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What questions we should be asking ourselves and loved ones about mental health?
The NAMI Medical Director outlines things to look out for and beneficial things we can do in this short clip.
In collaboration with Dauphin County NAMI. For more info visit: nami-dauphincounty.org.
By Elisabeth Kunkel, MD
Chief Medical Officer
Pennsylvania Psychiatric Institute
Covid Impact on Providers
One thing is for certain: Covid has made life harder for everyone, and the providers and staff at Pennsylvania Psychiatric Institute (PPI) are no exception. What started out as figuring out new protocols with PPE supply shortages soon turned into problems with staffing and burnout.
PPE: Staff and Patient Safety
When the pandemic first started, getting enough masks, gloves and gowns were a problem. N95 masks were in short supply in 2020 and although regular surgical masks and face shields were supported as a safe alternative by the CDC, some providers felt they were not “safe enough”. There were a lot of unknowns about the new virus and the medical staff was justified with their concerns. In the beginning, institutions needed to ration PPE starting with procedures that posed the highest risk. “Because of the aerosolized nature of the ECT procedure, we were accessible to obtain enough PPE, including N95 masks, so that all ECT staff were protected” explains Elisabeth Kunkel, MD, Chief Medical Officer at PPI. “It wasn’t until much further into the pandemic before we got enough PPE. We limited PPE use to contact with Covid patients and staff who interacted with such patients.” N95 mask shortages caused PPI to get resourceful. Now in 2022, they are investigating various KN95 masks for use with patients who are not known to have covid. Staff feel reassured regarding their own exposure risk when using the KN95s with patients who have an unknown Covid status.
Not only was PPE used to keep staff safe, but patients as well. “Patients would come in with ineffective cloth masks, so in 2022, we started providing them with surgical masks. Outpatients can interact with our staff from 30 to 60 minutes at a time, so protecting everyone was the main goal. Sometimes it’s difficult to keep masks on patients due to the nature of their mental illness, especially for acutely ill inpatients or distraught outpatients, so all PPI staff are required to wear masks.”
Mask use was not foreign to PPI staff as those who could not get the flu-shot were accustomed to wearing masks pre-pandemic. However, there was a big culture shift that happened with Covid. To enter the facility, everyone had to be Covid negative – but this wasn’t a definite solution.
“There were a few cases where patients developed Covid within the facility” notes Dr. Kunkel. “Our first option when this happens is to send the patient who is Covid positive home to quarantine, however, as a psychiatric facility, sometimes inpatients are not well enough to go home. Being isolated in single patient room is not therapeutic for patients who have Covid, and frequently, the Covid-positive patients were not sick enough to be transferred to a medical unit. Early on, we changed from semi-private rooms to private rooms, to mitigate exposure of patients to each other while hospitalized. On psychiatry, we want patients to interact to help with socialization. We were able to respond to these situations with iPads. The iPads allowed patients to still participate in therapy, as it is all group programming, but at a safe distance while they recover, and other patients remain safe.
Going Virtual
All meetings at PPI went virtual at the start of the pandemic. Though the separation is safer for everyone, it comes with its own challenges. Interactions are harder when there’s a delay in gestures and discordant eye contact, not to mention the learning curve of using several different virtual meeting platforms. There are many fewer interpersonal interactions and even masked in-person meetings provide a less personal connection.
Social distancing and working from home gave rise to an increased use of outpatient telehealth services. Due to the state of emergency, PPI was granted a waiver to provide telehealth services without needing to go through the lengthy process of getting licensure and implementing encrypted platforms. PPI has not been able to obtain licensure outside of the emergency declaration. A new normal has formed with a combination of telehealth and (mostly) live therapy sessions.
“We make half as much from a virtual appointment than an in-person session and it’s hard to sustain an outpatient practice, however, we realize telehealth provides a great service for patients who are too scared about being exposed to Covid, might have been exposed, may be ill with Covid, or are unable to find transportation for in-person meetings” Dr. Kunkel notes understandingly. Unfortunately, telehealth goes away when the state of emergency goes away which is currently slated for the end of March 2022. From that day, PPI will no longer be able to use telehealth, and the convenience that it provides patients also will go away.
