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The Highly Contagious Delta Variant Is On The Rise In the U.S.

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In the U.K. the Delta variant, or B.1.617.2, is now the dominant strain of SARS-CoV-2 and is causing surges of COVID-19 in parts of the country. Mark Kerrison/Getty Images hide caption

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Mark Kerrison/Getty Images

The Delta variant, which was first detected in India, now accounts for more than 6% of all infections in the United States, according to the Centers for Disease Control and Prevention. And this highly transmissible variant may be responsible for more than 18% of cases in some Western states.

The variant, also known as B.1.617.2, is spreading rapidly in the U.K., and has quickly become the dominant strain there, responsible for more than 60% of infections and causing surges in some parts of England.

“We cannot let that happen in the United States,” says Dr. Anthony Fauci.

Speaking at a White House COVID briefing Tuesday, Fauci warned that the Delta variant may be associated with more severe disease and a higher risk of hospitalization.

The good news is the vaccines look like they can protect people against the Delta variant. A new study from Public Health England showed two doses of the Pfizer-BioNTech vaccine were 88% effective against symptomatic disease from the Delta variant compared to 93% effectiveness against the Alpha variant, the variant first detected in the U.K. Effectiveness declined to 33% after just one dose.

Fauci urged everyone who has received the first dose of the Pfizer or Moderna vaccines to make sure to sign up for a second. “And for those who have still not been vaccinated yet, please get vaccinated,” he said.

He says vaccination is the best way to protect yourself and to stop this variant from spreading and becoming dominant in the U.S.

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Source: https://www.npr.org/sections/coronavirus-live-updates/2021/06/08/1004597294/the-highly-contagious-delta-variant-of-covid-is-on-the-rise-in-the-u-s

Covid19

A COVID Outbreak At The U.S. Embassy In Kabul Has Sickened 114 People And Killed 1

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A general view of the U.S. Embassy in Kabul, Afghanistan in 2013. The embassy is facing a coronavirus outbreak, according to the State Department. Ahmad Nazar/AP hide caption

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Ahmad Nazar/AP

The U.S. Embassy in Kabul says it is suffering from a major COVID-19 outbreak that has largely confined staff to their quarters and is disrupting many of its operations. Earlier this week, the embassy announced that it was suspending in-person visa interviews for Afghans who had worked for the U.S. military.

In a note sent to staff, seen by NPR, the embassy says 114 people “have COVID and are in isolation; one has died, and several have been medevaced.” The note goes on to say that military hospital ICU resources are at full capacity and that the embassy has been forced to “create temporary, on-compound COVID-19 wards to care for oxygen-dependent patients.” Most of the cases involve individuals who are unvaccinated or not fully vaccinated.

“We are saddened by the deaths of many valiant Afghans, who have been sickened by this pandemic and we in fact grieve the passing of an embassy local staff member,” said Ned Price, the State Department’s spokesperson.

The embassy requests staff to get vaccinated, stay six feet from others, suspends the use of pools and gyms, and demands strict mask compliance from staff. “Wear your masks, correctly! We are seeing a lot of noses.”

Failure to comply could see staff on the next flight home. The embassy asks them to make sure others are following protocols and to report those who aren’t.

Eric Rubin, who heads the American Foreign Service Association — the State Department’s union — says he’s hearing from members, who are “very concerned that their safety has been endangered by fellow employees, who have chosen not to be vaccinated.”

“Our understanding is that there is enough vaccine at every embassy and consulate in the world for anyone, who wants to get it,” Rubin told NPR.

The State Department does not disclose how many people are at the embassy, but it is one of the U.S.’ largest. The embassy reportedly faced a smaller coronavirus outbreak in June 2020.

The State Department and the embassy in Kabul did add some staff in recent months to handle a surge in visa applications for Afghan interpreters who worked with the U.S.

As the U.S. military pulls out – and is expected to fully do so by July, with a symbolic end date of Sept 11 – many of those who helped U.S. forces over the past two decades believe their lives are in danger, with the Taliban controlling greater swaths of the country.

