Ask Us Anything About…COVID 19 Fatigue

Scott Gilbert – From Penn State Health, this is “Ask Us Anything About COVID Fatigue”. I’m Scott Gilbert. More than nine months into the COVID-19 pandemic, a lot of people are tired of being cooped up and of being scared. Some would call COVID fatigue comes as COVID cases are sharply rising across Central Pennsylvania and across the whole state and much of the country, all of this just ahead of the holidays, a time when family gatherings are common. Here to help us navigate the many facets of what we’re calling COVID fatigue, are Dr. Julie Graziane a psychiatrist at Penn State Health Milton S. Hershey Medical Center. And Dr. Jonathan Nunez, he’s an internal medicine physician at the Milton S. Hershey Medical Center. My thanks to both of you for being here on this Friday. So Dr. Graziane, let’s start with you. I mean, you know, for good reason, there’s a lot of emphasis right now on the steps people need to take to avoid contracting and spreading COVID-19. But aren’t the psychological effects of doing these things and dealing with quarantine somewhat harmful as well?

Dr. Julie Graziane – So I think that’s a really good question and it’s really important to recognize that this is a very stressful situation. And like all stressful situations, they come with a host of emotions. And so, with quarantine, a lot of the common emotions that people might — might experience include boredom, frustration, fear, anxiety. And the good news is that once quarantine is over, for the most part, those emotions tend to dissipate. For some people, if they have an underlying mental health condition, or if they’re a healthcare worker, sometimes the anxiety and the anger might still stick around for a few months later. But there are things that we can do to kind of help mitigate a lot of those stressful emotions during this time. And one of the ways that we can do that is to change the way we think about quarantine. And so, instead of it being this forced thing that’s put upon us, we can instead think of it as an action that we’re choosing to do to help people. So, we kind of shift it into an altruistic action, because we’re doing it to help our loved one, our neighbor, our — the stranger in the community that we care about. And when we do that, that can affect the psychological [inaudible]. And then the kind of last part that the answer to that question is that there are always psychological effects to doing something and there are psychological effects of not doing something. And so, I spend most of my day talking to people about their feelings, and their emotions, and their stressors, and one of the feelings that people really struggle with trying to get through it is feeling. And so, I think if you’re going to think about not following quarantine, if that’s recommended, you also have to think about the guilt that could potentially come with potentially infecting someone else. Frankly, you know, nobody wants to be the person that gives their grandmother COVID at Thanksgiving, because they didn’t follow quarantine and just to be prepared of thinking about the psychological of quarantine but also of not quarantine.

Scott Gilbert – So, yeah. So Dr. Graziane, let me follow up with that. You talked about some coping mechanisms. Can you talk about other ones that people seem to be using? I mean, for example, when I take a walk or a run, I see a lot more people exercising than maybe eight or nine months ago.

Dr. Julie Graziane – Yup, that’s an actually a great coping mechanism. So when we think about coping mechanisms, we kind of want to think about, what have we done in the past that’s been healthy and positive to cope with stress, and that’s a really good way to start. And then the second really important thing is to think about establishing a routine. And that can be really hard when we don’t have the external pressures that we used to. You know, maybe you’re not getting your kids on the bus in the morning, maybe you don’t actually have to get in your car and go to work. But at the same time, having a regular awake time or regular sleep time, regular meal times is really important. And then incorporating some time during the day to kind of check in with yourself, how you’re feeling about the day, the situation, and incorporating healthy activities like exercise, mindfulness, and then pleasurable activities. So it’s really important to still reach out socially to our loved ones, our friends, our co-workers, and all of that can really set people up to kind of get through this in a much healthier sort of way.

Scott Gilbert – Well said. Dr. Nunez, what are you seeing and hearing with regard to patients, even members of the general public, people you encounter, adhering to those basic guidelines of wearing a mask, social distancing, and hand hygiene? I mean, did you feel like people are still taking those things seriously, or some people kind of slipping with that?

