 Hello, everyone. My name is Haris Lizidakis. I am the Chief Executive Officer of Designate of the World Organization of Family Doctors, WONCA, and I would like to welcome all in this second webinar on mental health and COVID-19. Before we start, I would like just to remind everyone how you can interact with our panelists today. For those of you who are logged in on the Zoom room, you will see that you have two buttons on the bottom of your screen. The first one is called chat, and here you can chat with each other and with our panelists. Then there is another button that is called Q&A, and this will open a window from which you can write a question, and this will be addressed. We will try our best to address this question. As you can imagine, there are two different channels to convey questions. Our panel, and the time is quite limited, so our panelists will do their best to speak those questions that are the most relevant for all the audience. You can also comment on our live stream on Facebook, and please note that we will be posting also the video on our YouTube channel. Now, without further ado, I would like to introduce to you the Chief Executive Officer of WONCA, Dr. Garth Manning. Thank you very much, Harris. Welcome, everybody, to the second in a series of WONCA webinars. You are all most welcome. Today, the topic is mental health, which is especially important given the stressors impacting on everyone at this difficult time. We are going to hear a number of presentations from WONCA luminaries, Professor Chris Derrick, who is chair of our working party on mental health, along with colleagues Sandra Fortes and Christos Leonis, and we're especially pleased to welcome a colleague from WHO, Dr. Fami Hannah, who will provide an overview of WHO's role in supporting mental health and the psychosocial aspects of COVID-19. Fami's coordinating intraagency response in this area. But before handing over to Chris, I'd first like to hand over to our WONCA President, Dr. Donald Lee, for his opening remarks. Donald. Good morning, good afternoon, good evening, and welcome to the second WONCA webinar. Family doctors around the world have risen to the challenge of this awful pandemic, working with our public health colleagues, as well as our specialist colleagues. In the midst of the massively increased workload for family doctors, I'm proud of the level of the work that we have done in WONCA. I'm proud of the level of support and collegiality displayed within and across our member organizations and from region to region. Next please. Colleagues are disseminating scientific advice, clinical updates, reflective messages, and professional support through their social media links and connections. They are keeping in touch with each other regularly, like family members, relaying information, urging courage in these extraordinary times. Tonight, our working group on mental health led by chair Christopher Dawg will, with contributions from WHO colleagues, will consider how COVID-19 affects everyone's well-being, how patients with preexisting mental illnesses are at particular risk, and how we family doctors can safeguard the mental health of our patients and ourselves. Family doctors are in the best position to take care of our patients with mental problems, as our close relation with them ensure continuity and avoids stigmatism. So with this, I'll hand back to Garth, who will introduce Chris. Okay. Thanks, Donald. Harris has described to you all how the audience can interact through Q&A and through chat, and later on we'll put some of the questions to the panel for comment. The Q&A and chat is being overseen by our President, Elect Anna Stavdahl, ably assisted on Zoom by Jina Nusta and King Griswold, and on Facebook by Sonya Tsukagoshi. I'm delighted now to hand over to Professor Chris Dyerick, chair of the working party on mental health and Professor of primary medical care at the University of Liverpool in the UK. So over to you, Chris. Thank you very much, Garth, and thank you for those introductions. So yes, so today we are thinking about COVID-19 and mental health problems. This is in the context of what I think we're all experiencing, a sort of general sense of stress and fear and anxiety, perhaps a sense of grief sometimes for a lost way of life, and we don't know how long that loss is going to go on for. I'll just look at this slide in a moment, but the general themes that we're going to look at are the symptoms the symptoms that patients are having in a context where there's less social support than usual, and the role of family doctors in helping those patients in these very troubling times, and also very importantly, thinking about ourselves and our own mental health and how we protect that. So I'm going to talk a bit on this slide, and I'm going to introduce some of my patients that I've been, I'm working with at the moment who are affected in some of these different ways. I'll also talk a bit about my own mental health, and then as we've heard, the family is going to talk about the WHO perspectives, and then Sandra from Brazil will be talking about fear and how we manage it. Christos from Greece will be talking about compassion, and they've all done their presentations. I will come back again for a few minutes to talk about how all these things are helping my patients and me personally. So this particular slide that we have here is a very brief summary. Farmy will go into this in a bit more in his presentation. A very brief summary about how COVID-19 interacts with mental health. The first thing to say is we have to think about the direct effects of the infection. There can be very specific effects in terms of delirium, in terms of people presenting in acute confusional states, but also people are recovering a sense of post-biral fatigue. So one patient, a 64-year-old woman that I was talking with on Friday, she's had COVID symptoms, she's getting over them, but she