“Not normal is the new normal”: How does the pandemic impact mental health treatment? We asked a CAMH psychiatrist

Over the course of his 15-year psychiatric career, David Gratzer has worked with inmates in jails, high-risk patients in hospitals and as a policy advisor on a presidential campaign. But during the pandemic, in his current role as the associate chief of inpatient care at CAMH, he’s witnessed an unprecedented shift in his clinical practice. We spoke to Dr. Gratzer about how the pandemic is impacting patients and mental health services.

How have things changed during Covid-19?
Many of our services have switched to virtual care, which involves phone calls or visits on a Zoom-like platform called Webex. The number of people visiting our emergency department was significantly down in the early days of the pandemic, since people were hesitant about going outside, but it’s started to increase. Meanwhile, our virtual care visits went up about 850 per cent between March and April. We’re now offering virtual group sessions and some addiction services virtually, too.

Has there been an increase in requests for services overall, or have the virtual visits jumped so dramatically because in-person sessions have gone virtual?
It’s primarily the switch from in-person visits to virtual meetings and phone calls. But I also think that over time, to get to your larger question, we will see more people requiring care. The other night, I was working in our emergency department until midnight, and I saw a person going through a very difficult time, suffering from a lot of anxiety because of the pandemic—namely, stresses from their job and thinking about the vulnerability of older family members. This is somebody with a genetic predisposition for major mental illness, as well as a personal history of anxiety, but I think more and more we’re going to see people with these types of problems.

Will the pandemic contribute to an increase in mental health issues?
At times of recession and depression, there’s a rise in suicide. Vulnerable populations, like front-line health care workers and those with a history of mental illness, are more at risk of suffering from mental health issues. And there’s obviously a lot more going on right now than just an economic crisis. The Angus Reid institute did a poll a couple of weeks ago asking people how they were doing from a mental health perspective during the pandemic. Only 14 per cent of people said they felt normal. So, it seems, not normal is the new normal. That said, the majority of the population is resilient, but we know from the scientific literature that quarantine and self-isolation for vulnerable populations are related to higher rates of PTSD and depression. So there’s a couple of things affecting people right now: the stress of the virus compounded with the negative impact of self-isolation.

Are you primarily working from home?
Most of my clinical involves inpatient work here in our emergency department, so I come into the office every day. But most of my in-person sessions, in which an outpatient would come into the hospital for treatment, have moved to virtual, which I run from my office. And I’ve got some administrative roles within the hospital. All those meetings are now done virtually.

What’s the environment like at the hospital these days?
Usually, when I’m walking around this floor, there are patients in the hallways, my colleagues are coming in and out of their offices. There’s a certain buzz during the day because there’s a lot of activity. Now, it’s awfully sleepy, since many of my colleagues are working from home, and there are no visitors allowed.

Can you walk us through a typical counselling session during Covid-19?
We use one of two methods. Either the Ontario Telemedicine Network (OTN), which has existed for decades, or Webex, which is functionally very similar to Zoom, in that it allows us to do face-to-face video calls. The advantage of those digital platforms is that we’re confident they’re secure and meet provincial and federal standards for patient privacy, which is important when you’re dealing with sensitive personal issues. For example, a patient wanted to do a Webex interview. Even though I’d never met this person, I got to see him in his own home. Towards the end of the conversation, I commented on a reproduction of a painting that was visible within his camera frame and asked if it was significant to him. Turns out it was, and we talked a little bit about that. Little moments like that can give me insight and add texture to the conversation. That’s about as much as I can reveal for privacy reasons, but it was nonetheless interesting.

If counselling sessions are usually done in-person, but now they’re done on video chat, how does that impact your practice?
In a way, it’s very similar to what I’ve been doing for the past 20 years. Talking to people and problem solving, figuring out how to help them. But it’s also different, in that I could follow a patient for many years and never see the inside of their home office or their den or their basement apartment. So, on some level, it’s maybe a little bit more personal. Overall, what studies have shown us is that telepsychiatry—or sessions done via videoconferencing—is effective and patients feel the same connection to providers that they would in person. I find that interesting. My experience with telepsychiatry also suggests that’s true. But it’s not appropriate for everyone in every circumstance, including for people with major mental illness or older people who are less comfortable with technology.

When you speak to patients during Covid-19, what are their biggest concerns?
The pandemic is front and centre in everyone’s mind, and the same is true for people with mental health problems. My recurring patients will come in and talk about things that they didn’t talk about just a short time ago, like getting laid off. They’re really concerned about finances and future prospects. I was talking with a small business owner about how stressful this period is, and how he just isn’t sure what he’s going to do.

What kind of pressure has Covid-19 put on CAMH as an organization?
The organization has worked incredibly hard to keep everyone safe. But we’re all worried about things that might change. In Canada, we don’t have an infinite supply of personal protective equipment. Right now, when I go to the emergency department, do I think we have enough equipment and staff? Yes. Do I think we’ve created a safe environment for patients? Yes. Do I think we’ve created a safe environment for our staff and our doctors? Yes. But we can’t rest on our laurels. Moving forward, we have to understand that this probably isn’t going away anytime soon, and we’ll need to consistently reevaluate what our patients need.

Will this pandemic create even more problems in the future?
That’s part of the challenge. I think front-line health care workers, people who’ve survived Covid-19, and people with a history of major mental illness will have a greater risk of mental health problems moving forward.

What advice do you give to people who are having trouble with self-isolation or the constant negative news cycle?
The dry, boring things that doctors tell us to do to reduce stress are actually worthwhile. So, turn off the devices now and then, get regular exercise, avoid excessive caffeine, alcohol and—at the risk of sounding like a stuffy old doc—cannabis. The literature, though it’s controversial, suggests that ongoing cannabis use increases anxiety and reduces mood, so we have to be a little bit cautious. There are good resources, including on the CAMH webpage, about building resilience and helping to cope with these circumstances. That might all be useful, but I also wish to emphasize that if somebody is feeling so overwhelmed as to have suicidal thoughts, that’s never normal, whether or not there’s a pandemic. They should come to an emergency department for care. Our emergency department is open 24 hours a day, seven days a week, but of course, there are many others in the city.

What can mental health professionals learn from the pandemic?
Even if the virus were to disappear tomorrow, it will still have implications for society. Australia recently named a deputy medical officer specifically to think about the pandemic and its implications for mental health. So, the pandemic planning there includes consideration and dedicated resources for mental health problems. I wonder if that would be appropriate for a country like Canada. We’ve had big announcements—a couple of weeks ago, the Prime Minister announced that the government would put forward roughly a quarter of a billion dollars for more virtual care, particularly mental health care. Shortly after, the Ontario minister of health announced that there would be more e-delivered mental health services, including Internet-delivered cognitive behavioural therapy. It’s great that they’re recognizing mental health problems. But while a couple of announcements are wonderful, I think we’ll need more resources moving forward.