Category Archives: Mental Health

COVID in the Mountains: What Works?

As the nation experiences its second, and by far more significant, increase in COVID-19 cases, visitors continue to flock to the Colorado Rocky Mountain region, while advisories from the CDC and government officials across the world continue urging people to stay isolated and home for the holidays. Unlike the Northern Mariana Islands or New Zealand, where physical distancing, the use of masks, travel bans and mandatory quarantines have allowed these island nations to maintain zero community spread, Colorado remains open to the potentially millions of travelers it sees every Winter season, and with far fewer mandates to control infection.

Although the beginning of the pandemic saw facilities managing to protect their staff with protective equipment and protocols, during this dramatic second wave of reported cases, we are seeing an increase in cases among essential health care workers. And with the regular flu season well underway, it seems more critical than ever that we do everything we can to limit exposure.

Ebert Family Clinic, in the heart of Summit County, Colorado, surrounded by world-class ski resorts drawing visitors from all over the world, has successfully managed to avoid infection among all its staff, in spite of continuing to serve its patient population since the initial lockdown this past March.

How?

“First of all, we kept our door locked. You can only come in one at a time, we meet you at the door, screen your temperature, ask if you have any symptoms; we screen when you make an appointment and make sure if anyone in your household is sick, you reschedule your appointment. If so, we made you a telehealth appointment,” says pediatrician and president Christine Ebert-Santos, MD, MPS.

And the telehealth appointments have been a success all year, saving a lot of travel and risk of exposure, making primary health care even more accessible.

Even now, Ebert Family Clinic’s pandemic protocol hasn’t changed. “But just as importantly, all of our employees are maintaining a bubble with close contacts,” adds Dr. Chris.

Operations weren’t always smooth: “Two times, when someone close to a staff member, like in our family, was sick, we stayed home,” says The Doc about having to close the clinic. I stayed home until [my husband’s] test was negative, [our nurse practitioner,] Tara stayed home until her husband’s test was negative; until we knew we didn’t have COVID. We based the risk of COVID on the standard that is described of having been within six feet of an infected person in a closed space.”

Is the vaccine going to change protocols?

“The vaccine isn’t going to change anything. The announcement from Public Health today tells exactly how many doses. That’s a drop in the bucket. What’s that when we have 30,000 residents and 90,000 visitors? It’s going to be six to nine months before we see any protection from this vaccine,” Dr. Chris confirms.

“Essential workers all have their protocols, and they’re just as important as ever. [If you can’t work] — all the parents who have to stay home with their kids, or the restaurant servers who are laid off — I’m hoping that the people who are doing well in our community can continue to help those who are suffering. There is a big sector of our community, like real estate or repairs or construction workers who have been able to continue working through this pandemic. I think [these people who are out of work] are getting help from the FIRC or applying for rent assistance. I haven’t had anyone say that they’re really struggling. And we conduct social welfare interviews, “Do you feel safe? Do you have food?” We’re doing anxiety and depression screenings on everybody. And there is a high level of anxiety among all ages. 

“We had a meeting with Heart-Centered Counseling, and now we’re plugged in with them. We have their brochures, and we’ve just signed care coordination to connect people with providers [who can help in this situation].”

Dr. Chris encourages everyone in the community to reach out with their needs. Ebert Family Clinic and other health care institutions have done very well maintaining a cohesive network of resources for everyone in search of financial, physical, mental, and emotional assistance.

Feel free to inquire about appointments or referrals to local resources at info@ebertfamilyclinic.com, or call the clinic at (970) 668-1616.

Dr. Chris with her granddaughter, comfy-cozy.

“Everybody enjoy their Christmas Zoom with their relatives. As for us, we are having a small family Christmas with six of us who work and live together, and we’re all wearing hoodie-footie flannel jammies.”

Happy Holidays from Dr. Chris, Ebert Family Clinic, and highaltitudehealth.com!

robert-ebert-santos

Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.

COVID-19 Update: Accordion Theory and Preparing for Next Steps

Today, I am going to share news gleaned from meetings and publications that address the importance of preventive care, returning to daycare, pulse oximetry as a screening tool for COVID, and the Accordion Theory.

Every Thursday the Children’s Hospital of Colorado presents a panel of experts with updates and answers to questions.

“Your offices are the safest place in the country,” they proclaimed. With social distancing many parents and patients are delaying routine care which has led to the largest drop in vaccination rates in 50 years. This could result in outbreaks of measles, whooping cough, pneumococcal and other infections. With the loss of revenue, small clinics may go out of business, and large clinics and hospitals are laying off workers by the hundreds. If there is a large outbreak of preventable disease, on top of a resurgence of COVID, there could be a devastating shortage of providers to care for the victims. Now is the time to call your clinic and set up appointments for check ups and vaccines. If you don’t feel safe yet you can do a Telehealth visit initially and schedule the vaccines and hands-on portion of the exam in a month.

Another reason not to delay preventive care is the increase in stress, isolation, and anxiety which can cause serious depression. We had a tragic teen suicide in the county this month. Students from middle school through college should be seen annually for mental and physical health screening as well as vaccines. One mother told me that the depression screening done at our office “saved my daughter’s life.”