Workforce Stress
PPE, staff and patient safety weren’t the only struggles during the pandemic. “We have issues related to turnover and recruitment. The hiring process is definitely different from pre-pandemic hiring. It’s hard to identify candidates when we’re not getting CVs for open positions. Since 2017, we grew from 17 PPI physicians to over 30. Currently, we are not able to replace those leaving quickly enough and must resort to hiring locum physicians in the meantime.”
Before the pandemic, two to three physicians were assigned to a unit. To limit the possibility of spreading Covid, we changed it to one provider at a time per unit during the early days of the pandemic. “We set up a weekly rotation, one provider in the unit, the others working from home. Telehealth, something that was not used previously at PPI, was also fully implemented in the outpatient setting. This was well-received by the doctors.”
This plan slowly dissolved as staffing became more of an issue. Provider and nursing shortages overlayed what was going on. Providers left for various personal reasons, like to be more available to their families or relocating to back their hometowns. Burnout can also be an attributing factor. Hershey Medicine provides resources to their physicians like yoga, laughter therapy, art-related activities, professional counseling, etc. to help staff through stressful periods, but part of the issue remains: the lingering pandemic. “There is no immediate return to normal that staff can look forward to. We went through four surges and wearing masks for long periods of time is hard to sustain” explains Dr. Kunkel.
People are frequently worried about getting ill. It’s overwhelming when a provider and their family members are both sick with Covid. Surges like Omicron took its toll on the physician workforce. In January 2022, eight physicians and five of their children got Covid, even though all were fully vaccinated, and the adults also were boosted. Since staff needs to stay home until test results are known, PPI can only fill as many beds as they can service, meaning PPI did not have enough staff or providers to serve at full capacity, and barely enough to provide for their current capacity. This paralleled the national shortages in healthcare.
Staffing shortages meant that some physicians were now rotating on more than one unit. Providers stretched their patient case load to cover for colleagues who were under quarantine. One provider even covered both the adolescent and adult units. Morning meetings occur simultaneously on all units, so providers needed to run from one meeting to the other to cover all their patients on 2 different team meetings.
Staffing challenges led to unit closures. “Our child unit has been closed for the entire past year, occasionally, it is closed during summer months for lack of patient referrals, but we currently are not able to reopen it because of staffing issues.” The child unit was considered for a Covid unit, it was even set up, but it did not materialize. “We had to close one unit twice due to quarantine in January 2022 and could not allow admissions because of it. Quarantines drops capacity of admissions and creates problems for patient access.”
Patients
Patients are psychiatrically sicker now – their conditions more acute due to delayed care and isolation at home – and are, therefore, more challenging to care for. Outpatient suicide rates are up, rates of mental illness across the board are up. Sicker patients are additional stress burdens for providers (along with the stretched staffing, higher caseloads and covering multiple units).
Patient acuity is measured by medication usage, whether they can tolerate a roommate, if use of restraints and seclusion are needed and/or if they are stressed. Higher acuity patients take longer to get better, so the average length of stay has gone up. “Staying longer is not good for a patient. Longer stays also mean that PPI can’t help more patients in need, since bringing in new patients can’t happen when beds are occupied.” Typically, there are other facilities that patients can be sent to: state hospitals, child facilities and extended acute units, but all placements elsewhere are harder to come by now.
Outside Pressures
Emergency Departments (ED) are completely overwhelmed. Patients are hung up in EDs because they tested positive for Covid and need to quarantine. EDs are getting pressure from administration to have facilities like PPI admit more patients. Patients have been sitting in EDs a long time, but there’s an inability to open more inpatient psychiatric beds in the region due to staffing challenges. PPI has a small footprint and taking in a patient who needs isolation and whose illness results in quarantining the unit, can shut down a unit to admissions. “Our hope is to get patients to PPI ASAP, but we do not have the bed capacities. If patients are Covid positive, they need to quarantine in the ER, even though it does not offer a therapeutic environment. We were, however, able to reduce the length of quarantine due to changing guidelines. Previously 14 days, quarantine is now 10 or 7 days for Covid positive patients. Getting rapid tests is another obstacle in the ED, but once they test negative, we can take them” outlines Dr. Kunkel.