is absolutely exhausted. And she tends to get depressed, she's quite down at the moment, and what she was telling me is that her usual coping mechanisms, she just hasn't got the strength of mind, she hasn't got the resilience to deal with those at the moment. So because of the post-biral fatigue, her depression is actually much worse than it would normally be. And then health workers, so the frontline health workers who are working in intensive care are under particular stress and are quite likely to develop post-traumatic stress disorder as a result of the things they're seeing. Another patient I was speaking with earlier this week, she's a nurse in our local hospital. She herself has been transferred to the intensive care unit, she doesn't usually work there, so she's finding that difficult to cope with. On top of that, her uncle has COVID symptoms and is really very unwell at the moment, so she's got a major anxiety about that. She's not at all sure that she can cope with being in work, but then on top of that she's feeling incredibly guilty because she thinks she ought to be in work but she doesn't know whether she can or not. So there's a whole complicated set of responses there. And then another health worker is myself. I'm not working directly there, but I'm working regularly in my practice doing remote consultations with patients. My own mental health is not as good as it usually is. I'm aware I'm much more anxious and more stressed than usual. I'm not sleeping as well as I usually do, and that's partly because I'm worried about my family, whether I'm going to infect them by going to work, but it's also because I'm increasingly worried about the patients that I'm talking with and the fact that their mental health is deteriorating or their physical health is not as good. And because everything is in lockdown, we're not able to refer them to counselling, to refer them to specialists and whatever. So there's a whole set of layers of stress and anxiety that are affecting me and I'm sure other family doctors. And then if we think about patients if we think about the impact of the sensible things that governments are doing, particularly quarantine and social distancing, there are obviously benefits of that, but there are also problems associated. A lot of people feeling isolated, a lot of people feeling lonely, and people losing access to the mental health support that they would normally have, whether that's informal support from family and friends, or whether that's formal mental health care, like being able to come and have a consultation with a family doctor or to see a counsellor or a psychologist, those things are just much more difficult. And then on top of that, we're beginning to see and this is going to go on for quite a long time, the effects of the economic downturn in every country. This is happening and will happen, which is going to lead to high levels of poverty, high levels of unemployment and homelessness. And any one of those things, but all of those things in combination are increasing and will increase cases of anxiety and depression. It's going to increase self-harm. It's going to increase people's attempts at suicide, some of which sadly will be successful. It's going to increase alcohol use, substance misuse and gambling. And then a particular thing which will be discussed in a session in a couple of weeks time, because people are locked up at home together, there is going to be more domestic abuse into partner violence and sadly more child abuse. The last thing I want to say before I hand back to Garthy is to tell you about a particular patient of mine who I'm calling Rosie. I've been in contact with her a lot in the last few weeks. She's 28 and she has a long history of mental health problems. As a child, she's suffered from a lot of adverse experiences. I won't go into detail on those. As a teenager, she frequently self-harmed and she was using a lot of drugs, not prescribed drugs. Things calmed down a bit in her early 20s. She's got a partner, she's got a job in a bank and she's got a dog and she's got a nice house and for the last year or so she's been managing quite well with a low dose of antidepressant and with occasional counselling. Covid has just knocked her for six. It's really disrupted all of her good ways of being. She wanted to work from home from the bank but the bank said she couldn't do that and she's been dealing with very sensitive material. Her usual social support, which is very good for a mental health, has all stopped because she can't go out and visit people. She's been surfing the web as many people do and she's picked up some quite serious misinformation, some false information from Facebook, which is telling her that you can get Covid just from the atmosphere, just from the air and just from the air. When I first spoke to her three weeks ago now, she was incredibly anxious. She wasn't sleeping properly and she was feeling very suicidal. I'm going to talk a bit more about her at the end but I just want to put that there as a case, which I'm sure family doctors and other people around the world will resonate with people. They're talking to people like that. I want to leave Rosie there and I'm going to come back to her when my colleagues have finished talking and tell you the things that I've been doing to try and help her and also the things that I've been doing to try and help myself. That's me for now. Hand back to Garth. Thank you very much Chris and thanks for setting the scene for some interesting clinical vignettes. I'm certainly interested in hearing more about Rosie later on. Next we welcome Dr Fami Hanna, technical officer within WHO's Department of Mental Health and Substance Abuse. So Fami, I'll hand over to you and hopefully you're unmuted. Thank you. Thank you Garth. I'm unmuted now and I would like to start by thanking Dr Chris Dorek and Natalie and all WUNCA colleagues for this opportunity to