More daycares are opening soon. Parents are asking me whether to send their child back. These facilities follow strict public health guidelines to prevent infection. Children are not likely to be affected by COVID. Any child with symptoms should be tested. Enrollment should be diminished due to parents preferring to keep their child at home.  However, if there is a high risk family member, I advise not to return to daycare yet.

School age children should be limited to playing with friends and family members who have been part of their social circle during the last two months. To borrow a slogan from the AIDS campaign, “KNOW YOUR NETWORK”.  This is not the time to expand friendships. There will be no team sports this summer. Children should play outside and not share toys or balls.

An emergency physician in New York, Richard Levitan, published an editorial in the NY Times on April 20 advocating the use of pulse oximeters to screen for COVID. Citing the many patients with low oxygen levels and abnormal x-rays who did not complain of trouble breathing, the delay in obtaining results and inaccuracy of the COVID testing, he sees the simple pulse oximeter as a source of immediate information as to who needs medical attention. I’ve been speaking and writing about this for weeks.

Finally, one of the panelists at Children’s mentioned the accordion phenomenon. As we reduce social distancing restrictions and open commerce and travel, there will inevitably be more cases of COVID. It is likely that restrictions will be imposed again, and this may occur in cycles during the next year(s). We may be able to decrease future shutdowns by wearing masks and gloves when we go out, using hand sanitizer, soap and water, not touching our face, covering our coughs and sneezes, and limiting exposure to large groups of people. I hope all these will be permanent behavior changes except the masks and the large groups (I love the Lake Dillon Amphitheater and the BBQ challenge).

Take care, stay engaged, and have another safe week!

Gone, Gaper, Gone:COVID-19 April 3, 2020

April 1 is traditionally celebrated in Colorado’s mountain resort communities as “Gaper Day.” Locals dress in their finest 70’s and 80’s outdoor fashions and commemorate the tourists who stop in the middle of the mountain to stare at the beauty that surrounds us. This year travel is discouraged, so the tourists are gone. Here are some local updates on the pandemic to reinforce these directives from Governor Jared Polis.

One day this week, several residents were intubated and transferred to intensive care in Denver. Physicians at St. Anthony Summit Medical Center have access to an ICU and ventilators, but patients with severe respiratory symptoms and hypoxia have a better chance at lower altitude. Let’s hope the day doesn’t come when the Denver hospitals are full, leaving us no choice but to provide this care locally in our low-oxygen environment.

As of April 3, 29 people in have been hospitalized with COVID illnesses, ranging in ages from 20’s to 60’s. There have been 43 confirmed cases in Summit County, according to the Summit Daily News.   It’s here, it’s real, it’s dangerous to all.

Follow the footprints of the fox.

EVERYONE LIVING AT ALTITUDE SHOULD HAVE ACCESS TO A PULSE OXIMETER. You can buy this simple instrument at the pharmacies or call Ebert Family Clinic. You don’t need to go to the hospital if you are breathing normally and your oxygen is above 88%. You can call your doctor or the Ebert Family Clinic for a Telehealth assessment and advice. Our nurse practitioner Tara Taylor will be available 7 days a week between 9 am and 5 pm and Dr. Chris will answer calls and texts for parents and children 24/7. We all know to keep washing our hands: the Corona virus hates soap. Don’t touch your face.

And now I’m going to endorse recommendations from New York and other hard-hit locations: wear a mask and gloves when you go shopping. A bandana, ski mask, surgical mask, anything that reduces the spray of droplets from your mouth and the chance you will inhale these from others.  We are all wearing gloves to keep our hands warm this time of year anyways.

For your mental and physical health, get outside every day. Walk around your neighborhood. Exercise stimulates the immune system. Sunlight helps prevent depression. Look up at the mountains. Gaze at the stars. Let us all be gapers.

First tracks on the track.

Mental Health at Altitude

Last year, 20% of U.S. adults experienced a mental health disorder (CDC). Mental illness is a leading cause of disease burden worldwide, and therefore, needs to be talked about. Mental health conditions, such as depression, anxiety, bipolar disorder, eating disorders, schizophrenia, drug/alcohol abuse, etc., have devastating consequences on the individual’s quality of life and overall wellbeing. Mental illness emerges from a complex interplay of genetic, psychological, lifestyle, and environmental factors. Environmental exposure is important to consider when looking at mental health, especially at high altitude. Up in the mountains, we must consider oxygen availability on the impact of our mental wellbeing. 

Numerous studies have shown rates of depression and suicide to be higher at high elevations (Figures 1 & 2), even when controlling for other variables such as socioeconomic status and demographics (Kim et al., 2014).

Why is this?

Some researchers propose that low blood oxygen levels from lower atmospheric pressure at altitude (called hypobaric hypoxia) has something to do with it. Animal studies done on rats and short term human studies have found this connection (Kanekar, 2015), and altering brain bioenergetics and serotonin metabolism could have something to do with it. Both pathways are affected by depression, and both are affected by hypoxia (Hwang, 2019). Hypoxia may lead to suppressed mitochondrial functioning, resulting in a change of how our cerebrum uses its energy. Patients with depression have a harder time using energy in their pre-frontal cortex, which makes it harder to concentrate and fight off negative thoughts. If this is already the case at low altitude, being at higher altitude may make moods more unstable and focus even harder to obtain. 

