Mental health has become a hot topic during the pandemic the past 18 months, but few want to discuss the ongoing issue of suicide. UMHS Psychiatry graduates Dr. Harki Kaur and Dr. Aaron Vazquez, in recognition of National Suicide Prevention Week (September 5 to 11) and National Suicide Prevention and Awareness Month through September 30, are helping UMHS create a better understanding about mental health in the healthcare industry this month by hosting a Facebook Live Virtual Event for National Suicide Prevention Week & the State of Psychiatry on Thursday, September 9, 2021 at 5pm Eastern.
Dr. Harki Kaur, a UMHS 2017 graduate, is co-host of the Facebook Live. The UMHS Endeavour spoke to Dr. Kaur in a telephone interview about why she decided to become a psychiatrist, her thoughts on being a mental health professional, helping prevent suicide and getting people the professional help they need, telemedicine and psychiatry, substance use during the pandemic, training primary care doctors to screen for mental health issues, the benefits of a bridge plan, mental health tips for frontline workers, and more.
Dr. Harki Kaur's story
Dr. Harki Kaur is originally from India. She and her family moved to the Boston area. Dr. Kaur attended the University of Massachusetts Amherst. She studied Public Health. Before going to medical school at UMHS, she also worked at a detox center in Springfield, MA.
“I worked very closely with psychiatry residents and also worked with therapists and social workers and also a lot of psychiatrists,” she said. “And I think that's kind of where my interest developed. I think the reason why I picked psychiatry is I knew I wanted to do it going into medical school because of my background.”
(Photo, inset right above): Dr. Harki Kaur. Photo courtesy of Dr. Kaur.
While at UMHS, Dr. Kaur took several Psychiatry rotations, such as adult Psychiatry, child Psychiatry and forensic Psychiatry. The scheduling of different psychiatry rotations at UMHS helped her tremendously, further igniting her passion.
“I really enjoyed it,” she said, adding that getting to work in different areas of psychiatry helped solidify her interest in the specialty.
She took a gap year and did research at Yale in their Psychiatry Department. She completed her first year of residency in a transitional year at Coliseum Medical Center through Mercer University in Macon, GA.
“After my first year of transitional year, I got accepted straight into second year into the Psychiatry program at Case Western Reserve University in Cleveland, Ohio,” she said. “So, I am finishing up. I'm in my last year right now.”
She will complete her fourth and last year of residency in June 2022.
Dr. Harki Kaur. Photo courtesy of Dr. Kaur.
Psychiatry & the stigma of mental health among the young
Dr. Kaur said it is important to understand the sources of stress in people’s lives, from personal issues to coping with work. Stress can be especially hard on the young. Suicide is the second leading cause of death in the USA for people ages 10 to 34, according to statistics.
“[Stress] is especially hard for people in the younger generations, just going through their relationships or not having enough support,” Dr. Kaur said. “I think that's kind of where it stems from. And there's a lot of stigma. People don't really want to talk about their personal issues or they don't want to seek mental health [treatment].”
The fact that people are hesitant to even talk about what’s bothering them only makes matters worse.
“It is really heartbreaking because now we do have a lot of options,” she said. “We do have a lot of counseling, but the reason why people don't reach out to mental health providers is just the stigma behind it, and that [some think], ‘Oh, my God, someone's going to find out that I'm seeing a psychiatrist or I'm going to see a counselor.’ And instead of that, they just end up taking a different route.”
That route they take could be dangerous. For college and medical students, there are many warning signs that someone might be struggling with mental health issues.
“I think isolation is one of the biggest signs,” she said, noting many start drinking, doing street drugs, depriving themselves of sleep or not eating.
People experiencing mental health issues, including suicidal ideation, are most likely to confide in someone they trust. In school and college settings, having someone students trust and to whom they can confide is essential.
“Especially in school, if we have a designated person, or anybody that they can reach out to first if they want to, that would be good too because having thoughts of suicide—when you're having even a thought—that means you can have a plan. You can have an intent, but we don't know if it's not talked out, right? Some people have chronic thoughts. Some people have acute thoughts. I would say to reach out to somebody who you can trust and feel safe with and just talk about it. And if that person can reach out to the crisis line or suicide prevention line, great; there's [even] a crisis text line. If somebody wants to use those options where they can talk to somebody 24 hours— if they don't want to talk to their peers and they don't feel comfortable—then I think these numbers and these lines should be made aware of where you can directly call a crisis counselor for free, or you can text them for free and all these services are available.”
The National Suicide Prevention Lifeline outlines three key facts about young people and suicide, including:
- Understanding risk factors. While not all risk factors will result in a suicide attempt, mental and substance use disorders, a major physical illness, history of trauma or experiencing a loss could increase the chance someone will “consider, attempt or die by suicide.”