share with you an overview on WHO contribution to mental health and psychosocial support aspects related to COVID-19. Next slide please. COVID-19 as rightly noted by Chris is not only a threat to physical health, it is also a threat to mental health. An anxiety, panic, feeling of helplessness, helplessness and uncertainty about the future is very common among population in all countries affected all around the world. People who test positive for COVID-19 has to deal with the anxiety of having a condition, the anxiety of the need to leave loved ones. They worry about their own jobs. Many people, not only people who test positive for COVID-19 also worry about their livelihoods, unemployment, homelessness and we know that adversity is also a risk factor for mental health conditions. People who are pre-existing mental health conditions are particularly a risk group here. Stressors can exacerbate symptoms of mental health conditions or lead to new conditions so people who used to get access to service might not be able to get access to the same services now. Next please. One of the uniqueness of this emergency is that older adults is a particularly vulnerable group here. There are other groups who are also vulnerable and as you can see here in the slide there are a number of these groups and I'm going to speak also particularly of another group who are people who are in long-term mental health facilities. For this population being isolated from social connection is a danger also to their mental health condition because social connectedness is indeed part of the therapy. This group will suffer from stigma of having COVID-19 if they get infected and stigma of having mental health condition. These groups in general in different humanitarian emergencies are among the groups that we see neglected in these facilities. So particularly in this emergency this group is another most vulnerable group and we hear reports about large number of mortalities in long-term mental health facilities. They say homes for older adults. So not only psychiatric institution but also long-term facilities for elderly care. Next please. And as you all know front-line responders, health workers is another particularly vulnerable group. They work extra amount of hour. They suffer from stigma of being in contact to health facilities and not always they get the ability to access mental health and psychosocial support or stuff or stuff care which this group particularly may find even more stigmatizing. So we hear unfortunately reports from different countries of suicide attempts of health care workers on the front-line of COVID-19 response. Next please. In humanitarian emergencies even before COVID-19 in conflict settings one in five people would be having a mental health condition either depression and anxiety, post-traumatic stress disorder schizophrenia or bipolar. COVID-19 stressors might exacerbate those who already have mental health conditions or lead to new group of population who would have more mental health conditions. The humanitarian settings are the catastrophe within the emergency. If you think of a place like Yemen for example, the world's largest humanitarian crisis. In fact at the beginning of the COVID crisis I was in Yemen myself. I was deployed there for country support around one month, one month ago. So the amount of stressors by humanitarian worker and by the population is presented. Just imagine on top of this there is a stress of lockdown, of quarantine, of isolation and of a new illness with many uncertainties. Yemen before COVID-19 according to the one in five estimate would have at least 7 million people with mental health condition. Just imagine the situation with COVID-19. Next please. WTO is the inter-agency standing committee reference group on mental health and psychosocial support in emergencies. This is a unique collaboration between United Nations agencies, international NGOs and Red Cross and Red Crescent societies mental health and psychosocial focal points who are active in humanitarian emergencies. This group is very active in humanitarian emergency response. In fact this group started to have weekly call when this emergency was happening only in Wuhan, China very early in the response. And through this group guidance was developed very early in the response and I'll come later to this. But this group until now is also meeting weekly and providing support to different organization. More than 56 humanitarian organizations are member of this coordination group. WTO also is in its response as a department for mental health collaborate with the emergency program within WTO incident management program with different pillars and I'll come to this later in my presentation as well. And work at the three levels of WTO at HQ, at regions and at countries. Next please. So this is the guidance I was mentioning in the previous slide developed by the inter-agency standing committee reference group on MHPSS in emergencies. It's guidance addressing mental health and psychosocial aspect of COVID-19. This was quite influential because we developed it early in the response as I mentioned by mental health and psychosocial support professionals but then we got a request from the inter-agency secretariat which is the highest level humanitarian coordination body that this would be a document for humanitarian wide system endorsement and it was endorsed at heads of agencies level. So it was endorsed at the highest level of humanitarian coordination as a system-wide document for response operations and preparedness. It is available on the ISC website in more than 20 languages and 10 plus languages are ongoing. A document that we developed early in the response thinking about preparedness for countries such as Syria, Bangladesh, South Sudan, Yemen was found very useful and endorsed by high-income countries. Many of them you will find also their ministries of health logo on the available