Dr. Jonathan Nunez – So I think I’ve been very fortunate, I think a majority of my patients that I both see in internal medicine and infectious disease have understood the severity of the illness that they’ve been taking precautions overall. I think the perspective that many of them have taken is mostly that they’re not just protecting themselves, it’s really about particularly protecting others. A couple of things that they highlight many of the times is that they are feeling tired in some difficulty, you know, always wearing the mask, when is the time that this will end. I think during the beginning of the spring and the summer, we had the advantage of having the opportunities to do many things outdoors, how that will change as we’re forced with the wintertime to be indoors will be intriguing to see. I think a couple things that I kind of highlight and notice at them seeing patients. And some of the common things that they’re mentioned to me, you know, some that are more effective than others. You know, some people may have lost their job, so I think losing that part of the routine or the financial struggles with everything kind of going on. You know, some have lost their hobbies. I mean, I think there’s a time that many of them would go to the gym for stress relief, you know, maybe they don’t all have the opportunity of a safe community or route around to outdoor activities. I think other things is, you know, screening for mental health, or some patients may feel more lonely at this time. So I think we always think about having a social support system at home, some people may not have that. And I think the other thing too, is as we switch a lot to telemedicine, I think a lot of our patients have been really frustrated from the perspective. You know, I think with all the advancements in technology, you know, really have some difficulties switching over to telemedicine, and it’s really hard to care for patients on that, you know, I feel like you don’t always get to have that experience when they’re actually in the exam room.

Scott Gilbert – Wow. You’re watching “Ask Us Anything About COVID Fatigue” from Penn State Health. I’m Scott Gilbert alongside Dr. Julie Graziane, a psychiatrist at Hershey Medical Center, and Dr. Jonathan Nunez. He’s an internal medicine physician also at Hershey Medical Center. We welcome your questions and comments. Feel free to add them to the comment field of this Facebook post and we’ll make sure we get to as many as we can live. And any that we don’t get to live, we’ll answer with a written answer after the fact. So Dr. Graziane, kind of leads to a general question I think about balancing quality of life and the dangers of a pandemic. You know, what advice do you have for people who are like, I still want to be able to live my life or at least I feel like I’m living my life the way I was before all of this, but at the same time staying safe. From a psychological standpoint, how do you counsel folks on that?

Dr. Julie Graziane – Yeah. So I think it’s important to kind of have people reflect on what’s important in their life, and what kind of gave them meaning before the pandemic, and then try to figure out ways to still incorporate a lot of those themes into kind of their current pandemic life now. So let’s say, you know, going out with a group of friends was really important before the pandemic, and you know, seeing your co-workers was really important in the — before the pandemic. Maybe, you know, setting up like a weekly phone check in or, you know, a weekly FaceTime date. And so, you can still have those social connections and still have kind of the meaning from the social connection, even with the physical distancing now that we have. And so, really just thinking about where you were beforehand, psychologically, and what you enjoyed, and how you can still do that, oh, yeah, it might be a little change, but you can still get a lot of that enjoyment.

Scott Gilbert – Dr. Nunez, as we head into this latest surge of COVID cases in our region, what do physicians and public health officials know now that they may not have known at the beginning of this pandemic, that knowledge that they’re armed with right now?

Dr. Jonathan Nunez – So I describe it, it’s like drinking out of a firehose. I think at the last like four or five months, I feel like every day we learn something new, every week, you know, something totally different. I mean, I think one of the big things from the beginning, but first we’re saying not to use mask, I think there’s been a lot of evidence overall that wearing masks may definitely slow the spread of the virus and help people from transmitting to others, especially if they’re asymptomatic. I think one of the big things we also learned is that there can be spread, even in people who do not have symptoms are considered to be asymptomatic. You know, even indoor gatherings, as we talked about, just being outdoors doesn’t necessarily make it totally safe. I think being outdoor and large gatherings where they can’t socially distance has definitely driven cases and we’ve seen this in like super spreading events. If we think about festivals, bars, works, events even at the White House, warm summer weather did not definitely stop the virus like other seasonal respiratory diseases. And we also have kind of learned a lot about other underlying conditions and how they can have huge impacts for more serious cases. Health disparities, something that we’re still seeing, especially patients with COVID-19, especially in underserved vulnerable patient populations, and even the initial presentation symptoms, you know, our case definition has definitely changed and been revised on multiple occasions where might have just started off with fever, has kind of expanded out to the other symptoms, including loss of taste or smell. Other things we’ve learned, even after infection, some people may have this long recovery and still have some long term complications after infections, so that’s something that we’ve also learned. And then reinfection, although, you know, it’s rare, it’s been documented in the literature, and then even coinfection with other respiratory illnesses. So I think as we go into the seasonal influenza season, really reminding everybody that there’s very, very big to get a influenza vaccination.

Scott Gilbert – And you know, Dr. Nunez, you mentioned something that I want to follow up on, and that is the changing guidance from the beginning of this pandemic. And, you know, for example, the mask wearing, you know, originally the [inaudible] public health officials said, don’t bother, now it’s very important. But can you put that into context a little and talk about why that is typical for a situation like this, because of the fact that the situation itself is atypical, right?

