Families in Psychiatry

The transitions of COVID-19


 

When I was preparing for the recent birth of my baby, I anticipated a period of transition for myself. As a reproductive psychiatrist, I have treated many women during the perinatal and postpartum periods, and have a unique appreciation for the life changes that accompany birth. What I did not expect, however, was the world transitioning with me.

Dr. Sarah Reinstein of Zucker Hillside Hospital of the Northwell Health System, Glen Oaks, N.Y.

Dr. Sarah Reinstein

“The new normal” is an economic phrase that describes the COVID-19 era. The pandemic has engendered economic instability, collapsed industries, challenged health care systems, and has led to many deaths worldwide. The COVID-19 pandemic also has been associated with overall increases in anxiety and depression.1 Emerging research suggests that frontline medical workers are especially at risk for developing psychological distress.2

COVID-19 has also created immense challenges for families. Because of concern for the spread of the virus, schools have been suspended, older grandparents isolated, and many parents continue to work remotely. For families in psychiatric care, this time has also been a time of change. Telepsychiatry might be more accessible, but the transition has been an adjustment for patients and clinicians.

As psychiatrists, how do we best treat families during this time? What are some ways to support our psychiatric colleagues? How do we ensure our own emotional well-being amid the tremendous changes occurring around us?

Background of interpersonal psychotherapy

Interpersonal psychotherapy (IPT) is a form of psychotherapy designed to treat depression following periods of transition. Its main goals include improving interpersonal connection and reducing psychological distress. Originally developed in the 1970s by Gerald Klerman, MD; Myrna Weissman, PhD; and Eugene Paykel, MD, IPT is a structured, time-limited form of psychotherapy.3

Conceptualizing depression as a treatable illness, Pim Cuijpers, PhD, and associates summarized the division of IPT into three phases.4 The initial phase involves history taking, forming an alliance, and choosing an interpersonal focus for treatment. The middle phase focuses on applying interpersonal problem-specific therapeutic techniques. The concluding phase of treatment involves consolidation of gains as well as formulating contingency plans for relapse of symptoms. Over the course of treatment, an IPT clinician focuses on life transitions and emphasizes that isolation and antagonistic relationships increase an individual’s vulnerability for a depressive episode.3

Randomized, controlled trials support IPT’s efficacy as a treatment for depression. Research also suggests it can possibly prevent the development of depression.4 Although IPT initially was designed as an individual form of psychotherapy, it has been adapted to both family and group contexts.5,6 IPT is also an empirically valid form of psychotherapy for postpartum depression.7

Interpersonal psychotherapy for families

Given IPT’s role for treating depression following times of transition, clinicians should consider adapting interpersonal psychotherapy to family treatment during this time. Addressing social isolation, managing complex family relationships, and monitoring the family’s overall emotional health should be prioritized. Families under quarantine or who are grieving the death of family members may especially benefit from improved interpersonal connection. Consistent with the IPT model, contingency plans for the family should also be explored to prepare for potential future waves of the pandemic.

In addition to supporting and strengthening families, psychiatrists can use IPT themes to identify positive changes for families tied to COVID-19. Despite its difficulties, the stay-at-home order provided some families a unique chance to slow down and adapt a more relaxed routine. Busy families were suddenly given the opportunity to spend more time with one another. Although many older grandparents were isolated, creative uses of technology provided a chance for grandparents to remain an integral part of family life. Psychiatrists can assist families in transitioning back to previous schedules, while also exploring ways to incorporate the positive changes gained during this time.

Interpersonal psychotherapy for psychiatrists

An interpersonal focus could also be helpful for clinicians to adapt to changes in psychiatric practice. Many clinicians have been thrust into telepsychiatry practice, some with little to no preparation. Because of the trauma associated with frontline work, some psychiatrists have expanded their patient panel to treat physician colleagues. For consult-liaison psychiatrists, the possible neuropsychiatric effects of COVID-19 are new symptoms to consider when evaluating patients in a medical hospital setting.8 Fundamentally, modern day psychiatrists have never encountered a pandemic nor attempted to treat its psychological implications. Prioritizing seeking support from colleagues and caring for one’s personal relationships are helpful tools for clinicians to maintain their own emotional health during this challenging period.

Personal reflection

When I reflect on my baby’s recent birth, I recognize the importance of interpersonal relationships. COVID-19 developed shortly after I gave birth, during the initial haze of the newborn period. Initially, I felt overwhelmed by the many transitions and emotions that were occurring simultaneously. However, as I began to prioritize socialization for myself and my family (albeit creatively at times while socially distancing), I witnessed its positive effects on my emotional well-being and recognized its value in managing times of transition.

Using IPT for families, colleagues, and ourselves

As general psychiatrists, there are several ways to utilize IPT-related themes during this time:

  • Connect with families: Although families may recognize they are struggling emotionally, some may find it difficult to navigate the sea of mental health resources. This is particularly true when a family’s financial situation is also stressed. Reaching out to local religious services and community medical resources or inquiring about the mental health of other family members are ways for psychiatrists to engage more families in mental health treatment.
  • Reach out to colleagues: Psychiatrists are not immune to developing psychiatric disorders,and it is important to support each other.9 This is also an unusual time when psychiatrists are treating symptoms in patients that they themselves may be also experiencing. Supporting help groups and hot lines, reaching out to colleagues who appear to be struggling and addressing interpersonal conflicts within one’s practice are crucial practices for psychiatrists during this time.
  • Explore within ourselves: Evaluating our own interpersonal relationships as well as areas for improvement are critical skills to maintain our own emotional well-being. Setting aside time to connect with friends in a nonclinical setting and prioritizing our family connections are helpful tools. In addition, exploring our reactions to past life transitions could improve our own level of insight into our response to COVID-19.

Conclusion

Conceptualizing COVID-19 as a period of transition and using IPT themes are helpful tools to mitigate the potential adverse psychological effects of COVID-19 on families. Similarly, they can also be helpful in supporting our colleagues and helping ourselves cope during this difficult period.

References

1. Qiu J et al. Gen Psychiatr. 2020 Mar 6;33(2):e100213.

2. Gautam M et al. Psychosomatics. 2020 Apr 20. doi: 10.1016/j.psym.2020.04.009.

3. Markowitz JC, Weissman MM. Clin Psychol Psychother. 2012 Mar-Apr;19(2):99-105.

4. Cuijpers P et al. Am J Psychiatry. 2016 Jul;173(7):680-7.

5. Dietz LJ et al. J Am Acad Child Adolesc Psychiatry. 2015 Mar;54(3):191-9.

6. Verdeli H et al. Child Adolesc Psychiatr Clin N Am. 2008 Jul;17(3):605-24.

7. Stuart S. Clin Psychol Psychother. 2012 Mar-Apr;19(2):134-40.

8. Rogers JP et al. Lancet Psychiatry. 2020 Jul;7(7):611-27.

9. Korkeila JA et al. Scand J Public Health. 2003;31(2):85-91.

Dr. Reinstein is a psychiatry attending at Zucker Hillside Hospital, New York. Her clinical interests include reproductive psychiatry and family therapy, with a specific focus on maternal mental health. She is one of the recipients of the 4th Annual Resident Recognition Award for Excellence in Family Oriented Care. Dr. Reinstein has no conflicts of interest. Alison M. Heru, MD, the Families in Psychiatry columnist, invited Dr. Reinstein to address this topic.

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