Psychiatry in the Time of COVID: Credibility, Uncertainty, and Self-Reflection by articles

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Psychiatry in the Time of COVID: Credibility, Uncertainty, and Self-Reflection

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David A. Adler, MD,* Matthew D. Erlich, MD,† Beth Goldman, MD, MPH,‡ Jeffrey Berlant, MD, PhD,§|| Matthew L. Edwards, MD,¶ Michael B. First, MD,† David W. Oslin, MD,# Samuel G. Siris, MD,** Rachel M. Talley, MD,†† Elizabeth S. Wagner, MD, MPH,‡‡ and Psychopathology Committee of the Group for Advancement of Psychiatry§§

Abstract: Public trust in the credibility of medicine and physicians has been severely tested amid the COVID-19 pandemic and growing sociopolitical fissures in the United States. Physicians are being asked to be ambassadors to the public of scientific information. Psychiatrists have an opportunity to help the public understand and accept a “new normal” during a time of such uncertainty. Using a case example, we review the impact of uncertainty and fear on scientific and medical credibility. Although the pandemic provides an opportunity for systemic change, the consequences of any change remain unknown. To help patients navigate the uncertainty, we conclude by offering four guidelines to clinicians: the public has little interest in understanding the scientific method; we need to acknowledge that we do not have all the answers; credibility and trustworthiness are linked to our ability to be trusted, believable messengers; and we can retain scientific credibility while acknowledging uncertainty. Key Words: COVID-19, coronavirus, SARS-CoV-2, pandemics, clinical adaptations to the pandemic, maintaining physician credibility, managing patient uncertainty, adaptations to care amidst social change, role of psychiatry during COVID-19 (J Nerv Ment Dis 2021;00: 00–00)

uch has (and will) be written about the impact of COVID-19 on societal transformation (i.e., massive societal reorganization, increasing tribalism, economic shifts, etc.) (Ahmad, 2020). In this upheaval, science as a whole and medicine specifically have suffered a crisis of credibility among segments of the public, and as such, an acceptance of professional “certainty” has been shaken. At the same time, psychiatrists, and physicians in general, are being asked to be ambassadors to the public of “scientific” information. The pandemic has amplified what we do not know as well as how to relate an ever-evolving science to a scared and, at times, skeptical public. But, as societal and scientific changes are being introduced at a breakneck pace with accelerated innovation, the reality is we do not know “what's next.” Add the fear factor and this conundrum of “trust what I have to say now, but I'm uncertain of what will follow” erodes that trust, alliances, and authority (Narayan et al., 2021). Psychiatry has an opportunity and a responsibility for helping the public understand and accept the “new normal.” However, it is impossible to both accurately define where we are now and where we are heading. As such, we find ourselves trying to define our present, uncertain about our future, and yet expected to speak from a position of authority. It is a difficult balancing act at a time of renewed concern about professional credibility. Consider Mr. B, a now 65-year-old former city public works employee, who was referred to Dr. Z in 2008 by his primary care physician (PCP) for evaluation and treatment of his road rage. Mr. B has had an impulse control disorder dating back to childhood with past legal issues. Nonetheless, he was in a successful long-term marriage with grown children. Mr. B had a stable job until a recent *Department of Psychiatry, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts; †Department of Psychiatry, New York State Psychiatric Institute/Columbia University Vagelos College of Physicians and Surgeons and New York Presbyterian, New York, New York; ‡Detroit, Michigan (retired); §Optum Idaho, Boise, Idaho; ||Canyon Manor Mental Health Rehabilitation, Novato, California; ¶Department of Psychiatry Stanford, Palo Alto, California; #Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, Pennsylvania; **Department of Psychiatry, Donna and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York; ††Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ‡‡Department of Psychiatry, Brown University Alpert Medical School, Providence, Rhode Island; and §§Group for Advancement of Psychiatry, New York, New York. Send reprint requests to David A. Adler, MD, Department of Psychiatry, Tufts Medical Center, 800 Washington St., #1007, Boston, MA 02111. E‐mail: dadler@tuftsmedicalcenter.org. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/21/0000–0000 DOI: 10.1097/NMD.0000000000001404