Dr. Jonathan Nunez – Sure. I mean, I think one of the big things is none of us have lived through pandemic, and this isn’t new illness and that we’re something that we’re always learning a little bit more. When we’re beginning back from the initial outbreak response, I think one of the big things we were very concerned that is that we didn’t have protective equipment for healthcare providers to actually take care of patients. And I think one of the limitations in the beginning was, well, if everyone’s wearing masks, will that kind of limit the protective equipment for people who might be at high risk for caring for patients and transmitting? So I think one of the things that we learned during the course is that, you know, with masks and social distancing, you can kind of have flattened down that curve. So, you know, for many of the states that we were expecting these surges, we actually kind of had a flat plateau of cases, which are much more manageable for us to take care of in the hospital, you know. We’re trying to take care of everybody keep them safe. It’s a little bit difficult if we have a huge surge of patients within the hospital. Going back to that too, I would probably highlight a lot with the treatment modalities. So I think in a pandemic, we really want to help everyone and save everybody. I think we’re — we throw a lot, we think of the path — pathology of the disease and we think of other treatments that we use for other diseases. And we’re like, hey, this should in theory work. But as we learned through and, you know, none of these are randomized control studies, we realize that a lot of the treatment options may not do much — may actually do harm. But I think a good example of that is the hydroxychloroquine. So I think, you know, overall, a lot of us where there’s a lot of press that’s may be beneficial and I think it really impacted our patients who are actually on those medications for other diseases, because they were concerned that they could get it. At the same time, you know, some of these treatment options that we offer, actually, might put our patients more at harm. So like, one of the things we noticed is like definitely arrhythmias. One thing that I think continually goes back up to date is that we’re learning more as we treat more. So like compared to the beginning of the epidemic, we do have some treatment options, I think Remdesivir, which is an antiviral had been approved, Dexamethasone, we definitely learned can help us with our patients who are hospitalized with COVID for having some respiratory symptoms. And I think now we’re even having the discussion of maybe even monoclonal antibodies. So I think a lot of things have changed as we learn more and treat more patients living with COVID.

Scott Gilbert – You’re watching “Ask Us Anything About COVID Fatigue” from Penn State Health. We welcome your questions for Dr. Julie Graziane, a psychiatrist, and Dr. Jonathan Nunez. He’s an internal medicine physician. Both of them from Hershey Medical Center, and both of them ready to take on your questions today. You know, this is — this pandemic, we — you know, we like to think optimistically early — in the early going that it might be something that lasted a few weeks or a couple months, but here we are seven, eight months later, and we’re seeing yet another surge. So it’s something we’re still living with and very logically, people are just weary of it. We were weary of it months ago, but even more so now, so ask your questions. We do have a question now from Mary, we’d like to go to, and I think we’re going to direct this to you Dr. Nunez. Mary is asking how concerned a high risk patient should be about coming in for bloodwork when there are usually many people waiting in that type of environment.

Dr. Jonathan Nunez – I think that’s a great question. I think one of the big things that as we were going through this and expecting and planning for our surge, you know, there’s some patients when I look back who really been stable like, you know, routinely. Maybe I would have checked bloodworks every three or six months, but if I didn’t know medication changes, and the area in the community that we have definitely has a high surge of cases, I would say like I’ve been deferring bloodwork. Now for some of my patients, we do need bloodwork. There are certain treatments that we definitely need to monitor. I think a couple of changes from the beginning of the epidemic or pandemic, actually, is that, you know, we’ve really done a lot to actually stretch toward patients that, you know, if you’re not feeling well, please do not come in. You know, we’ve been doing implementation of screening patients for symptoms as they come in, the expectation when you come in to get bloodwork, you’re actually having everyone actually wear masks and we’ve been spatially distancing. I think the other thing I’ve also highlighted with some of my patients is that there might be specific hours where we know that there’s less of a wait for patient labs as well. For some of our high risk patients, you know, we’ve done COVID testing even just meeting them at the car, or patients who have disabilities to have it a little bit harder for them to get actually in the clinic. I think one thing I just try to highlight to my patients is we all have to try to be understanding, and definitely flexible, because this is not something that’s really routine for any of us and we’re learning as we go.

Scott Gilbert – So Dr. Graziane, I’m curious as to you know, as we head into the winter months, I’m wondering if the psychological effects of COVID could actually be magnified. Because you know, these months ahead, they’re already characterized by less daylight, a little more isolation than we have over the summer. So are you concerned about that?