“We feel the pressure to take patients when no beds are available. With each patient, we must assess if PPI has staff to adequately care for the patient and consider how that will affect the rest of the unit. Some patients are very ill – they are assaultive and can’t be placed with other patients, have assaulted children or destroyed property. When we take in very ill patients, it limits what staff can do for other less acute patients.”
Despite demands, providers have been exceptionally helpful and willing to go to the nth degree to take care of patients. “They are weathering the storm despite how fatiguing this is for them. I have tremendous appreciation for our team because of this” expresses Dr. Kunkel in gratitude. “They help each other, and work collaboratively in the trenches.”
If you would like to speak to someone about better managing your stress and anxiety, or to make an appointment, please call (717) 782-6493 for more information.
This year for Black History Month, we will be highlighting different mental illnesses each week and two prominent members in the Black community who have spoken out about their experiences with them. We aim to highlight that even though someone has a mental illness, they can still be successful.
Sir Robert Bryson Hall II, aka “Logic,” is a streamer, writer, record label owner, and a recently retired rapper.
He grew up in poverty with substance-addicted parents. According to the U.S. Department of Health and Human Services, Black or African Americans living below the poverty level, compared to those over twice the poverty level, are twice as likely to report serious psychological distress.
In his late twenties, he was finally financially stable in his life. However, his hectic schedule and his own insecurities led to a severe anxiety attack and was hospitalized. He was diagnosed with derealization disorder – an anxiety-induced disorder with symptoms that include the sense of being out of one’s body, all of the time.
In 2017, the Grammy-Nominated rapper released “1-800-273-8255” in association with The National Suicide Prevention Lifeline. With record highs in Billboard charts, this single also stuck another interesting cord — A high number of calls to the hotline. The director of The National Suicide Prevention Lifeline said, “Overall, we saw about 26-27% increase in calls that year,” “The overall water level, so to speak, had risen and largely due — we believe — to the song.”
As a biracial rapper, he struggles with how the world sees him, especially with the negativity that lives on social media. He told the Recording Academy about his experience with mental health and anxiety. “I was so scared for so long to say that because society has led me to believe that my anxiety is stupid and shouldn’t be talked about, or that suicide, ‘Who cares, who’s weak enough to kill themselves?,’ which is the most terrible, disgusting, ugly thing somebody can say,“ In retrospect, he finds positivity to it all and wants to focus on living freely and being surrounded by happiness.
Black men are dying from suicide at increasing rates. A recent report released by the Congressional Black Caucus says that suicide is ranked as the 3rd leading cause of death in Black men from ages 15-24. “There’s a need for black male therapists because that is who they’re going to feel more comfortable talking to,” said Diamond Dale, a Black Mental Health Advocate.
Black women also face challenges with suicidal thoughts or actions, like Oscar- Winning actress Halle Berry.
In 1997, her first failed marriage with baseball star David Justice triggered an attempt to take her own life. The 40-year-old was so devastated by the split, that she attempted to gas herself. In the last minute, she thought of her mother and came to a quick realization that ending her life would be selfish. In an interview with Parade Magazine, Berry said “I was sitting in my car, and I knew the gas was coming when I had an image of my mother finding me. She sacrificed so much for her children, and to end my life would be an incredibly selfish thing to do.”
Since then, counseling and therapy helped her take control of her life. She reprogramed herself into focusing on motherhood and family.
According to an article, ‘What’s Going on with Our Black Girls’, by Christina Caron, suicide rate of Black females ages 15 to 24 years old rose by 59 percent between 2013 and 2019. The same article states that about 9 percent of the older girls experienced a relationship crisis before the suicide – similar to Halle Berry’s experience.
