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The Fragile Emotional State of Neurology Patients During COVID-19 Mean Heavier Case Loads for Neuropsychologists

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Neuropsychologists are experiencing a heavier caseload of neurology patients who are experiencing hopelessness and depression as a consequence of the emotional toll of COVID-19.

For a year that feels like an eternity, neurology patients have been riding a rollercoaster of emotions compounded by the COVID-19 pandemic. They're more anxious, nervous, depressed, lonely, angry, hopeless, and helpless than ever, several neurologists and neuropsychologists said in interviews with Neurology Today.

This upheaval stems from “a complete disruption of the daily routine,” Roseanne D. Dobkin, PhD, a professor of psychiatry at Rutgers University-Robert Wood Johnson Medical School in New Brunswick, NJ, told Neurology Today.

Many individuals with neurologic disorders have faced unparalleled emotional challenges during a multi-layered crisis of contagion, isolation, and disinformation, noted Dr. Dobkin, a clinical psychologist and expert in the mental health of patients with Parkinson's disease. [Dr. Dobkin led a study published online in Neurology in April 2020 on telephone-based cognitive behavioral therapy for depression in Parkinson's disease.]

Long gone are the social interactions that made patients' days better and brighter. Even allowing licensed therapists or caregivers into the home becomes fraught with fear and risk, she said.

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“Some patients have reported feeling overwhelmed, as someone else is always home or around and they have no time to themselves and not a moment of silence.”—DR. ROSEANNE D. DOBKIN

“Some patients have reported feeling overwhelmed, as someone else is always home or around and they have no time to themselves and not a moment of silence.”

Appointments with neuropsychologists and neuropsychiatrists are booked well over-capacity. Via telehealth or in-person visits, these specialists have their work cut out for them, as they sift and sort through worrisome signs and symptoms, and decide whether to mitigate them with medication, refer patients to counseling, or recommend a dual-pronged approach.

“Some practices have waiting lists so long that they are no longer taking names,” said Sharlet A. Anderson, PhD, a neuropsychologist and assistant professor in the neurological sciences department's section of movement disorders at Rush University Medical Center in Chicago.

Prior to the pandemic, Dr. Anderson's schedule mainly involved conducting neuropsychological evaluations for patients experiencing cognitive changes. She had only a handful of psychotherapy cases.

“Since the onset of the pandemic, that has flipped,” Dr. Anderson said. “I have a psychotherapy caseload that is five times larger than ever before, such that it is the predominant service that I provide right now.”

She added that “the pivot to telehealth services,” via video or telephone, has broadened access for patients with mobility and transportation difficulties while lessening their risk of exposure to COVID-19. Not only has the availability of telehealth allowed them to access mental health services, but it facilitated utilization on a more consistent basis.

In Dr. Anderson's practice, “patients have reported every kind of emotional stress imaginable,” she said, citing fear of infection, death of a loved one, and loss of their livelihood as the most significant stressors. For trauma survivors, loneliness is particularly hard to bear.

While technology is a boon for some, lack of access is a bane for others. Those who are unable to conference in via video have even fewer opportunities to engage in safe social interactions as they try to navigate a new normal.

“From my older patients, particularly those with cognitive impairment, I hear that they were emotionally hurt by family members' strict adherence to social distancing guidelines, which left them feeling as though they were a pariah,” Dr. Anderson said. “They watched their children and grandchildren have barbecues and birthday parties on social media or through video chats, while they remained isolated at home, missing all those family milestones.”

On the other end of the age spectrum, “younger patients are reporting frustration with being derailed in their academic or occupational pursuits, and sometimes feel demoralized by having to move back in with family members after having enjoyed a period of independence,” she said.

Drastic and unexpected lifestyle changes are fueling a sharp increase in new onset of depression, anxiety, and post-traumatic stress disorder. Also on the rise: the striking recurrence of these conditions even after long-lasting remission or adequate control, as well as the preponderance of unhealthy coping mechanisms, including alcohol and substance abuse, Dr. Anderson observed.

