wait for change. We must initiate change.

I will appoint a task force of faculty, staff and community members to further elevate equity and justice within SVSU, especially for those who are marginalized, and to provide recommendations for how we can extend those efforts into our surrounding community. Our university values of diversity and inclusivity and a safe, friendly and respectful campus climate support this important work. Please watch for more information on this in the coming days.

Finally, if you have been silent about an issue of racism or intolerance within SVSU, I want to hear from you. I want your voice to be heard. Please e-mail me at presidentsoffice@svsu.edu.

These challenges are even more difficult during a global pandemic that prevents us from gathering on campus, but we cannot allow that to be an excuse for indifference or inaction. I implore each member of our Cardinal family to step up and join in the cause of moving our university and our community toward the ideals on which our nation was founded.

Sincerely,
Donald J. Bachand, President

5/7/20

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Traumatic events and disasters can heighten a person’s anxiety. The COVID 19 pandemic with its tsunami of new infections, national surges and severe disruption of normal day-to- day routine creates increased stress in families. To weather these tumultuous times well and strengthen our emotional health, parents and caregivers must 1) assess their own stress levels and behaviors, 2) practice self-care, 3) recognize stress and anxiety symptoms in their children and 4) help them manage their fears in healthy ways. Equipping parents to care well for the mental and physical health of their children and themselves in the midst of the COVID 19 pandemic is my passion.

Signs of Stress in Adults  

Sleep disturbances are common symptoms of stress and anxiety. This includes difficulty falling asleep, frequent awakenings, or inability to stay asleep, with daytime fatigue. Altered appetite and eating patterns may occur, with decreased appetite or eating for comfort. “Stuck thoughts” about the health of oneself and loved ones or worsening of one’s own chronic health problems may arise with increasing anxiety or stress (i.e. worsened Gastroesophageal Reflux Disease (GERD), Asthma, COPD, Irritable Bowel Syndrome (IBS), Crohn’s Disease, Hypertension and Heart Disease, Generalized Anxiety Disorder, etc.). Sometimes adults increase their use of substances when stressed (tobacco, alcohol, prescription drugs, marijuana and/or illicit substances).

SELF-CARE for ADULTS

Creating A Family highlights the importance of caregivers’ self-care, using the metaphor from the airline industry: in an emergency, an adult should place the oxygen mask on themselves first, and then help their child. Daily exercise, healthy meals, frequent hydration, reducing or avoidance of caffeine, alcohol and other mind-altering substances, regular time of sleep every night, with limited screen time about the pandemic are all healthy, self-care behaviors. Mindfulness, prayer, meditation, breathing exercises (slow and controlled in and out), plus neck, shoulder and body stretches (Yoga or similar) can reduce physical tension in your body, further reduce anxiety, and provide emotional strength for helping your children.

SIGNS OF STRESS AND ANXIETY IN CHILDREN

Children are not “little adults. They express anxiety and stress in developmentally distinct ways. Preschoolers may revert to thumb-sucking, toileting accidents and fear of parental separation. Crying for no reason, irritability, anger outbursts, excessive sadness and disinterest in toys may be their behavior. Physical symptoms (stomach ache, headache), and lack of appetite commonly arise. Preschoolers may mimic their parents’ stress emotions. They may draw faulty conclusions from what they hear about COVID 19, such as a fear of dying, guilt for someone becoming ill, or “something bad is going to happen to me.” Primary school children may struggle with concentration, require more parental attention or regress in their self-care abilities (dressing, hygiene, etc.). Sleep problems are common in all ages. Middle and high school-aged

children may display indifference or a “cool” attitude (“I’m doing okay”) when they actually have physical symptoms of stress: headaches, body aches, and increased irritability. Acting out and poor concentration are common. They might lose interest in activities that previously brought them enjoyment. When older teens are feeling stressed, they are at risk for trying alcohol or other substances. The Centers for Disease Control and Prevention (CDC) as well as Substance Abuse and Mental Health Services Administration (SAMHSA) provide resources for understanding how children from infancy through adolescence express stress and anxiety, as well as healthy ways adults can help them cope in stressful times.

Parents and Caregivers ARE “first Responders,” Helping children manage Their stress and Anxiety

The over-arching purpose of helping children manage anxiety and stress in disaster or pandemic situations is to restore safety, security, love and predictability to their lives. Creating a consistent daily routine while schools are closed reduces stress by restoring security and predictability for children. Be sure to incorporate meals, chores, academic work, recreation, reading and family fun into the schedule. Visuals help younger children follow the daily routine. Incorporating older children’s ideas into the schedule provides a sense of control over parts of their life when much else seems uncertain.

Exercise daily and outdoors whenever possible, while still following CDC guidelines regarding “sheltering at home” or social distancing. Intentionally ask your children how they are feeling and reassure them that you get similar feelings. Share facts about COVID 19 in age appropriate language. National Public Radio (NPR) posted facts in comic form. Teach them healthy self-talk, with singing or listening to uplifting music, prayer, grounding activities such as the 5 Senses, and relaxation exercises for lowering stress and anxiety. Creatively connect with loved ones, neighbors, school or sports friends, using social media, phone calls, handmade cards and “snail mail.” Limiting COVID 19 media exposure reduces anxiety for everyone. Frequently remind your children that expert adults are working hard to keep everybody healthy and the safest place to be is in your own home. Model for your children confidence, compassion for others, and how to find good in the uncertainty.

But… WHEN CHILDREN OR ADULTS NEED MORE…

If you or your child feel overwhelmed by your emotions due to this pandemic or the death of a loved one, speak with a local mental health professional or visit the SAMHSA Helpful Resources Helplines or the National Suicide Prevention Lifeline, 1-800-273-TALK (8255)