Second, hypoxia may lead to decreased serotonin levels in the brain, which is a very important neurotransmitter targeted in the treatment of anxiety and depression. These medications, known as SSRIs (selective serotonin reuptake inhibitors) allow more serotonin to hang around in the brain. If normal antidepressants are less effective at elevation, we need to take another look at the current treatment plan. Researchers are looking into a medication that is a precursor to serotonin that bypasses the oxygen-dependent phase of the reaction. It is called 5-hydroxytryptophan. Creatine monohydrate may also be effective in treating depression at altitude (Ramseth, 2019). This is an exciting opportunity in mental health at altitude research; one that may yield more effective treatment for people living in the mountains.

However, we cannot be certain that high altitude is causing the increased rates of depression and suicide (Reno, 2018). After all, correlation does not equal causation. There are multiple confounding variables at play, such as population density, characteristics of suicide victims, access to health care, religious beliefs, and ownership and access to firearms. Even though we do not know the cause, the correlation is clear. Because of this, clinical professionals at high altitudes need to be vigilant when exploring this concern with patients. 

Looking at the flip side, multiple studies support positive effects of altitude on mental health. It is well known that physical activity is good for your body and mind. In general, exercise improves symptoms of anxiety, depression, and panic disorder, in addition to increasing quality of life and resilience (Hufner, 2018). An interesting report found that physical activity in the mountains has even more benefits on mental health than exercise at sea level (Ower et al., 2018). This was found to be because building a personal bond to an individual mountain enhances the positive effect of the outdoors on mental health. Think about that the next time you look up at a mountain you once stood on top of. In addition, a mountain hiking program in the Alps has been shown to improve hopelessness, depression, and suicidal ideation when added on to usual care in patients who were at high risk for suicide (Sturm et al., 2012). Programs like these utilize high altitude in a positive way to treat mental health conditions.

Overall, mental health at high altitude is a complex topic that needs more research. The most important thing we must all remember is to seek help when we need it, and to never feel ashamed if you are struggling with a mental health concern. Remember: You are doing your best. 

If you or a loved one are in a crisis but don’t know where to turn, consider calling Colorado Crisis Service toll-free at 1-844-493-TALK (8255) or text TALK to 38255 to speak to a trained professional.

If you are interested in hearing more about this topic, here is an interview with reporter Rae Ellen Bichelle on NPR news discussing mental health at altitude:

https://www.npr.org/player/embed/752292543/752292544

Maggie Schauer is a 2nd year PA student studying at Des Moines University. She is from Pewaukee, WI and obtained her bachelor’s degree in psychology at UW-La Crosse. After completing her pediatrics rotation at Ebert Family Clinic, Maggie will be going around the Midwest until her final international medicine rotation in Belize! She loves cheese, the Packers, hiking, running, waterskiing, and almost anything outdoors. Her current plan is to become a physician assistant in psychiatry and live somewhere exciting (like the mountains), until eventually moving back to Wisconsin. Her dream is to hike every 14er in Colorado; she currently has two under her belt: Grays and Torreys.

References:

  1. Ha, H., & Tu, W. (2018). An Ecological Study on the Spatially Varying Relationship between County-Level Suicide Rates and Altitude in the United States. International journal of environmental research and public health, 15(4), 671. 
  2. Hufner, K., Sperner-Unterweger, B., & Brugger, H. (2019). Going to Altitude with a Preexisting Psychiatric Condition. High Altitude Medicine & Biology, 20(3).
  3. Hwang, J., DeLisi, L. E., Öngür, D., Riley, C., Zuo, C., Shi, X. , Sung, Y. , Kondo, D. , Kim, T. , Villafuerte, R. , Smedberg, D. , Yurgelun‐Todd, D. and Renshaw, P. F. (2019), Cerebral bioenergetic differences measured by phosphorus‐31 magnetic resonance spectroscopy between bipolar disorder and healthy subjects living in two different regions suggesting possible effects of altitude. Psychiatry Clin. Neurosci., 73: 581-589.
  4. Kanekar, S., Bogdanova, O., Olson, P., Sung, Y., D’Anci, K. Renshaw, K. (2015). Hypobaric Hypoxia Induces Depression-like Behavior in Female Sprague-Dawley Rats, but not in Males. High Altitude Medicine & Biology; 16 (1)
  5. Kim, J., Choi, N., Lee, Y. J., An, H., Kim, N., Yoon, H. K., & Lee, H. J. (2014). High altitude remains associated with elevated suicide rates after adjusting for socioeconomic status: a study from South Korea. Psychiatry investigation, 11(4), 492–494.
  6. Ramseth, L. (2018, July 1). University of Utah research shows high altitude linked to depression and suicidal thoughts. In The Salt Lake Tribune. Retrieved October 17, 2019.
  7. Reno, Elaine, et al. (2018). Suicide and High Altitude: An Integrative Review. High Altitude Medicine & Biology, 19(2).