Dr. Julie Graziane – I think that’s certainly a possibility. And like you said, I think people are starting to get this sense of fatigue from the pandemic, so that already kind of sets it up in a way to kind of even make us more exhausted. And then we certainly know that there is a seasonal component to some folks’ depression, so that’s also a concern. And so, now is a really good time to — if you haven’t already started making like these routines that we talked about and starting to incorporate these healthier coping skills, it’s a really good time to kind of prepare and make that more part of your daily life.

Scott Gilbert – And as we do head into the holiday season, Dr. Nunez, a tricky question here, because this is that season marked by family gatherings. What is your guidance to people who asked you, should I, can I, is there any way for me to get together with family and friends over the holidays?

Dr. Jonathan Nunez – You know, I think one of the big things I would highlight is there’s this excellent medical minute that actually was done by my co-colleague, Dr. Buck Berger [assumed spelling], and I think we’re on the same line. I think what’s important this holiday is really remembering that we’re trying to stay healthy, but we’re also really trying to keep others healthy, especially our patients who are especially vulnerable and at risk for severe complications of the disease. I think this is a really tough year. I mean, the only way to really avoid infection is not to gather in large gatherings. The higher level of community transmission in the area, which is the thing we don’t always know because of limitations of testing, and the more people — individual interacts with that gathering and longer interaction last, the higher potential risk of becoming infected with COVID and spreading COVID. I think many individuals asked me this, and I think including my own family members, and I think really a discussion to have as a family, I think we really have to discuss the risk. We shouldn’t assume all family members are super comfortable with this. And I think one of the big things is, you know, I really wouldn’t want to get my grandparents or even my parents ill. If it’s a discussion that overall everyone feels OK with taking that risk, and I would say the best approach probably would be to do a strict 14-day quarantine ahead of the holiday. Really people traveling should be traveling by car. They shouldn’t be traveling by public transportation or flights. You know, I know there’s a lot of stuff talking about air purification, strict cleaning, wearing a mask on a flight, but that may not necessarily be enough. Another option is to try to do something that might be a little bit more outdoor gathering, although I think the risk remains, especially if there’s large groups. Having people an aspect to this is to think of the college students that are coming back, right. So I think one of the big things is many of us are having college students and coming back and what to do with that. So I think one of the big thing, I’ve been suggesting to everybody is also trying to quarantine at home if possible, or quarantine prior to them coming down so that we don’t spread that risk of infection to our highly vulnerable patients. So whenever I look at this question, and as an infectious disease doc in an internal medicine doc, I always look at risk. So what’s the lowest risk? Virtual only. And I think one of the big things is I think a lot of us have become creative of alternating food or big life events, even if it’s [inaudible]. So I think a couple of us, you know, through like virtual weddings or like drive by birthdays, I think one aspect is maybe to incorporate a virtual event during holidays. The more risk, even in smaller outdoor and in person gatherings, you know, I think if you’re going to do it, you still have to remain 6 feet apart, mask I think is still highly beneficial, you really don’t want to share object. You want to try to limit it where’s peoples coming from the same local area rather than necessarily from farther away, but it does still carries a risk and I find that very hard to say, yes, that’s totally doable and safe for my family members. So I think this year, we decided to do more of a virtual event. And in the end, I think what we’re trying to do is not just take care of ourselves, but really also trying to take care of our loved ones.

Scott Gilbert – A great point. Now, Dr. Graziane, I’d like to explore kind of psychological side of that, because holiday is about tradition for so many people and for people that have to modify, or even forego what they think of as their regular holiday traditions. Now, for some this is their only chance all year to see family members. What advice can you give them for how to approach, you know, the kinds of mental approach they should take to the weeks ahead?

Dr. Julie Graziane – Yeah. And I think people look forward to the holidays, but also I think for many people the holidays can be a very stressful time to begin with. And then you throw a pandemic in to it and it’s just like stress on steroids. And so I think, again, it kind of comes back to having the individual check in with themselves, kind of just figure out what their level of risk is, and then realize that their loved ones who they want to perhaps spend time with may have a different level of risk or a different expectation. And then it really, I think, comes down to acceptance that your expectations may be different and open communication, and kind of be able to meet the answer with tolerance and compassion, so that you can kind of still do these other events, maybe virtually, so that you can really mitigate the risk as much as possible. Because we can still be socially connected, perhaps just not physically connected, but still do a lot of these traditions. And there’s no reason why people can’t start new traditions, either going forward [inaudible].