translated documents which show again the uniqueness of this emergency that the experience in humanitarian settings is also helping high-income countries in response. There are a number of derivative products including powerpoint slides for presentation within countries for this product and also guidance on how to integrate the program activities recommended in this document because this document provides guidance on programming for agencies. So you will find guidance on how to integrate mhps into country response plan which also is available in multiple languages. Next please. This is a unique product. We wanted to give messages for children. So we had a global survey through the wide network of agencies within the reference group and we got responses from 1,700 children and their reference from 104 countries around the world. What we did with this survey results, we didn't only develop messages but we had a professional story writer and develop a children's storybook using the findings from this survey. And this storybook we tested in more than 25 countries before dissemination to the field through storytelling to children just to see if the story and messages is working from children from different cultures. This was launched with quotes from Dr. Tedros, Director General of Deadly Show, Executive Director from UNICEF, UNESCO Director General and UNICEF R-High Commissioner and was disseminated widely through the media. CNN, Forbes, New York Times and many other media porters has been reporting about this document among many others. This is released only two weeks ago. So far I sent this slide I shared with Dr. Dorek last night. In fact, this is outdated now because it's 104 languages where this document is currently being translated which show how the field really need documents addressing these needs among children. Next please Haris. And Deadly Show have a document developed with the risk communication and community engagement pillar of the COVID-19 response. And next please. And this document was designed mainly for risk communication and community engagement messages and since social media play a key role in disseminating messages, the number of social social media cards was disseminated on Facebook and other social media platform disseminating these messages about stress coping for different target groups including health worker including also older adult parents for children and many other groups in many language. And this was the basis of the Deadly Show campaign on healthy at home available in Deadly Show website which have a mental health component. Next please. Deadly Show also launched a call for stories for healthcare workers on how they adapt their mental health services in the times of COVID-19 that will be published in collaboration with Mental Health Innovation Network. Next please. We are working also on adapting our guidance for tele-mental health and psychosocial programming including tele-counseling which will be launched in an annex to the interim briefing notes that we have released. We're developing an orientation manual which will be released as an illustrated comic book for first line responders not only health workers but law enforcement officers, grocery store worker, funeral workers and many others who are on the front line will benefit from this orientation manual and also providing guidance and continuity of care of comprehensive clinical services in humanitarian settings. Next please. The severe acute respiratory infection document from Deadly Show for treatment of COVID-19 got already in its previous iterations mental health and psychosocial components. But the next update which is currently ongoing will include also more emphasis on neurological aspects as well as psychotropic medications. This is currently under review by guideline review committee but we expect this will even be more emphasized in the next iteration of the documents. Deadly Show is also working from now on a responsive framework for the recovery phase to use this emergency as an opportunity for building back better sustainable mental healthcare systems in the recovery phase. Thank you. Very many thanks for that lovely presentation and some great resources there. So very, very interesting. Thank you again. Thank you. We will move on now to Professor Sandra Fortes of Brazil. So Sandra, if you're unmuted it's over to you. I would like to discuss a little more this other epidemic that is coming together with COVID-19. Next slide please. Which is the anxiety epidemic. All over the world as Chris people are very anxious and for them family doctors are their main source of help. They trust, they know, they rely on their family doctors. So how can we help? The first question is why people are afraid? What exactly do they fear? Next slide please. The first answer would be like of course they are afraid of dying but having worked with political care for several years I find that usually people are not afraid of death itself. Most people over the road are religious and they believe in another life but they are very much afraid of how they're going to die. People are afraid of pain, isolation, loneliness. Of course nobody wants to live life. Life is beautiful but the way you're dying is something that's very, can be very scary and COVID-19 is especially cruel in this aspect because people lose contact with loved ones when they get to be more severe. So an experience I would like to bring from Rio is that when hospitals started in Rio and it's going around other ones from the national health system to keep a cell phone sterilized and protected in plastic for isolated patients to talk with loved ones by phone and people are donating old cell phones because the main tool we have against loneliness today is communication and technology is going to help. Next slide please. And then the point is that we are in a very ambiguous situation. We fear loneliness but we also fear contamination. So