Testifying before a congressional committee recently, Secretary of State Antony Blinken said there are currently 18,000 Afghans who have expressed interest in moving to the U.S. and about half were in the early stages of their application process.

Trying to reassure Congress, he added that while the military was leaving, the embassy would continue with its job and was focused on getting those who helped the U.S. out: “We’re not withdrawing. We’re staying. The embassy staying. Our programs are staying. We’re working to make sure that other partners stay. We’re building all of that up.”

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Source: https://www.npr.org/2021/06/17/1007625010/a-covid-outbreak-at-the-u-s-embassy-in-kabul-has-sickened-114-people-and-killed-

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Dr. Fauci Says The Risks From The Delta Variant Underscore The Importance Of Vaccines

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In this March 18, 2021 file photo, Dr. Anthony Fauci testifies during a Senate Health, Education, Labor and Pensions Committee hearing. Susan Walsh/AP hide caption

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Susan Walsh/AP

The Centers for Disease Control and Prevention has declared that the variant of coronavirus first detected in India is a variant of concern, meaning it poses a significant threat to those who are not vaccinated.

The Delta variant, also known as B.1.617.2, is the most contagious yet. The CDC estimates that it may be responsible for nearly 10% of all new COVID-19 infections in the United States. In some Western U.S. states, the variant may be responsible for nearly 20% of cases.

That risk has public health officials stressing the benefits of vaccines, which have been shown to be highly effective against the Delta variant. In one recent study, researchers in the U.K. found that a two-dose regimen of the Pfizer-BioNTech vaccine was 88% effective against symptomatic disease from the Delta variant.

“If you are vaccinated, you’re going to be protected, which is another very good reason to encourage people strongly to get vaccinated,” says Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “If you are not vaccinated, you are at risk of getting infected with the virus that now spreads more rapidly and gives more serious disease.”

In an interview with NPR’s Morning Edition on Thursday, Fauci elaborated on what led the CDC to designate the Delta variant a variant of concern, what the science says so far about how long protection lasts from vaccines and whether he’s worried about a new surge.

Here are highlights of the conversation, edited in parts for clarity and length.


Interview Highlights

On what prompted the CDC to elevate the Delta variant to a new level of concern

Some studies have recently come out essentially documenting that indeed, this particular variant does transmit significantly more readily between people and among people than the virus that is now the dominant virus, which is the Alpha variant, which is the one that’s more dominant in the United States. In addition, a very recent data — literally yesterday and the day before — shows that, in fact, it is a more dangerous virus in the sense that it can potentially make people more severely ill. So the combination of more transmissibility and a greater severity of disease appropriately prompted the CDC to elevate it to a variant of concern.

On his concerns that the variant could make people more sick as COVID-19 restrictions are lifted nationwide

I’m not concerned about the people who are vaccinated because the good news about all this among the seriousness of the situation with regard to the variant is that the vaccines work really quite well. A recent study came out showing that against any clinical disease with 617, which is the Delta variant, that the efficacy or the effectiveness is somewhere close to 90% — 88, 89, 90%. Importantly, the protection against severe disease resulting in hospitalization and death is over 90%, 93, 94%. So if you are vaccinated, you’re going to be protected, which is another very good reason to encourage people strongly to get vaccinated, because if you are not vaccinated, you are at risk of getting infected with the virus that now spreads more rapidly and gives more serious disease. The Brits are having a very difficult time with this. They have about 90 plus percent of their isolates are the Delta. As you mentioned correctly just a moment ago, about 10% of our isolates are Delta. We want to make sure we don’t get into the same situation that people in the U.K. did.

On what we know now about how long vaccine protection lasts

We don’t know for sure. We certainly know that it’s several months up to a year, because people who have been vaccinated early on, the original people who were vaccinated, seemed to continue to have protection. What we do is we monitor cohorts of people who have been in clinical trial, both for laboratory indication of durability, of protection, as well as clinical indication. For example, if we start seeing breakthrough infections, there’s a thing called correlate of immunity, which is a laboratory test that you could follow. And as that goes below a certain threshold, then you know you’re going to have to give someone a booster. So we’re preparing to boost people, but we don’t know at exactly what point we will have to do that. But we’re doing tests right now, clinical trials to determine various options for boosting people.