A study by sociology doctoral student Heather Kugelmass, MA., showed that counseling offices are not always available for black women and therapists are less likely to offer appointments due to a possible internal bias of their own. Aside from this lack of resources, psychologists are now working to make the mental health field more welcoming to Black women and more responsive to their needs.
Suicide is death caused by injuring oneself with the intent to die. A suicide attempt is when someone harms themselves with any intent to end their life, but they do not die as a result of their actions.
A combination of situations could lead someone to consider suicide. Risk factors increase the possibility of suicide, but they might not be direct causes.
Risk Factors:
Individual:
• Previous suicide attempt
• Mental illness, such as depression
• Social isolation
• Criminal problems
• Financial problems
• Impulsive or aggressive tendencies
• Job problems or loss
• Legal problems
• Serious illness
• Substance use disorder
Relationship:
• Adverse childhood experiences such as child abuse and neglect
• Bullying
• Family history of suicide
• Relationship problems such as a break-up, violence, or loss
• Sexual violence
Community:
• Barriers to health care
• Cultural and religious beliefs such as a belief that suicide is noble resolution of a personal problem
• Suicide cluster in the community
Societal:
• Stigma associated with mental illness or help-seeking
• Easy access to lethal means among people at risk (e.g. firearms, medications)
• Unsafe media portrayals of suicide
If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.
If you would like to speak to someone about better managing your stress and anxiety, or to make an appointment, please call (717) 782-6493 for more information.
Sources:
• https://blog.gfuel.com/logic-rapper
• https://nypost.com/2017/08/03/how-a-rapper-fought-through-crushing-anxiety-to-become-no-1/
• https://www.grammy.com/news/logic-opens-about-his-truth-hardest-years-my-life-mentally
• https://www.npr.org/2021/12/28/1067880209/logic-1-800-273-8255-suicide-prevention-lifeline
• https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24
• https://www.cbs8.com/article/news/local/black-male-suicide-deaths-rising-faster-than-other-racial-groups/509-1dea0383-e5d8-4ce2-95dd-12ee43b52b62
• https://www.nydailynews.com/news/halle-berry-admits-suicide-attempt-article-1.213921
• https://www.nytimes.com/2021/09/10/well/mind/suicide-rates-black-girls.html
• https://www.cdc.gov/suicide/facts/index.html
During Black History Month, we are highlighting some of the top Black professionals in the mental health field that many have not heard of.
Today we are highlighting the first Black male and female to receive their PhD in psychology. Francis Cecil Sumner, PhD, and Inez Beverly Prosser, PhD.
America’s first black female psychologist, Inez Beverly Prosser, PhD, was born around 1897 to Samuel Andrew and Veola Hamilton Beverly in the small town of Yoakum, Texas. Not much is known about her early years besides the fact she was the oldest daughter of 11 children. A bright student, she graduated valedictorian from Yoakum Colored High School in 1912 and then went on to receive a degree in teacher training from Prairie View Normal College where she was also valedictorian. Though common today, in her time, education beyond high school was not common, especially for a woman. Even more unheard of was an African American woman with a college degree.
![Inez Beverly Prosser, PhD. Source: uwgb.org](https://ppimhs.org/wp-content/uploads/2021/10/ibp01.jpg")
After receiving her degree, she went back to Yoakum and taught for a short time at their segregated schools, before accepting a teaching position in Austin, where she took up classes at Samuel Huston College. In around 1924, she graduated with distinction from Samuel Huston with a major in education. Shortly after her graduation she married Rufus A. Prosser. Unable to stay away from academia, Inez decided to continue her education obtained a Master of Arts degree in educational psychology from the University of Colorado. She then accepted a position at Tillotson College teaching education, where she was recognized as an excellent teacher and leader. Then from 1921 to 1930 Inez served as dean and registrar at Tillotson College. In 1931 Inez was awarded the Rockefeller Foundation General Education Board Fellowship because of her excellent and well-known work as a teacher.
