Psychiatry & Psychotherapy Podcast - The Link Between Unemployment, Depression and Suicide in the COVID-19 Pandemic

Episode Date: May 2, 2020

As the economy continues to shut down during COVID-19, people are growing more concerned about work and finances. Even if the virus is miraculously contained in the next few months, the economy will still be reeling from the damage of the lockdown.  As psychiatrists, we are concerned about the increases in mental illness from the lack of employment and a potential increase in suicides. In this episode, we begin to look at past studies on the links between economic disaster and the subsequent rates of depression and suicide, and what we might be able to do to help. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. Welcome back to the podcast. I am joined today with Lauren Joffrean. She is a soon-to-be fourth-year medical student going into psychiatry, and we have been working together, looking through some literature on how in this season of high unemployment, mental health is going to be influenced. Okay. So in this episode, we will be going through the history of previous recessions. previous times of high unemployment. We'll be talking through some of the numbers, the data that supports the importance of

different things that can be done that can decrease the burden psychologically on people who are unemployed and further how those rates will be influencing the times that we're living in. Okay, so we know that depression is increased. We know that suicide is going to be increased in people who are unemployed. And so the question becomes how much are we going to expect there to be a rise in the rights of suicide? And how can we as a nation prepare for that and hopefully make some actions that can actually decrease the amount of suicides that take place? How can we improve the chance that people go into treatment? Get good treatment.

How do we improve access to care? How do we decrease the things that labor psychiatrists? I'm going to speak as a psychiatrist here, speak in my specialty. The things, if I could make a wish list of the things that would change, I'm going to put those in there at the end of this episode, and we're going to talk about those. So in this episode, we're going to estimate, you know,

the amount of increased suicides that will potentially take place with the unemployment, with the great trials that America and the world is seen. And subsequently, we're going to talk about some things that can be done. So I hope you enjoy this episode. Okay. So where do you want to start? We can just start with the past, I guess, looking at what we know already and have seen studies on studies of connection between unemployment and suicide and depression.

Yeah, let's look at the recession of 2007, 2008, which also had a global effect, right? And there's actually quite a bit of studies on this. So what did they find about how it changed depression? Oh, yeah. Well, a lot of studies, even if they didn't particularly mention the Great Recession were published shortly after. So one of them by McGee and Thompson in 2015 found that unemployment created increased odds of depression by three times. They used PHQ 8 for their assessment of depression, and unemployment was defined as out of work for less than one year or some more than one year. Yeah, so three times higher the odds of depression for unemployed compared to employed adults. Wow. Okay. And then tell me about this other study here.

Yeah, Crabtree in 2014 published a study just based off of a poll. And so looking at Americans who already, well, they were unemployed. And so it found that 19% of Americans who are unemployed for 52 weeks or more were treated for depression. And then for a smaller amount of weeks unemployed, 27 to 52 weeks, there are 17% were treated. And then 10% for those who were treated. were unemployed for under 11 weeks, which is similar to the population, general depression and the general population. Yeah. So this is actually treated, actually, you know, seeing a therapist, seeing a psychiatrist. So if people are only unemployed for less than 11 weeks, it's 10%, whereas if it's greater than 52 weeks of unemployment, then it's 19%. So almost like double the rate of those being treated. Yeah. Now, we know a lot of people don't get treated, right? So although the unemployment odds may go up three times, that doesn't necessarily mean that everyone who gets depression is going to be treated. That's right.

Okay. Yeah, but actually the longer the person is unemployed, the greater the chance of becoming depressed. So that's kind of what this study was showing. Okay. Yeah, tell me about this cardiac study. By Wolley Keefe and Chesney in 2002, they pulled 5,115 adults, ages 18 to 30, whether they had depression, and then they actually followed up after that to see their job success. So those with depression at the outset had 60% increased adjusted odds of subsequent unemployment

and 90% increased odds of decreased family income in five years. A couple of the other predictors they found for decreasing financial success, were a history of unemployment, whether they're married or not, being less educated or part-time employed, and cigarette smoking, actually. Okay. So what did this study kind of add to our understanding of this? It kind of showed that people with existing depression are at a risk of an unemployment. And so thus, if they lose their jobs, it might be more difficult for them to get another.