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“Some patients who already suffered from anxiety disorders in the pre-pandemic world have been coping more easily with lockdowns and other safety precautions than those for whom excessive worrying and new standards for cleanliness altered their reality.”—DR. SCOTT HIRSCH

As a clinical psychologist and neuropsychologist, Dr. Anderson is constantly on alert for harbingers of emotional distress and mood disorders: complaints of excessive fatigue, changes in sleeping patterns (too much or too little), nightmares, difficulty concentrating and curbing worries, intrusive thoughts, irritability, restlessness, heightened muscle tension, loss of interest or pleasure, feelings of sadness or hopelessness, and, of course, suicidal ideation.

Among the more subtle signs and complaints that her patients' exhibit are procrastination, lethargy, and withdrawal from methods of communication that abide by social distancing recommendations, such as responding to phone calls or texts.

Determining the root cause of anxiety attacks and depressive episodes is essential for a clinician to properly evaluate a patient's mental state during the pandemic, said Scott E. Hirsch, MD, clinical associate professor in the departments of neurology and psychiatry at NYU Langone Health.

Since the pandemic swept through New York City in early 2020, Dr. Hirsch, who normally would concentrate his practice on patients with epilepsy and behavioral issues, has found himself in a new role: reinforcing public health messages aimed at curbing virus spread. By engaging in “supportive therapy,” he is helping patients “feel like what they're doing is the right thing,” even when they express angst or guilt over not being with family or friends on important occasions.

Interestingly, Dr. Hirsch said, “some patients who already suffered from anxiety disorders in the pre-pandemic world have been coping more easily with lockdowns and other safety precautions than those for whom excessive worrying and new standards for cleanliness altered their reality.”

For instance, some individuals with obsessive-compulsive disorder now “feel vindicated in many ways,” due to widespread public health recommendations that promote mask-wearing, hand washing, and social distancing measures, he said. Those with “contamination fears” and previous experience in living like “a little bit of a recluse” have summed up the situation to him like this: “I told you so.” And “this is something I've been preparing for my whole life.”

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“Some practices have waiting lists so long that they are no longer taking names.”—DR. SHARLET A. ANDERSON

For his part, Dr. Hirsch, who is triple board-certified in neurology, psychiatry, and neuropsychiatry, concluded that “what we consider to be the norm depends on the mores of the time.”

For some neurology patients, loneliness can have a negative impact on their physical health. Missing out on human connection creates a recipe for descending into the depths of depression. In turn, this undermines sleep, exercise, and general wellness, said Indu Subramanian, MD, a neurologist at the David Geffen School of Medicine at the University of California, Los Angeles, and director of the Southwest Veteran Affairs Parkinson's Disease Research, Education and Clinical Centers.

UCLA scientists, led by Dr. Subramanian, and colleagues from other institutions found that when people with Parkinson's disease are deprived of meaningful social interactions, they may be at elevated risk for severe symptoms. The results of their study, published in NPJ Parkinson's Disease on Oct. 8, 2020, also examined patients' nutrition and exercise habits. [For more about the study, see the Neurology Today report, “It's a Triple Threat: Loneliness, Parkinson's, and COVID-19.”]

In pre-pandemic times, support groups filled critical gaps. Even a leisure activity such as a book club could help alleviate loneliness, Dr. Subramanian said. To simulate that type of connectedness during the pandemic, she launched a virtual support group, which meets up to two times per week, for people with Parkinson's disease.

Dr. Subramanian describes this form of therapeutic intervention as “social prescribing.” It's a way of bringing light to darkness. For many patients with movement disorders, it has been a lifeline to some sense of normalcy.

To maintain that lifeline, Dr. Dobkin of Rutgers, who said caseloads for specialists in her line of work have “exploded” during these unprecedented times, has decided: “The best thing we can do for our patients is to continue advocating for federal legislation that will maintain the telemedicine advances that went into effect in response to the COVID pandemic.”

Link Up for More Information

• Dobkin RD, Mann SL, Gara MA, et al. Telephone-based cognitive behavioral therapy for depression in Parkinson disease: A randomized controlled trial https://n.neurology.org/content/94/16/e1764. Neurology 2020; 94(16).
    • Subramanian I, Farahnik J, Mischley LK. Synerge of pandemics-social isolation is associated with worsened Parkinson severity and quality of life https://www.nature.com/articles/s41531-020-00128-9#:~:text=Social%20isolation%20was%20associated%20with,the%20recent%20COVID%2D19%20pandemic. npj Parkinson's Disease 2020; 6:28.