In 1933 she received a PhD, one of the first African American women to accomplish this in the United States, in educational psychology from the University of Cincinnati. Her dissertation, which received a huge amount of recognition, was on The Non-Academic Development of Negro Children in Mixed and Segregated Schools. It was also one of the earliest treatises on the social domain of elementary school children.
During Inez’s lifetime she established a fund, while completing her own education, that enabled her sisters and brothers to obtain a college education. Of the eleven brothers and sisters, all completed high school and six further completed a college education. Then in 1934, tragedy struck as Inez Beverly Prosser was killed in an automobile accident near Shreveport, Louisiana.
Inez Beverly Prosser, PhD, was a strong-willed individual who beat the odds, and if not for a terrible accident, would have been able to make even more contributions to psychology as we know it.
This year for Women’s History Month, we are highlighting different women each week who, although you may have not heard of previously, have contributed greatly to society.
The final woman to be highlighted this month is Martha Bernal, the first Latina to receive a PhD in psychology in the US.
Bernal grew up in El Paso, Texas and was raised by Mexican immigrants. Her successes in school started at a young age.
Her father did not initially support her educational aspirations. According to the obituary published in the American Psychologist, “He believed that women were to be married and a college education for a woman was a waste.” When he noticed her persistence and the support of her mother and sister, he eventually supported her through college and graduate school.
In Martha’s childhood, she experienced discrimination against Mexican Americans. In the American Psychologist obituary, “Spanish was not permitted in school, and both the community and the school were ethically segregated.”
In 1962, she earned her doctoral degree in clinical psychology from Indiana University, Bloomington. At the University, she encountered many accounts of racism and sexism. According to author Linda Woolf, “At Indiana University, female students were not invited to participate with their professors on research projects. The ones that participated were mainly white students.” She almost dropped out of the program but succeeded with the help of peers and faculty.
After graduating with her PhD, Dr. Bernal narrowed her focus of psychology to two areas: learning theory and multicultural studies.
In the 1970s, she dedicated herself to the goal of ensuring students of color would have the opportunity to receive graduate training. She applied much of her research to increase the status of ethnic minority recruitment, retention, and training. According to Society for the Psychology of Women, “Her social action research focused attention on the dearth of ethnic minority psychologists and to recommend steps for addressing that problem.”
She continued to implement strategies to increase the presence of ethnic minority students. She received numerous National Research Awards from NIHM (National Institute of Mental Health) and other foundations.
At Arizona State University, Martha and a colleague worked to develop methodology for measuring ethnic identity and how it correlates in Mexican American children. Her work has been widely published and has had a significant impact within the field.
Bernal also was involved in creating the Board of Ethnic Minority Affairs (BEMA), where she would serve on the Education and Training Committee. This helped form the National Latino/a Psychological Association.
She was active in committees like the APA’s Commission on Ethnic Minority, Recruitment, Retention and Training (CEMRRAT) and the Committee of Gay, Lesbian and Bisexual Affairs.
Her numerous awards and life achievements provided guidance and inspiration to a wide range of psychologists of color, both men and women. Her commitment to advancing scholars of color, had a special impact on Latina women and other women of color.
In 2001, Martha died of cancer at age 70. To honor her contributions, a scholarship fund has been set up at Arizona State University.
Sources:
Dr. Martha Bernal: The First Latina with a PhD in Psychology – Salud America (salud-america.org)
This year for Women’s History Month, we are highlighting different women each week who, although you may have not heard of previously, have contributed greatly to society.
Third to be highlighted is Thai Lee, CEO of IT provider, SH International.
Lee was Born in Bangkok, Thailand but spent most of her childhood in South Korea. Her father, a Korean economist, traveled the world promoting South Korea’s postwar development plan, so Thai and her family moved around a lot in the early phases of her life.