- Recognizing warning signs. National Suicide Prevention says to “take note of sudden changes in behavior, especially if it seems related to a painful event, loss or change.” They recommend you “start a conversation with your child or loved one about how they’re doing if something feels off. “
- Know when to reach out for help. “Knowing, supporting and loving a young person who is struggling with their mental health can be stressful, but resources are available. Call the behavioral health number on the back of your insurance card or call the National Suicide Prevention Lifeline at 1-800-273-8255,” the organization notes.
The pandemic & mental health
The COVID-19 pandemic has had a tremendous impact on both the public and the medical world. Unfortunately, people contending with sheltering in place and lockdowns has resulted in isolation for many, creating anxiety and depression. Many have faced financial losses or the loss of friends and loved ones. Doctors and nurses have experienced grim scenes in hospitals.
Dr. Kaur said the pandemic has had a substantial impact at Case Western University Hospital where she works. The hospital offers a crisis line that employees and the public can call when they want to speak to somebody.
“I'm one of the ambassadors where anybody from the hospital, a nurse, a doctor, anybody, a janitor, just people can reach out to us,” she said. “I think that anxiety and depression has spiked quite a lot during the pandemic because of just the way everything went down.”
The adaptation to the lockdowns and changes in daily lifestyles added new stress levels people did not know how to handle.
“I think the main thing that affected people even during the pandemic was the isolation because you couldn't go to work. You were working from home and there were kids at home and you've not lived with kids and your husband or your wife and everybody working together now because people had schedules [before Covid hit].
“Normally people had to leave for work or school. And when that didn't happen, a lot of people became super anxious. We used to see a lot of people for counseling, especially in the beginning. I think that was very difficult for even us as psychiatrists to deal with because we felt really overwhelmed at the same time, because people would call us and say that they had lost somebody. They were worried about somebody; somebody has survived a suicide attempt or is having thoughts. And all of those are very heavy things, I think, at times to carry with us as well.”
The pros & cons of telemedicine
Like most doctors, the pandemic caused psychiatrists to experience an increase in telemedicine, with large numbers of new and current patients needing psychiatric care. Dr. Kaur admits it was a difficult adjustment.
“Last year we were all telemedicine, but it was hard for me,” she said.
Because the third year of residency for a psychiatrist normally involves working in outpatient clinics, Dr. Kaur was not expecting to be seeing everyone via telemedicine.
“It was honestly very difficult for me to transition from doing all inpatient rotations as second year to all of a sudden being in front of a computer screen and trying to talk to the patients.”
Some patients, particularly older adults, had trouble with the technology involved with telemedicine appointments. Dr. Kaur did a rotation at the VA (Veterans Administration) as well and notes that some elderly veterans had trouble working with Zoom. Other patients simply were not comfortable with telemedicine.
Things are somewhat easier now for her because her hospital is in a hybrid format of in-person and telemedicine appointments. She said some patients may have thought, “I feel like I'm just talking to a machine because I don't even know you. How can I tell you my problems or how can I feel comfortable?"
She has overcome the initial challenges of building a relationship with patients via telemedicine.
“I think now, since I've been doing it for almost a year and a half, there's a level of commitment that patients have with me now. And there's a level of trust as well, but it took a while to experience that, especially when you're a resident. But now I feel comfortable with them.”
However, treating pediatric patients via telemedicine remains tricky.
“Child psychiatry over Zoom is very difficult because you may have a five-year-old who can't sit still in front of the computer.”
Overall, however, telemedicine has many benefits.
“It's a good technology, especially for patients who are elderly or who live in rural counties and can't really travel much,” Dr. Kaur said. “And if you can see them and help them out through tele-psychiatry, I think it's a great tool for mental health providers.”
Substance use during the pandemic
Alcohol and substance use has increased during the pandemic.
“I have seen an increase in alcohol use, especially in college students a lot,” Dr. Kaur said. “On Mondays, I work at Case University’s college mental health clinic, where I only see college students. And since everything went remote, even for the students, classes were remote and they weren't able to see their girlfriends, boyfriends, or other partners. There has been a huge increase of especially alcohol use where they say, ‘We're bored. There's nothing else to do. We can't go to the gym; we can't go outside.’ Social drinking is not social drinking anymore. I think it has increased a lot for sure. Not so much in any other recreational drugs. Maybe like marijuana, but I think alcohol intake has substantially increased since the pandemic for sure.”
How to talk to someone considering suicide
Whenever a doctor feels a patient might be at risk for suicide or when a friend or family member knows someone who could be in danger, being honest with them and being a good listener helps.
“I think one of the best things is having an honest conversation with your patient,” she said. “Like sometimes I talk to them in private, or I listen to their stories. A good, compassionate physician and a good listener who can be empathetic and can understand what's going on helps. And just also telling them that you care about them; you can talk to me. And sometimes ask directly if they're thinking about suicide.”
She outlined ways to be honest and non-judgmental with people at risk. She encourages them to avoid debating the value of life.