The federal government has agreed to buy 200 million more doses of the Moderna vaccine to prepare for necessity for boosters. Can you explain how that will work?

It’s going to be a combination of the need — potential need — for boosters, but also for the pediatric population, because as you know now, we’ve shown that at least with one candidate and likely more to come, that 12 to 15 year olds can be vaccinated. We are doing studies now to determine the proper dosage and the proper regimen for children from 12 to nine, and then nine to six and then six to two. So we have the, I wouldn’t say challenge, but at least facing ahead for the likelihood — of more than just the likelihood, I’m sure we’ll be doing it — of vaccinating children as well as possibly needing to give people boosters. They’ll be a varying requirement for boosters. For example, it is likely that the elderly who have less of a powerful immune system than people who are younger, those people would likely need a booster longer than that. So we’re looking at this. Hopefully we’ll get the right answer, which I believe we will and will be prepared for it.

Right now, 51% of eligible peaceful people nationwide are fully vaccinated. But we’re seeing people traveling. Could we see another surge?

Well, not among vaccinated people. You know, we have a disparity throughout the country. Certain states have low level. They will be at risk.

The audio for this story was produced and edited by Nina Kravinsky and Jill Craig.

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Source: https://www.npr.org/sections/coronavirus-live-updates/2021/06/17/1007493934/the-delta-variant-is-the-most-contagious-of-covid-19-strains

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Covid19

What Does the Future of the Mental Health Pandemic Hold?

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Health experts across the country agree: we are in the midst of a mental health pandemic and have good reason to believe that this mental health crisis will lead to increased cases of depression1 throughout the year.

This debilitating illness currently impacts more than 17.3 million American adults, with research2 showing rates have tripled as a result of the COVID-19 pandemic. Unfortunately, many sufferers — an astounding 6.2 million3 — do not find relief using antidepressant medications. Depression treatments are simply not one-size-fits-all. As we rebound from the COVID-19 pandemic, it is more critical than ever for clinicians to take a hard look at our patients and their needs to ensure we are exploring all available options as early as we can, to give them the best chance of relief — and potential remission — from this disease that plagues too many.

The Two Health Crises


Continue Reading

Because the physical toll of COVID-19 is very visible, the mental health ramifications were often overlooked and not prioritized early on when fear of contracting the virus permeated every element of life. As businesses closed, schools turned virtual and quarantine orders extended, the impact of the pandemic snowballed. Young adults saw major milestone events, such as graduations or proms, cancelled and 46 percent of parents4 said their teen showed signs of worsening mental health. Parents were forced to juggle their careers and childcare, causing an increase in depression, stress, and loneliness.5 Job loss also contributed to an increase in rates of depression or anxiety1 at 53.4 percent. 

Unfortunately, depression and anxiety are not the only lingering effects. We’ve seen patients who have relapsed, leaning back on substance use in an effort to alleviate the feelings of hopelessness that the uncertainty of the pandemic has brought on. In fact, recent statistics show 13 percent of adults6 have turned to substances over the last year to help themselves cope. 

What Happens Next?

Now that vaccines are rolling out and people are slowly resuming a bit of normalcy, many will likely start to feel better, but for others, the battle with mental health will continue. This pandemic has impacted us all, but our frontline workers, especially those in health care, have been the ones to experience unprecedented stress. As a result, I expect to see an increase in post-traumatic stress symptoms7 in frontline employees and long-term effects on their overall mental health.

Shifting back to pre-pandemic lifestyles without the opportunity to properly process what has happened over the last 15 months and the grief and pain associated with it can be dangerous. As depression rates rise, so too will the demand for treatment, ultimately resulting in a shortage of mental health professionals equipped to support those suffering. In my region, patient volume has exponentially increased. We are lucky to have been able to rely on telehealth technology that became popular last year to help keep us connected and providing that critical care.

Aaron M. Hawkins, MD, The Hawkins Group

As shelter in place orders began and people found themselves confined to their homes, many mental health professionals stayed open for in-person care. Clinicians in underserved areas began scheduling virtual appointments to reach patients who would not have otherwise been able to receive in-person care — and the use of telemedicine skyrocketed8 as a result.