I found it interesting that they looked at, you know, the amount of family income, not just unemployment. And so actually their total income of the family decreased even if they weren't completely unemployed. Yeah. And then there's this Institute of Work and Health study in 2009. What did that show? That was looking actually, it was more of a review, kind of a pamphlet published by the Institute for Work and Health. And it looked at a study from 1999 that reviewed 16 other studies from 1986 and 1996, and 14 out of those 16 shows significant negative association between unemployment and mental health. So job loss reduced mental health and reemployment improved it. Right. And some of the proposed explanations were decreased standard of living,

decreased security of income, stigma with being unemployed, loss of self-esteem, loss of social contacts from work. So all of these things kind of adding up to worsening mental health. A lot of people don't think about the loss of social contacts and kind of the norm of a person's rhythm of life being affected by their losing their job as well. Okay, greats. Ninety-three looking at general health, not just mental health. What did they find? Yeah, they found employed people reported less health disorders than students in the unemployed, but actually the highest levels of health risk were with dissatisfied workers and the lowest were with satisfied workers. So it seemed that what happens in the workplace has more

effect on your health, both mental and physical, than whether or not you have a job. Yeah. I mean, it's one study. I think what I got from this study was that the highest, you could still be at risk if you're very dissatisfied with your job, which, of course, I see all the time as a psychiatrist, people who are dissatisfied with their job. for various reasons, usually some form of harassment that's going on at work. Okay, Paulin Moser, 2009,

this is a study I found. They found that the overall effect size for worsening mood symptoms with people who are unemployed is 0.51, which in effect size is like how far, like, let's say you have a bell curve of people okay now you make a group of them unemployed like how far does that move from the mean it's a 0.5

standard deviation move which it's kind of like the opposite of an antidepressant or psychotherapy right so psychotherapy around 10 sessions will move people like 0.6 you know wow maybe an antidepressant if it's severe depression will move them 0.5 so it's kind of like a move in the opposite direction yeah so sometimes I'll have a patient that is doing well, and then they get unemployed, and you see their mood acutely worsened. Wow. And so I've seen this a lot. And I've seen it in this time because a lot of people are unemployed all of a sudden.

Mm-hmm. Okay. What about the Great Recession Data? What about the study Goldsmith and Deity 2012? Well, in that article, they mentioned that 10 million jobs were lost. Probably somewhere around there, you know, plus or minus, a couple million probably. But they found that mental health is affected by joblessness, primarily looking at the mechanisms of incomplete psychosocial development, feelings of helplessness from perceived lack of control. And then, as we mentioned before, the failure to obtain non-monetary benefits of work like social connection or purpose.

Yeah, that's so important. those non-monetary benefits, I think, are forgotten by a lot of people as they see people who become unemployed. Interesting, this study showed that the negative effects were larger for minorities, black and Latino individuals, specifically had a more negative result. And they showed that, in this study, at least, that it was the long-term unemployment which was correlated with worse mental health issues. So larger than 52 weeks.

Very interesting. So short-term unemployment maybe wasn't significant in this study. In this study, right. But I think you have to look at it all together. And, yeah. Okay, let's talk about suicide. So actually there's a pamphlet kind of published by the VA with a lot of different resources,

and they just summarized a lot of facts on their pamphlet. looking at the effect of unemployment on suicide risk. And so unemployment in the U.S. actually has a greater suicide risk the older a person is. But what was interesting, they mentioned that that doesn't necessarily apply in other countries. And the longer the unemployment, the unemployment, the risk increases and peaking within the first five years. Right. So the highest risk time is in the first five years of suicide for being unemployed. So it seems that from this study that an increased suicide rate among men is the highest when the national unemployment level is the lowest. And it's that like comparison, you know, where like if everyone else is doing good