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Commentary

The Journal of Nervous and Mental Disease • Volume 00, Number 00, Month 2021

work injury led to his obtaining disability and retiring from his public works position. When asked why he was seeking psychiatric care, he noted, “I'm here because my trusted Jewish PCP and my wife said I need help.” Thus began an intermittent supportive and pharmacological treatment of 13 years. Dr. Z explained that, as a result of their discussions, he suspected Mr. B had lifelong mood instability and impulse control issues both as a result of his biology and his upbringing. Mr. B did not disagree. He had no interest in exploring these issues. Instead, he wondered if Dr. Z had a medication that might help as his PCP had suggested and his wife wanted. In fact, Mr. B had an adequate response to a mood stabilizer. He also acknowledged that what put him “over the edge” to seek treatment was the election of a Black President. He believed that President Obama's tenure was going to precipitate a revolution in which “those minorities would cross the Charles and attack us true Americans.” Mr. B would call for periodic appointments to review resurfacing impulsive thoughts and feelings. He was comfortable expressing political dissatisfaction in sessions with Dr. Z. He was adherent with medications and was feeling better. Importantly, he trusted the medical advice of Dr. Z while acknowledging their increasing tribalistic differences. In 2012 after President Obama's reelection to a second term, Mr. B began building an underground bomb shelter in his backyard stocked with 2 years of supplies and munitions to protect his family. In 2014, he revealed this to Dr. Z in the following manner: “I know you are one of those liberal doctors who voted for him [Obama], but I always choose Jewish doctors because if you have a health problem that's who you want. So, I want you to know that, even though you stand for everything I detest, you and your wife will always have a space in my bomb shelter when it happens.” Dr. Z understood this invitation as a testament to a therapeutic alliance, but with Mr. B acknowledging that his trust for Dr. Z's medical advice transcended their stark political divisions. Mr. B disappeared from treatment in December 2016, and his PCP continued to prescribe his mood stabilizer. It was only by a chance meeting in an airport when Mr. B and his wife were going on vacation that Dr. Z learned from Mr. B he was no longer in need of his services due to the change in Presidency. Mr. B was relieved as the country had been saved with the election of President Trump. The next contact was December 2020 when Mr. B, again at the urging of his wife, called Dr. Z in a panic because of the election defeat of President Trump and wanted to resume psychiatric treatment. Once again, Mr. B reiterated the bomb shelter offer to Dr. Z, and Dr. Z thanked him for the offer. When we are uncertain and afraid, we look toward individuals, institutions, and others who we believe are credible. For some, this may be a prominent scientist, such as Dr. Anthony Fauci. For others, it may be a leader who offers false reassurances that minimize the harms of the pandemic using pseudoscience to hedge, cajole, and feign credibility. For many, however, science and medicine provide little comfort. Even before this pandemic, there have been concerns with respect to the diffuse opinions in the scientific literature. Psychiatry as a discipline has its own history of assertions in the past that have been disproven (or abandoned) over time (e.g., slavery as “drapetomania,” equating slaves' desire for freedom with insanity; homosexuality as a pathological condition, among other examples of scientific falsehoods) (Warner, 2021). There continues to be the belief that psychiatry is in the pocket of the pharmaceutical companies preaching the false promise of “better living through chemistry” (Whitaker, 2011). The interactions between Mr. B and Dr. Z were filled with elements of racism and political 2