patients miss their families and friends sometimes they are isolated inside the home and at the other side they are also afraid of contamination which is creating a sort of stigma that who is going to contaminate me so people that even go to supermarket get worried about going to the supermarket. And I think the point here is to increase correct information. In reality the majority of people will get mild and asymptomatic forms of the virus. So we have to be very careful to make sure it's not like a plague. It doesn't contamination doesn't mean immediately death because we also have in this humanitarian cultural aspects of plagues since the very, very old time and it's important that COVID-19 doesn't occupy this position. So once again keeping in contact even if you are distant maybe the main sentence is to stop computer and in those referring to those old people they demand a little more attention because they are not so used to media and to computers and technology but you can get them connected by telephone which is accessible to most people. The point is that fear is increased by fantasies. Our mind wanders and we worry about the future and we imagine terrible outcomes and these thoughts increase anxiety so information brought by somebody who is very well known and whom we trust and this is the position the family doctors have. They can help with changing the way people live and look at the situation and also helping them to overcome the problem of misinformation that Chris has already brought and also asking them not to stay so much connected all time because it's necessary to keep our mind under controls so the orientation for family doctors we are having is try to help people to concentrate at the present moment deal with the needs of what had to be done, try not to eliminate, limit time connected to news and especially get good quality information especially from your doctor. Also other new practices like meditating or praying or getting religious support is very useful at this moment. Next slide please. So of course the people with mental disorders they are more fragile and people with previous anxiety and depressive disorders are turning out to be worse and another point is that we have to keep on contact with the doctor that they trust and so that they won't have problems with prescription as the doctors being so overwhelmed with other problems so the personal bond and knowledge that family physicians have will help them support these patients and what we are doing in Rio and in Brazil is that intensifying collaborative care so that mental workers can help and work together with family doctors even if not presential at least by teleconsultation or something like that. Next please. So in Brazil we have another extra problem because in our culture anxiety is presented by physical symptoms so call centers professional having some difficulties because people complain of difficulties in breathing and it's difficult to find out in the first contact if it's from anxiety or COVID-19 itself so which of course demands different orientations so what we are doing is that we are supporting that differential diagnosis needed to be done not on the traditional model of including one disease but thinking about what is the more important and looking for other symptoms like fever, cough or anosmia for COVID-19 but also pressure on chest trembling being nervous which make it clear that it's anxiety. What we find out is that after talking to a family doctor or a nurse from primary care on the telephone these will clarify the doubts patients have and utilize them and help stop adequate treatment. Next please. So an important point when dealing with fear is that fear increases with lack with the feeling of lack of control and feeling that you are unable to overcome problems so this empowerment is the word we need to empower people and empower ourselves as professionals and family doctors can help a lot in that because listening to patients worries talking about them discussing solutions with them managing problems it's the way talking about any type of fear is like turning a light on in a dark room it reduces the darkness it reduces fear but first of all our we professionals should not expect ourselves to solve critical problems we are just together with them if we ask ourselves to solve their problems it will only increase our anxiety so let's just stand by people in Brazil we say that a shared sadness is half a joy so that's the point doctors and nurses from primary care especially in Brazil when the system is territorially organized we stay together. Next. Next one. So being together with the people we may and knowing their lives and knowing their family we can help them making lemonade out of lemons you know being at home is a time to learn new things new technology languages meditation and also improving things that we like doing play music cooking and so on enjoy the time at home keeping contact with people by phone or internet keeping touch with friends that you haven't seen for a long time because you didn't have the time call grandparents to chat at the phone arrange a virtual meeting with friends and family sometimes enjoy the time you're at home to do things that you have always wanted to do at home like reorganize your wardrobe you know and now you have time at home do it and you have a virtual world museums play movies next one please. The point is that we have to empower people and we have an empower people will empower us and to empower empowerment comes out of facing fear and overcoming it with contact and information as this old saying from a student asking master what if the void comes to me if the fear of illness and death comes and the master answers talk to them set the table for them to reserve a place for each of your fears invite them to dinner with you and ask them why they come so far to your home what message they want to bring to you what