and you're struggling, like that's really hard. That's hard to see yourself in that position. It's hard to see yourself in that position. It's kind of like the Ginny coefficient, which we've been talking about a little bit, about how when it's one, it's like there's, there's. one person that owns everything and everyone else doesn't own anything. And when it's zero, everyone has equal, has equal amounts of income. Okay. And so what we found is that the Ginny coefficient is correlated pretty highly with rates of violence for men. Yeah. And that's kind of another picture of this of this study i think it's like when there's that discrepancy you know that's when it gets people either suicidal or with a lot of the studies with the income inequality and the gene

coefficient increased violence oh yeah seems like the same psychological principles are definitely at play in both yeah anything else from this study that you want to touch on or from this VA information they adds a couple of suggestions of protective factors against suicide and this was just perceive social support and good employment benefits, but we're going to talk a little bit more about that later. Right, which is, there's a part of me that when I see social support, I'm like, oh, but we're all isolated, you know, not actually having in-person interactions. So that actually is another risk factor for this time that we're in.

That's hard to, it's hard to really know how much that's going to influence things because it's never really happened the way that it's happening right now, right? Right. Okay, let's talk about this Blakey 2003 study. This was an interesting study. It was done in New Zealand after a census, and so they had 2.04 million people in the census. And then they counted the number of deaths by suicide three years after the census. They found the unemployed people were two to three times more likely to commit suicide within those three years after the census than those who were employed at the time of the census. Yeah, I was looking at this. other things that were interesting about this study was that they showed that men who are married

have a decreased odds or if they're not married they have almost a two times increased rate of suicide for men and for women as well so there's something about marriage which was protective which you know it's like that sort of social connectedness piece and then yeah if they were unemployed, 2.4 times higher risk of committing suicide. That's huge. And if they were not active, like if they were not searching for a job or not considering themselves unemployed, those people also had a higher risk. Okay, let's talk about this Kim and Cho study, 2017.

This study was looking at unstable employment or kind of, in their words, a low level of employment protection. And that showed an increased effect on suicide rates, whereas for their study, unemployment itself actually showed no difference. So it was this kind of instability piece that was worse for psychological outcomes. Right. It's hard to take one study and say that unemployment doesn't affect things. It's the low level of employment protection.

But what I think it did, what I took from this study was that for the unemployment that's very unstable, when there's not a lot of protections, it's much worse for psychologically. Okay, let's talk about this great recession that took place 2007, 2008. There was a study by Hinkin, 2014 in Forbes, which looked at the potential. that there was a spike in the suicide rate that happened right after and sort of growing out of the recession. Right. They look particularly three years from 2007 to 2010 at the number of suicide rates compared to the expected or projected amount of suicide deaths over that time.

And so they said something like 10 as a more roughness. number 10,000 economic suicides more than would have been expected. But when they looked closer at their graph in specific calculations, they found an estimated 4,750 definite excess suicide deaths after the recession from 2007 to 2010 over those three years. Yeah, interestingly, they point out that not all countries saw this rise and tragedy isn't inevitable and interventions are warranted. And I think it's important when you look at this, and all of this will be on my website

and in the resource library where we'll give the citations and show you this picture. But it shows like the suicide rate going up slowly, and then there's this jump in the suicide rate. So there's this sort of red area above the natural slope of what was happening before the recession. And it's like this is the excess deaths of about 5,000. And what it shows,

is that, you know, if it was about 11 per 100,000, it jumped up almost one percentile. So it jumped up from 11 to 12. So what was expected would be like 11. And what we actually happened was 12. So there was like a one in 100,000 person increase in the suicide rate from this recession. And I think that's important. We're going to talk about that a little bit more as we sort of make estimates for what we might see in this time. Mm-hmm. One other interesting point from this study, they noted that the majority of these deaths were among people who already were suffering from depression.

And the antidepressant prescriptions at that time spiked at the same time. Right, yeah. And it's interesting because when I looked at some of these issues a little bit closer, like where do the suicide rates increase the most, it's actually in places where the treatment was the least. If you look state by state in the U.S. map, you know, California has a lower rate of suicides. We have a lot of treatment providers here in California, whereas some other states saw a bigger jump. The other thing is if you use drugs and if you have a major psychiatric illness, 90% of the time, you're not seeing anyone. and those are the people are at the highest risk of suicide. So there was one study in England that showed like a good two-thirds of people who committed suicide had not been in any mental health treatment prior.