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polarization. Despite this, Mr. B twice turned to Dr. Z as a credible support first because of his trust of his “Jewish” PCP, his wife's support of the treatment, his distress, and, later, the supportive relationship he felt with Dr. Z. Importantly, despite the known differences between Mr. B and Dr. Z, he was able to put aside his ideological beliefs in his pursuit of getting good care. Despite a worsening sociopolitical divide with Mr. B and Dr. Z inhabiting different realities and the ever-hardening political divides leading to distrust of the “other side,” Mr. B found Dr. Z to be a credible physician and was willing to transcend the breakdown in trust in other realms of their lives. Credibility transcended the opposing views, and Mr. B and Dr. Z communicated, not as soldiers in a culture war, but as patient and doctor. The scientific method as a process has inherent uncertainty that can be challenging to communicate effectively to the public. As technological advances and treatment lessons lead to new findings and outcomes, it is the belief in the process of discovery, disclosure, and acknowledgment when one is uncertain, wrong, or has to change course that is the most likely path to discovering what is true (Jhangiani et al., 2019). We want to believe credibility does not derive from a physician (or a public personage) extolling certainty. Rather, credibility stems from the accurate appraisal of when we are unsure, when we need to learn more, and when we recognize that we cannot predict the future. Then we have to successfully explain this to the public. The credibility issue has impacted the field's certainty (read: trust) among patients, peers, and critics alike. Although there has been a process in the past to attempt to compensate for these realities, to work to set the record straight, and to bolster certainty by admitting error when applicable, the public is left confused, uncertain, and distrustful. For Mr. B, it was less about Dr. Z's demonstrable facts and more about Mr. B's trust in Dr. Z's management of his care and the successful outcome of better containing his impulses. Traditional approaches to treatment are shifting: COVID-19 is forcing us to move “fast”—too fast, perhaps. Using the thinking fast/ thinking slow framework of the psychologist Nobel laureate Daniel Kahneman (Kahneman, 2011), most decision-making is based largely on intuition. Unfortunately, this is in conflict with thoughtful discussions about potential solutions in times of uncertainty. Too often, we forget how history recurs, providing context for our current situation. Past pandemics, too, have impacted mental health. For example, recognition that the 1918–1919 influenza outbreak led to mental health sequelae later in life (Eghigian, 2020), and the HIV/AIDS impact on both the immediate health of those afflicted and managing its physical-behavioral health burden of patients and caregivers alike (Remien, 2019). Moreover, economic, racial, sex, and sexual orientation divisions—more due to biases and prejudices than a natural predisposition—are highlighted, as COVID-19 has especially impacted vulnerable communities. They face health service scarcity, disparities, and a higher likelihood for adverse events. Each of these challenges has created a societal crisis, but, like other massive upheavals before, it catalyzes and provides an opportunity for change. COVID-19 provides an opportunity for systems to change entrenched patterns, but we have no understanding of how this will impact psychiatry in the long run. As we think about the future of psychiatry and how our responses to COVID-19 will change it, we must acknowledge the uncertain outcomes. Perhaps, the pandemic will increase the use of telemedicine (i.e., telepsychiatry improves access, reduces personal, logistical, and financial barriers to care). But to what degree and with what consequences (e.g., it may lead to more disengagement with care, it may not be a profitable service delivery model, its long-term outcomes may be inferior, etc.)? Although the pandemic has brought health inequalities to light, will addressing such inequities be a priority for our policy makers and the general public, or will we go back to business “as usual?” And how will we as a field address the ongoing concerns about the credibility of those decisions? We also cannot ignore how Mr. B's concerns, shaped by a socio-cultural-political landscape in which variance on how factual © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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information is interpreted, has contributed to the current credibility crisis. Long before the current public health emergency, Mr. B was “primed” to see the United States within a dominant cultural view of “us versus them” that should be feared and organized against. As polarization escalated and Mr. B's apocalyptic vision became more realizable, the “us” and the “them” become more entrenched. Facts were not only politicized but also tribalized. The “us” has their own authority figures, set of facts, vision of the present, and disdain for the “them.” Scientific authority and credibility become subservient to whose side you are on. A Dr. Fauci is a tool of the “deep state,” and credibility itself becomes politicized. This is especially dangerous now, where we need credibility more than ever as our response to COVID-19 is not a political exercise alone; it is a matter of public health and all our futures. Uncertainty is intrinsic to the “scientific method.” Knowledge is iterative. Information is constantly reviewed, revised, and revamped. Doctors observe, question, test, hypothesize, analyze, rule out, and then arrive at a conclusion with a high degree of certainty, not total certainty. The “method” is really a process of scientific inquiry, testing theories, discarding what we can certify as false, and formulating new hypotheses with enhanced knowledge. For example, early in the pandemic, it was reasonable to assume that contact with the COVID-19 virus through surface transmission was dangerous. As more data accumulated, this hypothesis seemed less likely as a main vector for the virus. The initial assumption was credible at the time based upon the science, and the current finding that we are less likely to transmit COVID-19 by touching a door handle is no less credible than the science from Spring 2020. Determining how we react to the evolving science of the pandemic is the scientific method at work whereby credibility stems from how we translate the science. How can we build and maintain credibility in a period of uncertainty and mistrust? In trying to help our individual psychiatric patients navigate the reality of uncertainty without their losing confidence in our ability to help them, we offer four guidelines. 1. It is important to note that some in the public may have little interest in committing to scientific methodology, which may be seen as one more (unbelievable) belief system. In their first meetings, Dr. Z reviewed Mr. B's life story and presented him with a series of options to consider, given that each choice had its costs and benefits. Sharing the uncertainty and the “art as much as science” choices, Mr. B fell back on his trust in his PCP referral in asking Dr. Z to recommend which treatment to try first. Mr. B had no interest in the scientific methodology, but his belief that a trained physician had the moral authority to advise him how best to proceed, even during a time of unfolding scientific advances, uncertainty, and an evolving science. 2. Clinicians need to acknowledge that they do not have all the answers. For Mr. B, it was Dr. Z's listening and making him feel heard that allowed him to trust Dr. Z's expertise even if the outcome of the treatment was unclear. This is both reflective and aspirational. Expertise, and subsequently credibility, derives from both knowledge and experience. In times of massive change, what we know, the humility of acknowledging to our patients what we do not know, and that we are learning too are imperative. It is difficult balancing credibility amidst ever-changing scientific findings for the psychiatrist to address. 3. Credibility is inextricably linked to trustworthiness and our ability to explain our understanding to our public. Credible facts can be delivered by untrustworthy individuals and vice versa. Pseudo-credible false assertions can also be delivered by both those with whom we trust and vice versa. How the message is delivered, by whom, and receptivity of the audience matter. Although not universally reassuring, despite the changing story, Dr. Fauci's even-handed, somewhat humble style and unflappability convey the consistency of our methodology even if it is not understood. Psychiatrists such as