Thanks to its benefits and convenience, this newer technology has become a more widely accepted method of care amongst my patients who understand the importance of seeking help but do not yet feel comfortable returning to in-person treatment. Since an increasing number of practices are safely seeing patients in-person, I do predict a majority of patients will return to in-person care in the coming months, and telemedicine is a great alternative in the meantime. I also believe the reliance on telemedicine for behavioral health care will outlast the pandemic, especially for those in less populated areas and with remote working expected to continue. 

A Rise in Alternative Treatment Options

While it does appear we are nearing the end of the COVID-19 pandemic, people are still struggling with mental health illnesses and searching for new treatment options. Because statistics  show medication therapy does not work for all depressed patients — in fact, research indicates9 the likelihood of remission drops in depressed patients who do not benefit from multiple antidepressant medication attempts — one of my top recommendations for adult patients struggling with depression who don’t benefit from antidepressants is TMS therapy. TMS therapy, or transcranial magnetic stimulation, is a non-drug, non-invasive treatment that uses magnetic pulses to stimulate areas of the brain that are underactive in depression. Of my patients who have been treated with NeuroStar Advanced Therapy since the opening of my practice in early 2020, we have seen a 70 percent response rate and more than a 50 percent remission rate. And this is only the beginning. It is important that both clinicians and patients alike are aware of this technology. Hope is not lost when drugs fail.

While the first TMS device received FDA approval back in 2008, it still seems to be a relatively unknown treatment option to patients and sometimes even clinicians. I’ve heard colleagues say they learned about electroconvulsive therapy in residency, but not TMS therapy — which means there is an opportunity to enhance our conversations about alternative treatments for depression. At my practice, we’ve recognized this critical need for education and have launched a campaign designed to raise awareness about TMS therapy among fellow health care professionals, resulting in interest from local universities who want information to help educate their students.

Given the growing prevalence of depression within the US, and the probability that cases will significantly increase, physicians would be wise to help mitigate the damage by making patients aware of non-drug treatment options, like TMS, as early on in their treatment journeys as possible. TMS is safe, effective and readily available. It is covered by most major insurers, free of the side effects often associated with antidepressants, and patients can drive themselves home after treatment.

We all agree that the “end” of the COVID-19 pandemic does not mean a magical and seamless switch back to pre-pandemic life. That transition will be a slow one as the impact of the past 15 months may be long-lasting, particularly for those who have felt an incredible weight on their mental health. The good news is that there is hope with TMS therapy. Remission from depression is possible when we look outside of antidepressants and think differently about how we approach mental health wellness.

References

  1. Panchal N, Kamal R, Cox C, Garfield R. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. Published February 10, 2021. Accessed May 17, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
  2. Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galeo S. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Network Open. Published September 2, 2020. doi:10.1001/jamanetworkopen.2020.19686
  3. Major Depression. National Institute of Mental Health. Updated February 2019. Accessed May 17, 2021. https://www.nimh.nih.gov/health/statistics/major-depression
  4. Mott Poll Report / How the pandemic has impacted teen mental health. C.S Mott Children’s Hospital. Published online March 15, 2021. Accessed May 17, 2021. https://mottpoll.org/reports/how-pandemic-has-impacted-teen-mental-health  
  5. Bargeron E. Survey shows single-parent households with young children bear the brunt of COVID-related stress. Georgetown University Health Policy Institute Center for Children and Families. Published online January 7, 2021. Accessed May 17, 2021. https://ccf.georgetown.edu/2021/01/07/survey-shows-single-parent-households-with-young-children-bear-the-brunt-of-covid-related-stress/
  6. Czeisler, MĖ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Centers for Disease Control and Prevention. Published online August 14, 2021. Accessed May 17, 2021. https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm
  7. Benfante A, Di Tella M, Romeo A, Castelli L. Traumatic stress in healthcare workers during COVID-19 pandemic: a review of the immediate impact. Front Psychol. Published online October 23, 2020. doi:10.3389/fpsyg.2020.569935
  8. Mochari-Greenberger H, Pande RL. Behavioral health in America during the COVID-19 pandemic: meeting increased needs through access to high quality virtual care. Am J Health Promot. Published February 8, 2021. doi.org:10.1177/0890117120983982d
  9. Haddad PM, Talbot PS, Anderson IM, McAllister-Williams RH. Managing inadequate antidepressant response in depressive illness. Br Med Bull. Published online August 26, 2015. doi:10.1093/bmb/ldv034