When she moved to America in her teens, a family friend took her in as she finished high school and then enrolled at Amherst College, Massachusetts where she earned a double major BA in biology and economics. Since her English was not fluent, she ruled out professions that involved writing and speaking. She knew she could be successful as a businesswoman. Lee said, “I knew then that the best chance of success for me was to start my own business, because after I x-ed out all the professions I could not be successful in, that’s what I was left with.”
After college, she returned to Korea. She worked at an auto parts maker so she could earn enough money to pay for her MBA. A few years later she was back in Massachusetts, and in 1985, she graduated Harvard Business School.
In 1989, Lee married Leo Koguan, a lawyer with a passion for entrepreneurship. Lautek, a small struggling software company, had a tiny division, Software House. It had only a few customers, but some of them were big (like AT&T, for example). Koguan and Lee paid less than one million for that business – funding through savings and small loans.
Lee and her now ex-husband renamed the company Software House International, reflecting Lee’s global ambitions. Melissa Graham, the company’s first hire, said, “We had no inventory, very little money, no market presence, no marketing, no promotion. What we did have was someone who wanted to make this thing work.”
There were no ground rules on how to manage their customers. Lee let it up to her staff to make company decisions. She said, “If you are responsible for a customer, you own that. Being empowered that way, it’s very important.” Because their service was so trustworthy, customers had no reason to switch.
After expanding and creating a new division, the company earned six billion dollars in revenue and doubled in size. SHI currently holds $11 billion in revenue and has 20,000 plus customers.
According to Forbes, Thai Lee founded the largest woman owned and minority owned business in America. A study by two economists, found that today’s Forbes 400 were able to access education while young, and apply their skills to the most scalable industries: technology, finance, and mass retail. The share of the Forbes 400 who are self‐made rose from 40% in 1982 to 69% in 2011.
Sources:
By Elisabeth Kunkel, MD
Chief Medical Officer
Pennsylvania Psychiatric Institute
Pennsylvania Psychiatric Institute (PPI) is taking bold steps to improve access to inpatient and outpatient behavioral health services for patients from Dauphin, Cumberland, Perry, Lebanon, and York counties and beyond. A Penn State Health Enterprise, PPI is the region’s only academic free-standing psychiatric institute, and we’re committed to making it easier for people to receive services right when and where they need them through a targeted growth approach with an emphasis on:
• Clinical services
• Education
• Research and
• Community outreach
PPI is expanding clinical services through an aggressive recruitment effort to raise the complement of highly skilled faculty members to 25 by the end of summer 2018. With a national shortage of psychiatrists, competition for providers is intense as we seek to build a team that can care for patients at all levels of need, often with other medical and addiction issues compounding their illness. We have inpatient, partial hospitalization, and both general and specialty outpatient psychiatric services for people of all ages.
Our recruitment process is already well underway. The effort is bolstered by a competitive compensation package as well as the opportunity for faculty to treat patients, teach, and conduct research while living in a great region that has good school districts, a low cost of living, and venues for outdoor recreation, arts, culture and entertainment as well as easy access to major metropolitan areas.
Our PPI psychiatrists are employees of the Penn State Health Milton S. Hershey Medical Center. PPI is specifically seeking psychiatric professionals with training in a variety of subspecialties who will enhance our ability to diagnose and treat complex cases in all settings and at all levels of care. Our faculty are committed to both the community and to academic psychiatry, interested in educating medical students, residents, and fellows and in helping to develop innovative teaching tools.
As we add faculty and nursing professionals to build up our clinical services and expand the Department of Psychiatry at Penn State, excitement for PPI and its programming is building, and that is assisting with retention of current faculty and staff, too. The professionals at PPI are embracing the opportunity to continue raising the caliber of our program and the quality of care while expanding the use of evidence-based treatments, in order to assure the community is always receiving the best mental health care services available.
As our faculty grows, wait time for appointments and treatments will continue to decrease, and PPI will be able to see and treat even more patients. We’re proud of this effort, and will be sharing details about initiatives to improve access through education, research, and outreach in a future column.
To learn more about open nursing positions, click here