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Dr. Z understand the importance of trust as central to the therapeutic alliance and are therefore well-positioned to be credible sources of information. We must become trusted, believable messengers (successful communicators) and deliver understandable normalizing messages (Remien, 2019). 4. One can retain scientific credibility and its relativity while acknowledging uncertainty. Much of psychiatry is composed of unknowns. These include unknown mechanisms of action of our medications, unclear neural processes, and a lack of clarity between a particular syndrome and normality. Yet, credibility is not elusive. Reaching the conclusion that one has a diagnosis of exclusion, maximizing investigation, or acknowledging that science is not there yet is part of routine practice. For example, much has been written about the post-COVID syndrome (“long haulers”) or PASC (postacute sequelae of SARS-CoV-2), which describes myriad lingering health problems. These range from neurological symptoms (e.g., brain fog, headaches, fatigue), autonomic nervous system symptoms such as POTS (postural orthostatic tachycardia syndrome), lingering depressive and anxiety symptoms, increased suicide risk, “COVID19 psychosis,” as well as PTSD (Sher, 2021). Although these syndromes are recognized as correlated to COVID-19, causation remains unclear. Who is predisposed and what is the prognosis? Will these sequelae present as neurological disorders, autoimmune sequelae, or mental disorders? Are they reversible, permanent, or taper with time? How well will they respond to available treatments (Rogers and David, 2021)? As psychiatrists, we have an obligation to explore and try to treat these symptoms, recognizing that one may not have the answers and the science may not be known despite our best efforts. It is the acknowledging that knowns have been exhausted which lends credibility to uncertainty.

Lisa Rosenbaum reminds us that at this moment in the pandemic we do not know what the future will hold (Rosenbaum, 2021). There may be both significant positive (e.g., new modes of doing our work) and negative (e.g., another time of destructive funding cuts) impacts. The pandemic has been a (long) “moment” in the context of a “perfect cultural storm.” It is human nature to crave certainty as an antidote to fear, but the pronouncing certainty relies upon credibility. What does a psychiatrist do when current events produce a climate of uncertainty? Rely upon expertise, examine all hypotheses, be trustworthy, and acknowledge to one's patient when knowns are exhausted. These are the traits of credibility and the tenets of alliance with our patients. DISCLOSURES David A. Adler, MD, is a cofounder of Health and Productivity Sciences who has no assets and has been an investigator on research grants from Janssen Pharmaceuticals. The remaining authors declare no conflict of interest. REFERENCES Ahmad A (2020) Covid-19 pandemic: A public and global mental health opportunity for social transformation? BMJ. 338:m1383. Eghigian G (2020) The Spanish flu pandemic and mental health: A historical perspective. Psychiatr Times. 37:26–28. Jhangiani RS, Chiang ICA, Cuttler C, Leighton DC (2019) Overview of the scientific method. Available at: https://socialsci.libretexts.org/@go/page/19612. Accessed May 19, 2021. Kahneman D (2011) Thinking, fast and slow. New York: Farrar, Strauss and Giroux. Koh KA, Raviola G, Stoddard FJ (2021) Psychiatry and crisis communication during Covid-19: A view from the trenches. Psychiatr Serv. 72:615. Narayan KM, Curran JW, Foege WH (2021) The Covid-19 pandemic as an opportunity to ensure a more successful future for science and public health. JAMA. 325:525–526.

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Commentary

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Remien RH (2019) The impact of mental health across the HIV care continuum. Psychology and AIDS Exchange Newsletter. Available at: https://www.apa.org/ pi/aids/resources/exchange/2019/01. Accessed June 14, 2021. Rogers JP, David AS (2021) A longer look at COVID-19 and neuropsychiatric outcomes. Lancet Psychiatry. 8:P351–P352. Rosenbaum L (2021) No cure without care—Soothing science skepticism. N Engl J Med. 384:1462–1465.

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