So the idea that, you know, psychiatry is not helping solve the issue is, I think, a little bit, well, you hear that, especially if you're in social media like I am, you hear like a lot of negative critique of psychiatry. But the reality is that most people who kill themselves, are not receiving any mental health treatment. They don't have a therapist. They're often socially isolated and they're often using drugs.

There's a high rate of alcohol in the blood of people who die of other drugs. So these are the people who are at high risk. And so sometimes I'll have a resident who comes in. They'll have a patient who is using drugs. I just had it this last weekend. I was on call. using drugs and struggling with some very significant mental health issue. And I said, well,

let's, let's hospitalize this patient. And then we got some collateral from the family. And lo and behold, this person has been like really paranoid for three months. Mom is freaked out. And so it was kind of like the presentation was a little bit mixed, you know, like one minute the person like could pull it together and look okay. But after we got the collateral, We were like, yeah, this is a big, this is a big issue. We got to like help this person. So my point in all this is, yes, the antidepressant prescription spiked during this time, but there's still a majority of people who are committing suicide who don't have any treatment.

And so this is, I think, where as a nation, you know, we can think through how do we get these people treatment? And if you're a primary care provider, like there's a lot of people who see primary care provider in the months before they kill themselves. So then thinking through, okay, how do I do proper screening to identify the people that need treatment? Okay. Let's keep going. Mm-hmm. That's good. Looking at another study just of England after the Great Recession by Barr in 2012, they found there was a 10% increase in unemployment that was significantly associated. with a 1.4% increase in the male suicides.

Yeah. So, yeah, and it's in this other study, Stuckler, 2011, they looked at countries with severe financial downturns like Greece and Ireland that had the greatest rise in suicides, 17% in Greece, 13% in Ireland. So when we look at other countries like Austria, which has a really good safety net, strong social support network,

they actually had a decrease in suicides despite an increase in the unemployment, a decrease in just 0.6%. So we have to sort of look at the big picture of what policies we create to help people who are struggling through unemployment, what kind of access people will have to therapists and psychiatrists do change outcomes

on like a national level, right? Oh, yeah. All right, let's talk a little bit about the present, the present conflict, the present issue that we're having. Yeah, what's going on right now? So looking at the most recent unemployment trends before COVID and this whole pandemic, at least in the U.S., and for all the present statistics, we're just going to be talking about the U.S. majority. But unemployment was 3.5% before the whole pandemic and quarantine. And then looking at the Great Recession, which was recently, the most recent, the high was 10% unemployment, and during the Great Depression, the high was 24.9%.

Early predictions, estimated, early predictions meaning in March, estimated that the U.S. unemployment could get as high as 40%, but kind of averaged it out to a prediction of 32%. So those are all predictions from a man named Faria E. Castro from St. Louis Reserve Bank. And that was a prediction end of March. Okay. So as of April 16th, and we're recording this on the 30th, 22 million filed for unemployment in the U.S. And there was a loss of 22.8 million jobs after the nation's huge rebound. So that's a lot of people who are now unemployed.

You lost almost all the ground we've covered from the Great Recession. Yeah. So it's at 20% unemployment now, which is it's pretty mind-boggling if you think about it. Like the Great Recession had a high of 10%, like all the studies that we showed before where there was a 1% increase in that suicide rate or like one added one per 100,000 people. committing suicide. This is 20% now. It's not guaranteed stable either. A lot of the experts estimated that it's expected to remain at at least 10% through the end of the year and then probably remaining high as 6% through 2021 or another estimate said maybe 8% through the final months of 2020 and lingering at 5.4% through 2022.