This article originally appeared on Psychiatry Advisor

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Source: https://www.medicalbag.com/home/news/the-covid-and-mental-health-pandemic-will-lead-to-increased-cases-of-depression-throughout-the-year/

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Covid19

What Does the Future of the Mental Health Pandemic Hold?

Published

on

Health experts across the country agree: we are in the midst of a mental health pandemic and have good reason to believe that this mental health crisis will lead to increased cases of depression1 throughout the year.

This debilitating illness currently impacts more than 17.3 million American adults, with research2 showing rates have tripled as a result of the COVID-19 pandemic. Unfortunately, many sufferers — an astounding 6.2 million3 — do not find relief using antidepressant medications. Depression treatments are simply not one-size-fits-all. As we rebound from the COVID-19 pandemic, it is more critical than ever for clinicians to take a hard look at our patients and their needs to ensure we are exploring all available options as early as we can, to give them the best chance of relief — and potential remission — from this disease that plagues too many.

The Two Health Crises


Continue Reading

Because the physical toll of COVID-19 is very visible, the mental health ramifications were often overlooked and not prioritized early on when fear of contracting the virus permeated every element of life. As businesses closed, schools turned virtual and quarantine orders extended, the impact of the pandemic snowballed. Young adults saw major milestone events, such as graduations or proms, cancelled and 46 percent of parents4 said their teen showed signs of worsening mental health. Parents were forced to juggle their careers and childcare, causing an increase in depression, stress, and loneliness.5 Job loss also contributed to an increase in rates of depression or anxiety1 at 53.4 percent. 

Unfortunately, depression and anxiety are not the only lingering effects. We’ve seen patients who have relapsed, leaning back on substance use in an effort to alleviate the feelings of hopelessness that the uncertainty of the pandemic has brought on. In fact, recent statistics show 13 percent of adults6 have turned to substances over the last year to help themselves cope. 

What Happens Next?

Now that vaccines are rolling out and people are slowly resuming a bit of normalcy, many will likely start to feel better, but for others, the battle with mental health will continue. This pandemic has impacted us all, but our frontline workers, especially those in health care, have been the ones to experience unprecedented stress. As a result, I expect to see an increase in post-traumatic stress symptoms7 in frontline employees and long-term effects on their overall mental health.

Shifting back to pre-pandemic lifestyles without the opportunity to properly process what has happened over the last 15 months and the grief and pain associated with it can be dangerous. As depression rates rise, so too will the demand for treatment, ultimately resulting in a shortage of mental health professionals equipped to support those suffering. In my region, patient volume has exponentially increased. We are lucky to have been able to rely on telehealth technology that became popular last year to help keep us connected and providing that critical care.

Aaron M. Hawkins, MD, The Hawkins Group

As shelter in place orders began and people found themselves confined to their homes, many mental health professionals stayed open for in-person care. Clinicians in underserved areas began scheduling virtual appointments to reach patients who would not have otherwise been able to receive in-person care — and the use of telemedicine skyrocketed8 as a result.

Thanks to its benefits and convenience, this newer technology has become a more widely accepted method of care amongst my patients who understand the importance of seeking help but do not yet feel comfortable returning to in-person treatment. Since an increasing number of practices are safely seeing patients in-person, I do predict a majority of patients will return to in-person care in the coming months, and telemedicine is a great alternative in the meantime. I also believe the reliance on telemedicine for behavioral health care will outlast the pandemic, especially for those in less populated areas and with remote working expected to continue. 