“Because sometimes people think, ‘I don't think I'm doing a good job’—just help them by minimizing their problems. I think that's the way to approach it. And then that, at times, eases the patient because they feel comfortable because they know that you are showing that compassion, you're taking your time, and you are a good listener. And you're trying to give that comfort where they can open up. I think just letting somebody know that you care [helps]; ask them directly about if they're feeling unsafe or feeling suicidal. Calmly without judgment is the best way to go because then the other person, no matter what crisis they're in, will listen and will trust you in that time of need. I think showing understanding and taking their concerns seriously is also really helpful. And just letting them know that their life matters to you as well. It gives them that reassurance that there is somebody who cares.”
What if someone admits they are considering suicide?
“I encourage them to seek treatment, like contact me or contact even the crisis lines, or call 911, or go to the emergency room if they feel like their mood is changing or they're feeling unsafe and they're noticing changes in their behavior.”
Training doctors to screen for mental health
Most primary care doctors should be trained in mental health screening for patients. Although most have the proper training, some primary care providers start patients out on antidepressants and other psychiatric medication without referring anyone to a psychiatrist.
Dr. Kaur said she believes if a patient has mental health issues, it is best to refer them to a psychiatrist as soon as possible.
“Even though doctors are aware, I think referring a patient to a psychiatrist sooner rather than later can really be helpful.”
Dr. Kaur notes that sometimes primary care doctors or nurse practitioners prescribe too many antidepressants or anti-anxiety meds or a dosage that is too high or too low, or medications that may not be right for certain patients.
“Sometimes they start the patients on medications like antidepressants. But even though they're aware of the medications, by the time some patients come to us, they are on so many. I feel like they're started on all different kinds of medications. And then we have to clean that up and it gets frustrating. And then I wonder why couldn't the doctor have sent the patient to us sooner?
“I think that awareness should be made more to the other providers because it's hard when the patients are on so many medications and we're trying to wean them off.”
Benefits of a bridge clinic
Case Western offers a bridge clinic to serve patients with serious mental health issues, where patients can be sent when their primary care doctor is unable to treat prolonged depression or other complex conditions.
“We have an access clinic. It's one of the nicest things. Sometimes the primary care doctor will start a patient on an antidepressant, for example. And after that, the doctor says, ‘You know what? You need to go see a psychiatrist at this clinic and as a follow-up,’ so that if med adjustments need to be made or another follow-up is needed [we can handle that]."
The bridge clinic helps promote “intercommunication between all these other providers, which is a great way to keep everybody in the loop so that the meds are not changed or they're not just dropped.”
Bridge clinics also help educate patients about the need to see a specialist because there is such a stigma regarding mental health and psychiatry. When someone is told by their healthcare provider that they need to see a psychiatrist, they can feel overwhelmed or confused.
“Then the patient is kind of hesitant, like, why do I need a psychiatrist? But just properly educating the patients that it'll be the best way helps. Like saying, ‘There's nothing serious, but I think your depression or your sleep insomnia can be handled or treated better by a psychiatrist.’”
Mental health relief for frontline healthcare professionals
Since the COVID-19 pandemic began in early 2020, doctors and other healthcare professionals have had to face overflowing emergency rooms and treat an unparalleled number of COVID-19 patients, put patients on ventilators and see many people die. Things have become worse with the Delta variant and it has been frustrating watching many unvaccinated patients die.
Dr. Kaur recommends that healthcare professionals learn to take time out from all the stress by going on walks, exercising, doing yoga, eating healthy, and using meditation and mindfulness apps, the latter of which she said really helps when taking breaks from work for 10 to 15 minutes.
Coping with patients who are against COVID-19 vaccines is perhaps one of the most exasperating aspects of being a doctor today.
“I just don't know how to deal with that because I just get really frustrated,” Dr. Kaur said. “I tell my patients [who are against vaccines] that ‘you're putting me in danger as well. I'm your provider. You should do this for yourself. And also, you should think about the people you're interacting with as well.’ ”
Help for UMHS students
Dr. Kaur encourages UMHS students with questions about psychiatry or anyone with questions about mental health to contact her. She would like to start a helpline for UMHS students eventually, to offer support to students away from home, being on the island or those studying remotely, feeling isolated.
“I want to give back to our school,” she said. “This is something that I had talked about with Dr. Aaron Vazquez as well. Like if anybody wants to reach out to us and wants to talk with us about anything. We are available. That's something that I want to put out there.”
(Top photo): UMHS alumna Dr. Harki Kaur is in her fourth & final year of a Psychiatry residency at Case Western University in Ohio. Photo courtesy of Dr. Kaur.
Scott is Director of Digital Content at UMHS and editor of the UMHS Endeavour blog. When he's not writing about UMHS students, faculty, events, public health, alumni and UMHS research, he writes and edits Broadway theater reviews for a website he publishes in New York City, StageZine.com.