So we don't know for sure, but it looks like unemployment's going to remain high for a couple years at least. Yeah. And I know, like, just in, you know, the patients that I have who run businesses, some of them, right when this started, they were like, okay, I got to let all my people go. Some of them are now thinking, you know, oh, I got to let more people go. So depending on how long this goes on, the shutdown of different spheres in our economy, I think it's going to, you know, it could go up past 20%, it could go up to 30%. It could get to the levels of, you know, the Great Depression, which was 25%. But what the estimates all point at is that it's not going back to 3.5%.

it's going to be higher than that. It's going to be, you know, maybe even in the best situations, 2020, it's going to be like 5.4%. So it's going to be a tough time. Oh, yeah. Yeah. Okay. So suicide, depression rates. In 2017, CDC data, there were 47,000 deaths by suicide.

Okay, so there's approximately 1.4 million attempts, 47,000 people killed themselves in the U.S. That's 14 per 100,000. Okay. So one way of thinking about this is 14 per 100,000. It's helpful, I think, to think about this as like if over the course of the life, you take away two of the zeros. Like, let's say people live to 100. So instead, that's like 14. per 1,000 over the course of like a you know if every year's accounted for which is um it's basically

like 1.4% of people will die by suicide okay does that math make sense to you i think so okay so if um so one point over the you know how many people total will die by suicide like over the course of their lives you know people die of different things some people most people might Most people die of heart disease. Very few people die of, you know, things that used to kill people because we have some good vaccines now. So a lot of the infections that used to kill us don't kill us anymore. Oh, yeah, that makes sense. Does that make sense a little bit?

Yeah, it does. So if you think about it like that, 14 per 100,000, I think other countries are even 30 per 100,000. So U.S. is not the highest suicide rate. It's higher than a lot of other developed countries. But, you know, we have unique things going on here in the U.S. So it's the 10th leading cause of death in the U.S. And I did a series that's, I think, two parts so far on suicide. So we go through all the statistics.

So I'm not going to belabor a lot of these points. But it is the fourth leading cause of death for people ages 35. to 54 and the second leading cause of death for those 10 to 34, accidents being higher. Okay, so what did they find in this gunwale 2020 article? So the article, it was just published last week, and some have already, in this article, they've already begun to anticipate the effects of the pandemic on the population

in relation to suicide and depression. But as we've seen with the recent suicide of New York physician in relation to the stress of the crisis, there may be more suicide deaths related to healthcare workers, families of patients with COVID, and as other stressors increase. But these are difficult to predict based off of numbers and possibly more difficult to protect against.

And we might look into these kinds of suicides in a later episode, right? Yeah. You know, I think what's important to note here is that this is a stressful time for healthcare providers as well. Like we're talking about those who are unemployed, but um and we're focusing on them during this episode but there is a unique stress to those who are employed in this time and employed sometimes working harder than ever um i think in my psychiatry

practice i'm busier than i was a couple months ago and it's it's an interesting kind of busy as well because it's um it's a lot of zoom calls and there's a certain level of fatigue that happens to my brain by the end of the day um like often like a dull headache from from Zoom calls all day long. And, you know, it's worse if the patients are, like, moving their phone. So sometimes now I have, like, very low tolerance for it. I'm just like, hey, can you set your phone up on, like, a desk and kind of just let it prop there? So it's not, like, moving around yesterday.

There was a patient who, like, all they were showing us was their neck the whole time. It was kind of interesting. Okay. Yes, there's unique stress on healthcare workers. And that's really something we're going to see as well. And in our hospital, what we have is we've set up a system where there are physicians like myself that are willing to see health care providers that are in crisis. And so we've set that up and we've had a bunch of people open up some extra hours so that these people don't have to wait weeks and weeks. And I would say if you are a health care worker and you're listening to this and you're going through stress yourself and you need someone to talk to, it can help.

you know it can really help decrease your stress um then i would say you know reach out reach out ask around um we want to i would say as health care workers we want to help you we um just need to know that you need help so if you just reach out to people you'll probably be able to get some some help and therapists are still seeing patients so it's not like they're not seeing patients okay so So now for the ominous foreshadowing of what might happen. Okay. So we're not going to pretend to be any kind of psychic. But looking at the numbers, so our current unemployment is at 20%, what we said.