Scott Gilbert – Sure. You know, Dr. Nunez, you know, we’ve seen over the last several months, even restaurants have been open. But especially as we head into the winter months, and those patios won’t be open at those restaurants anymore. You know, we hear that going out to eat comes with some risk as do other things, like getting a haircut. And these are things that I mean, really, there were a lot of rules and regulations clamping down on these businesses. A lot of them remain open right now. What is your advice for people about some of those activities that we at least initially heard could be moderate or even high level risk?

Dr. Jonathan Nunez – I think we’re all looking for normalcy and I get it. I also from a family that owned a bodega, which is like a Spanish convenience store in the back, we had a takeout restaurant, people are trying to make a living, right, they have their business, they’re trying to keep it open, I understand that. I think as we know, the more individual interacts in an area that’s not highly ventilated, the longer that interaction is, the more people that are there, the higher risk of COVID-19 spread is. When I’m viewing this, I think of it more as the level of risks. So, I’m having the discussion with my patients. You know, I look through and I mentioned to them, you know that there is no decrease risk. There’s no necessarily say, hey, there’s zero percent risk, I think of it as a level of risk. The lowest risk, I probably would say I’ve mentioned is mostly drive thru delivery or takeout curbside pickup. You can still support the businesses that are there. You can still get the variety of meals and that safe to do as we start thinking about, you know, settings to eat, you know, I do recommend outdoor seating if the area has to be allow for separation 6 feet. I think that will be challenging to think about as we enter the fall, there will be more risk. How I describe it to my patients is really looking through and go, hey, you know, if you were to have [inaudible], these are the things I noticed in your medical history that might push you more for severe COVID, and I think it’s something to point out. I really highlight that we can still support our local businesses, we can still do eating, you know, maybe as takeout. Now, as you flip over to some of the other businesses, a lot of things have changed since the beginning of the pandemic. You know, getting haircuts, for example, you bring up. They’re supposed to actually get the number of people that are actually there. There’s some beautician and hairstylist that are only doing individual appointments, and it’s staggered so that it’s actually a waiting room and they’re actually cleaning down most of their equipment. As you look for these activities, one thing I would highlight too, is just to make sure that the people that are actually there are also abiding by the rules, wearing masks, covering the whole face, sitting 6 feet apart. You know, if you are going to eat inside, really covering your mouth during the times where you’re not necessarily eating. But again, I mentioned to everything, there’s no absolute decreased risk. One thing’s for the normalcy, I think it’s really getting creative. I think one of the big things that it’s nice about the time in social media is many people can post intriguing things. And how I bring it up, as most of my inspiration has come from the internal medicine residents, you know, they’ve been able to still have game nights, it’s through virtual. I think other things that we’ve done, and I’ve seen people do like training sessions or yoga, again, virtual. And I think like even thinking about like a virtual cooking class where it gives us an opportunity to still be social, right, we’re still being social, though we’re not physically near each other.

Scott Gilbert – As we bring this to a close, the last call for questions for Doctors Graziane or Nunez, feel free to add those to the comment field in this Facebook post. But otherwise, I’ll wrap up with a rather general forward-looking question. And that is, as we, you know, look toward — look ahead and say that, you know, some people would say there’s really no end to the pandemic in sight. What advice do you have for people for staying the course, especially on those days when it seems toughest to do? So Dr. Graziane, let’s start with you.

Dr. Julie Graziane – I would say don’t be afraid to reach out. Like if you feel like you’re struggling with getting through this, I would say talk to someone, so whether that’s a loved one, whether it’s a physician, whether it’s a counselor, or a friend, I would say, you know, we are social creatures. You know, interpersonal interaction is really important and I think that’s kind of what will be able to get us through that.

Scott Gilbert – That’s great advice. Dr. Nunez, what about you?

Dr. Jonathan Nunez – You know, I would say we’re at an age where we’re totally connected, and have always were, you know, really taking that time and thinking about checking in with others, right. Anyone that we know, maybe they’re struggling and just because we don’t ask they don’t mention that. So I think one of the big things is really being there for everybody. We’re all going through this. I think I’m always been an optimist and I think we’re going to be through this and I think we’ve looked in through history. We’ve had other issues in the past that we’ve survived and persevere. I think one of the things I mentioned to everybody is, we’re not alone at doing this and I think really just taking that opportunity to check in with each other.

Scott Gilbert – Some great advice from both of you. Thanks so much for both — to both of you for your time today. Dr. Julie Graziane, a psychiatrist at the Milton S. Hershey Medical Center. Dr. Jonathan Nunez, an internal medicine physician also at Hershey Medical Center. Thank you so much for your time today. And thanks to you for watching “Ask Us Anything About COVID fatigue” from Penn State Health.

Dr. Julie Graziane – Thanks, Scott.