they want to communicate to you Sandra really nice presentation thank you so much and there's been very positive chat about it somebody described you as a very enlightened professional which I think is lovely so it obviously hits home with people thanks a lot for that okay our final presentation is from Professor Christos Leonis of Greece so Christos over to you remember to unmute yourself thanks I feel very privileged being a modern panelist and that's next Mr. Ligidaakis next please next line it is a privilege for me at the moment in a very difficult and ahead period to focus on our attention on the front line practitioners including the general practitioners and primary care physicians next line and over the past decades there is a great interest in brain science and in motivation that allows species to survive that's a focus on compassion next line please and not only as a professional task but as an important determinant of the survival of the human being has decided to be included in this short presentation next line please that's a we decided to revisit the concept of compassion self-compassion and compassion fatigue with them next line please to close this presentation with some recommendation on especially to primary care practitioners that are having a fundamental concept and the reasoning to enhance resilience in this period by reading the book of Dr. Ronald Epstein entitled attending a focus on medicine mindfulness and humanity I have realized that the concept the word suffering is everywhere framing all important definitions although it's frequently absent in conversation among physicians and patients it's a very important in refocusing on suffering and turning towards suffering means in each patient as a person as Dr. Epstein said that's one of our central task and obligation of all of us and especially healers is to address in suffering not just a cure disease or a live pain I'm certain that all of you are focusing always in suffering always in our voice is the word suffering but unfortunately suffering is not so much used when we're talking with our patients next slide please that's a we decided in focusing and making the connection between suffering next please slide with the compassion and as you can see one of the formal and internationally accepted definition of compassion is using the concept of the word suffering next to pain that means the suffering is not just a symptom it's a more than one symptom and that's simply saying compassion is equally to suffering with of course much discussion has dedicated to answer to a text and compassion is a virtue or to a extent is innate or how we could cultivate compassion next please next please this is one of the book that's widely used in Europe next please and that's a after compassion is another important concept is the notion and the concept of self compassion next please it is a very very important quite critical and important to the period we now all experience it is important concept having an impact when things go wrong as in this period and is this pandemic and our experience suffering that means self compassion is an action that's attention is to our self that we're suffering from our self next please that independently if suffering is coming from external conditions or if from internal conditions like suffering is deriving from understanding of our mistakes errors, failures or personal experiences next please next please there is a much discussion about the three facet of compassion I very much asking your attention in the second sense of common humanity sense of common humanity means that it's very relevant to experience or failures that potentially we can fill in down that is a common humanity issue that is a common just ourselves especially in the extreme conditions in making errors or falling in mistakes next please much discussion of course in the literature is how could self compassion teach self compassion how we could learn self compassion is any evidence or any materials any networks that could give us the empowerment or how it could enhance our self compassion next please and of course the clinical impact is very very important and one of the core components of mildly based cognitive therapy is one of the most powerful tools at our hands the hands of general practitioners family physicians next please how compassion or self compassion is now connected with the compassion fatigue compassion fatigue is something we are not aware about it especially in the current situation Charles Fickley and Kathleen Reagan Fickley say that compassion fatigue is the heavy price that the people ourselves paying giving services to others how to what extent are unaware or aware about compassion fatigue from this compassion fatigue model which usually we're talking about compassion fatigue resilience model I think a few concepts deserve your attention the first is a so-called empathic response empathic response is derived from empathetic concern and ability when they help practitioners exposed to the suffering at a high level of concern for the patients this response implying a kind of stress so-called compassion stress and all of us who are aware that persistent stress causes damage and in the model in this model that you appear you identify empathetic response and compassion stress leads to so-called secondary traumatic stress that jointly with other stressors like prolonged exposure to suffering or traumatic memories could just a guide or lead us to compassion fatigue next please I think that this is very important in stressing how we could avoid compassion fatigue or compassion stress in this challenging period how we could recognize the designs and symptoms of compassion fatigue in our self but also in our colleagues in our friends and all the people they offer in their services and how we could lower in the symptoms what evidence there is that if lowering a symptoms to our others and of course how