And during the Great Recession, the unemployment height was 10%, which is, so we're at nearly double, or about double what it was a little over 10 years ago. So looking at the Great Recession data, suicide increased above predicted for three years, at least at the trend we were looking at. The predicted trend was 11.25 per 100,000 in 2007, which immediately rose to 11.5. So that's a 0.25 increase. Then predicted for 2010, it was 11.5 per 100,000, but it was actually showed to be 12.5. So thus, there was a 2.2% increase immediately and an 8.7% increase by 2010 from the predicted suicide trends.

So that resulted in about 4,750 suicide deaths above the predicted for that three-year span. Yeah, this is, let me simplify all that math in case you're driving, and it's hard to sort of put your mind around that. With the unemployment rate going up to 10%, there was basically a, like, instead of 11 per 100,000, and increased to 12 per 100,000. So that was an added like one person more for every 100,000 people that would die by suicide. And if you think about how many people are in the U.S.,

there are 330 million people. So one person added to 330 million per 100,000 would basically be 3,300 more suicides. So just a one increase, right? Like what we're saying, increase the rates of suicide by 3,300. Wow. That's a lot of death. That's, yeah, that's tragic, right?

It's very tragic. And so what we're looking at in this time period, which is there's 14 per 100,000 currently. That's around the current suicide rate. if we increase that one point over the course of a couple years more than it would be because of the recession and everything, we're looking at a very conservative estimate that there will be 5,000 more suicides in the U.S. I think there might be considerably more because we know that some of the protective factors are social networks. And right now we have a lot of social distancing. we don't have that real contact with friends and family that we had on the level that we had it before.

Another added stress is the fear of the unknown, the fear of death, the fear that family and friends may die from COVID or having family and friends die. I know, I know, I know, you know, it's going to potentially touch, touch us and our networks and the people that we're close to. There's a lot of close contact with family members. So there are, you know, I've seen increased partners fighting. There's been rates of increased domestic violence, unfortunately. There's been some reports of increased child abuse even. So all of these things are going to be negatively influencing the numbers in a way that we didn't even see in 2008, 2009. So it could go up one, you know, if it goes up one point, that's an added 3,300 more suicides per year.

If it goes up two, that's an added 6,600. And then carry that over a couple years because there's going to be like a delayed effect. And it could be, you know, upwards around 10,000, added deaths just from suicide that could have from this recession that we're going through. Wow. So, okay, and that being said, we don't really know what's going to happen, right? There could be other things that influence and decrease the suicide rate. So overall, the suicide rate may be unchanged or go down.

But what we do know is that with unemployment, there is an added risk and the longer the unemployment, the bigger the risk. And we are about to go into a state of prolonged higher rates of unemployment. And so there will be increased risk. That's right. Anything you want to add to this sort of, before we move on to this next part of like, what can we do? No, I think we've pretty much covered it.

I mean, I don't want to be a harbinger of just bad omens, but it sounds, it looks like, you know, we could be facing something that's pretty significantly dangerous for our populations. and we want to look at what we can do to help prevent it or at least mitigate the damage a little bit. Yeah. Okay, so let's talk about what we can do now because I think it's really important to emphasize that we as a nation and as psychiatrists and therapists who are listening to this podcast,

we can advocate. And I want to start advocating for this on social media. Like, hey, we can do things that will help decrease the amount of of suicides that will decrease the stress, the burden on people. And one of them is financially. There are studies that show that increased financial strain and increased financial issues, you know, make things worse. There's one study in particular. It was Walters 2002. I'll put that on the website so you can look at that more if you want to. It showed that, you know, financial strain was correlated with lower mental health.

So helping people financially can be one small thing that can be done, both at a community level and at a government level. So, yeah, any thoughts on that study or anything you want to add there? I think just data from the study is hopefully what the government is doing now with stimulus checks and all of the boosting of small businesses will actually have a positive protective effect on the predictions that we made. Yeah.