A Rise in Alternative Treatment Options

While it does appear we are nearing the end of the COVID-19 pandemic, people are still struggling with mental health illnesses and searching for new treatment options. Because statistics  show medication therapy does not work for all depressed patients — in fact, research indicates9 the likelihood of remission drops in depressed patients who do not benefit from multiple antidepressant medication attempts — one of my top recommendations for adult patients struggling with depression who don’t benefit from antidepressants is TMS therapy. TMS therapy, or transcranial magnetic stimulation, is a non-drug, non-invasive treatment that uses magnetic pulses to stimulate areas of the brain that are underactive in depression. Of my patients who have been treated with NeuroStar Advanced Therapy since the opening of my practice in early 2020, we have seen a 70 percent response rate and more than a 50 percent remission rate. And this is only the beginning. It is important that both clinicians and patients alike are aware of this technology. Hope is not lost when drugs fail.

While the first TMS device received FDA approval back in 2008, it still seems to be a relatively unknown treatment option to patients and sometimes even clinicians. I’ve heard colleagues say they learned about electroconvulsive therapy in residency, but not TMS therapy — which means there is an opportunity to enhance our conversations about alternative treatments for depression. At my practice, we’ve recognized this critical need for education and have launched a campaign designed to raise awareness about TMS therapy among fellow health care professionals, resulting in interest from local universities who want information to help educate their students.

Given the growing prevalence of depression within the US, and the probability that cases will significantly increase, physicians would be wise to help mitigate the damage by making patients aware of non-drug treatment options, like TMS, as early on in their treatment journeys as possible. TMS is safe, effective and readily available. It is covered by most major insurers, free of the side effects often associated with antidepressants, and patients can drive themselves home after treatment.

We all agree that the “end” of the COVID-19 pandemic does not mean a magical and seamless switch back to pre-pandemic life. That transition will be a slow one as the impact of the past 15 months may be long-lasting, particularly for those who have felt an incredible weight on their mental health. The good news is that there is hope with TMS therapy. Remission from depression is possible when we look outside of antidepressants and think differently about how we approach mental health wellness.

References

  1. Panchal N, Kamal R, Cox C, Garfield R. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. Published February 10, 2021. Accessed May 17, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
  2. Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galeo S. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Network Open. Published September 2, 2020. doi:10.1001/jamanetworkopen.2020.19686
  3. Major Depression. National Institute of Mental Health. Updated February 2019. Accessed May 17, 2021. https://www.nimh.nih.gov/health/statistics/major-depression
  4. Mott Poll Report / How the pandemic has impacted teen mental health. C.S Mott Children’s Hospital. Published online March 15, 2021. Accessed May 17, 2021. https://mottpoll.org/reports/how-pandemic-has-impacted-teen-mental-health  
  5. Bargeron E. Survey shows single-parent households with young children bear the brunt of COVID-related stress. Georgetown University Health Policy Institute Center for Children and Families. Published online January 7, 2021. Accessed May 17, 2021. https://ccf.georgetown.edu/2021/01/07/survey-shows-single-parent-households-with-young-children-bear-the-brunt-of-covid-related-stress/
  6. Czeisler, MĖ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Centers for Disease Control and Prevention. Published online August 14, 2021. Accessed May 17, 2021. https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm
  7. Benfante A, Di Tella M, Romeo A, Castelli L. Traumatic stress in healthcare workers during COVID-19 pandemic: a review of the immediate impact. Front Psychol. Published online October 23, 2020. doi:10.3389/fpsyg.2020.569935
  8. Mochari-Greenberger H, Pande RL. Behavioral health in America during the COVID-19 pandemic: meeting increased needs through access to high quality virtual care. Am J Health Promot. Published February 8, 2021. doi.org:10.1177/0890117120983982d
  9. Haddad PM, Talbot PS, Anderson IM, McAllister-Williams RH. Managing inadequate antidepressant response in depressive illness. Br Med Bull. Published online August 26, 2015. doi:10.1093/bmb/ldv034

This article originally appeared on Psychiatry Advisor

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Source: https://www.medicalbag.com/home/news/the-covid-and-mental-health-pandemic-will-lead-to-increased-cases-of-depression-throughout-the-year/

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