And we'll probably see more of that. I'm thinking we'll see more of that. I think there's a lot of people who are not getting any help with that, which is unfortunate. And so I hope that the government can come through more and more with that because financial strain is correlated

with worse mental health. The second thing, I was thinking about is connection. And we know that a protective factor is your social support. And so I was thinking, you know, marriage therapy, tele therapy, therapy that helps maybe encourage people to have meaningful connection points, not only in therapy, but outside of therapy. So, you know, scheduling meaningful Zoom calls, maybe visiting people, but keep. being a good social distance, you know, I was thinking, like, you could go visit family, you could sit in a chair in the backyard, far from each other, talk. You know, there's ways of

still having social distance wearing protective PPE, but I saw this, I saw this TikTok video where, like, the grandparents were completely covered in PPE and they were hugging their grandkids. And they had, like, snorkel gears on them. They straight up had snorkel gear. and they were completely covered head to toe with like plastic. And they were like just hugging their grandkids. Oh, it's so cute. Yeah. That's awesome.

So, yeah, so social support. Thinking how we can encourage that and encourage that on like a global scale, you know, social media is probably not enough to give you a feeling of social support, right? So as much as I'm on social media, it doesn't replace. in person to person contact with meaningful friends and family. The second thing I was thinking about was exercise. You know, getting out in nature, I think is important. I think you can get out in nature in places where people are not and go walk around.

Funny story, my wife was trying to do this with my kids, and she got yelled at by this, like, person that she's like, this is private property. My wife's just trying to get out in the middle of nowhere and have like a walk with the kids, you know? Oh. So people need to like calm down and just be like okay with other people like being in nature, you know, like there's no reason to close down all nature places, I think. Like we have to wear, sure, wear a mask.

Sure. Keep six feet or more from each other. But I don't know. It's frustrating. Right. People need to get outside. People need to get outside. Yeah.

Go for a walk. Wear a mask. But go for a walk for goodness sakes. It's like really good to get out there. and other forms of exercise I'm recommending strength training. I'm trying to get some of my patients to start, you know, even getting personal trainers. There's a lot of personal trainers who don't have work at a gym right now. And so they're willing to do Zoom calls and walk you through workouts and get you started.

And so those are things I'm recommending. And then psychiatry access. So access to psychiatry, to psychotherapy, I think a lot can be done. through legal means and through the government's intervention, and also by insurance companies improving the way that they do things. But a couple things that come to mind are prescribing across state lines. I think it's kind of antiquated that there's 50 separate boards and that you have to be boarded in each one to see patients.

That obviously makes it much harder to do something like telepsychiatry where you can see patients across state lines. and we know that some states have higher suicide rates. So I think it would be really great just to eliminate that altogether and that you can see if you're board certified in one state, you can see patients in every state and prescribe medications in every state. So I think that would be one thing that would be really valuable.

A second thing is true parity. So by that, I means how much is a billing code reimbursed? So, you know, for every $1, an insurance company reimburses primary care docs, they reimburse mental health about $0.83. That was in 2015. And, you know, a lot of psychiatrists and psychotherapists decide to go off insurance panels because of this. I have a private practice on the side. You know, I practice mostly at a university setting, but on the side, I practice, and And I cash pay and out of network. And insurance companies reimburse only about 30% out of network

for most billing type of situations. And so, you know, why do we only accept out of network? Well, because insurance companies want to pay us such a low fee that we would need to see six or eight patients an hour just to make a reasonable salary for a doctor, you know, and otherwise we would just work for the county or the VA or, you know, some big organization that would pay us. So one thing that could be improved is improved parity, improved reimbursement for psychiatric codes for psychotherapy codes. Right now, there's very low reimbursement for psychotherapy codes for psychiatrists. And so you only get

about 10% of psychiatrists who consider themselves doing psychotherapy, whereas, you know, it used to be a lot more than that. And it's unfortunate because, once again, that drives any psychotherapist into more of the cash pay model because otherwise it's just reimbursed so poorly. So, you know, can we adequately fund the treatment that these patients need? And can we expand the coverage? across state lines, those would all be huge wins. Another thing is funding for partial and day treatment programs. Medicare is pretty good at that. Medicaid is not so good. So if someone is, you know, young and they don't have insurance and then they get on one of these basic government plans, they don't have access to the one treatment that may actually help them.

significantly. So, you know, if you are borderline per size sort of, for example, and you're struggling, the best evidence right now available is a good partial program, a good dialectical behavioral therapy, mentalization-based therapy, or transfers-focused therapy, track. But these are very frequent appointments, and this is what makes a big change over time. And actually, you know, like in the mentalization-based therapy, you know, seven years later, only like, I think it was 20%, somewhere around 20%, met the criteria for borderline personality disorder anymore. So, you know, having access to that to patients would be huge, would be absolutely huge. Partial date treatment programs, IOPs, that's what we need. Another thing that really weighs down mental health providers is the paperwork. So

insurance companies often create difficulties that are unnecessary that keep us away from seeing patients. For example, prior authorizations, even for things like generic, low-cost SSRIs, if you've ever done a prior authorization phone call, sometimes it can take 30 minutes, and sometimes they make it take time to make it difficult so that you think about never prescribing that medication ever again in the future. And it does change behaviors from providers. So we think less about prescribing the medications that may be the best fit, but may be also expensive. So prior authorizations, you know, eliminating that, allowing the doctor to make the decision on what is the best treatment. There are other things that are roadblocks and psychiatrists

prescribing the best care possible. One is, you know, in residency, we learn about prescribing suboxone. That's a part of psychiatric residency. Why? do residents then have to take extra classes and get this sort of test passed, you know, outside of psychiatry residency, it would be a whole lot easier. And it would be really beneficial for us to be able to have that without doing that extra training. We're trained in it in psychiatry residency. Psychiatry residency is four years long.

We do rotations in chemical dependency. We know to not use medications inappropriately. So I think it would be good to just eliminate that need. for that special license if you go through psychiatry residency. And further, you know, there's a lot of maintenance of certification exams and CME and all that stuff. Is it like really necessary? And is there evidence to support it being actually useful for us to, you know, continue to grow intellectually, right? So do we need all that handholding? Do we not? Now, I provide CME for this podcast. And so if you're listening, I hope you consider that.

But the truth is that it's very difficult and there's lots of hoops to jump through and extra fees and extra costs and extra things to check off. And it just adds to the overall cumulative burden of non-clinical work that we do that is not necessarily helpful for the patient. Okay. So take me through your take-home points. Yeah. So want to kind of summarize what we've gone over today. unemployment has increased significantly in just the past six weeks, and it might stay that way for quite a while. As our second point, the incidence of depression and suicides have been well correlated with unemployment in studies of populations during stable and unstable economic times.

So looking at U.S. and the majority of the world, we saw an alarming increase in suicides after the Great Recession a little over 10 years ago, and we should expect a similar threat with this coming economic recession. And then the majority of suicides after the Great Recession were from people already diagnosed with depression, so we also need to particularly take care and be vigilant, noticing and asking about any changes with our existing patients. Good. Well, I think this is an important thought exercise, important also exercise that we can put out there and hopefully action can be taken. You know, I don't see a lot of psychiatrists in the news.

You know, we're not in the news enough advocating for what we need. We're not putting pressure on. We need to be more organized. And I think, you know, looking at this data, this is a good time to really take some action, I think, and to sort of come together and say, you know, we really need to make these changes. Because we can prevent this from being as bad of an issue as it's going to be, right,

by financially helping people, by giving people access, advocating for people to get into a therapist, get into a marriage therapist, not just, you know, live in chaos. If their home is in chaos because of domestic violence or, you know, other reasons in this time, like we need to advocate that people get into treatment and people take things seriously like that. So I don't want it to be, you know, an added 10,000 deaths by suicide. And I hope that in some small way, our article and this talking about this can put this out there as like, hey, this is a real issue. There's just going to be a real number of increased deaths by suicide.

And we want to get people treatment and access to treatment who otherwise would be at higher risk. without treatment. Oh, yeah. So if you are listening to this and you want a copy of this, we will put this up on our website and I hope that you share it with people who might be helped by it. If you know any politicians, I hope you share it with them as well, and advocate for this need for this time that we have. So I think we'll leave it there.