to enhance resilience next please I think that is one before okay probably is missed but it's not that the key issue the last slides that I have prepared is just giving some recommendation and guidance and saying be present and be understanding the suffering from the other and please recognize the suffering of the others but also do not forget giving an insight and having an understanding of the suffering of yourself it is necessary in the time of this period just be kind with yourself avoid this exposure to suffering that means not enhancing a sorrow very much or living at a high level of compassion stress just invest in a compassion satisfaction one of the guidance is at this important stressful period enhancing your prolonging your self support and especially your social network is so very important at the moment and that's enhancing your social network but also it's a key message to ourself to Vonka, the professor Dorik, the Akris just invest in more on mindful communication and just living or giving more support in this critical period on compassion, on empathy and then especially on how to protect the self compassion and avoided compassion fatigue, I think that is our new challenging and with that words I'd like to thank you very much for giving the time and the privilege hearing the thoughts and being among eminent panemists, many thanks. Thank you so much Christos, I particularly like the quotes that you gave from and one of the participants reminded us that Epstein along with Ron Zeilig did a recent webinar on Covid-19 and self care so that might be worth if anybody's interested that might be worth googling. Right back to Chris Dirick then for some reflective thoughts. Thank you very much, thank you very much indeed I've actually learnt a lot from what Hami and Sandra and Christos are saying and it actually helps me in thinking about caring for my patients and caring for myself. Just to remind you about Rosie who was the patient I mentioned before, she's the person who's had long-term mental health problems which have got a lot worse recently with Covid and she's very stressed she's very anxious, she's sleeping very badly and she's got a lot of suicidal thoughts so in my first conversation with her a few weeks ago the most important thing I started off with was to listen and to acknowledge the suffering and acknowledge the reality and the validity of her suffering that it actually made sense, it was real, there was nothing wrong with it, that was just it was real and important. And then the second thing following on from what Sandra was saying was about correcting some of the misinformation that she had particularly about this business, about worrying about picking up infections if she just goes outside the house. Well then a couple more practical things if you remember she was very worried about going to work and I gave her a sick note, I printed out a sick note for her to pick up from the surgery so that she could have some weeks off from work which would reduce that particular stress. The other thing we talked about and we agreed together was that it might be sensible to increase her medication for the time being so she was taking metazepine, 15 milligrams and that's actually quite helpful sometimes as a sedative, helps with sleep as well so we agreed to increase that to 30 milligrams. So that was all good, sort of good family doctor stuff but then we were talking a bit more about some other things that she could perhaps be doing herself and I floated a few things and there were two things in particular that took her attention. The first was a simple breathing exercise called the 478 breathing exercise where you breathe in through your nose for a count of four you hold your breath for a count of seven and then you breathe out through your mouth for a count of eight and then you do that four times in a row and then you leave it and that can be very helpful for a cute stress, it can be helpful for sleeplessness. So she said yes I'll try that and then the other thing that I suggested to her and she said to try this as well was to start a gratitude diary this is where you get a little notebook and you have it by your bedside at night and you write down each night you write down three things that went well during the day no matter how many disastrous things you find three things that went well or three things you feel grateful for and you write those down and she said Rosie said yes I'll try that as well and then the last thing I did perhaps the most important was to say okay I will ring you next week and I made an appointment in my practice diary that I would ring her at the same time next week to see how she was doing so I did she was a lot calmer she was not experiencing suicidal thoughts in the way that she had been before she was sleeping a little bit better she was enjoying the breathing exercises and the gratitude diary and I think was feeling the most important thing perhaps was that I was there that I was there to listen I was there to support and I was there to help even though it was not in person it was over the phone but it was still a human connection and so I've been following her up on a weekly basis since then I think we've had four conversations last Thursday she was a bit down again but we agreed that that wasn't too bad and we were thinking about trying to build in some specific enjoyable things in her life and I was asking her what was enjoyable and two things she came up with one was walking her dog which she hadn't been doing but she was worried about what was happening outside but we agreed that was fine so this week she's going to be walking her dog every day if she can and the other thing she likes doing is internet games and she's got one I guess many people have had this one called Animal Crossing so she was she was going to spend sort of 15 or 30 minutes tending to animals online on Animal Crossing so I will find out next Thursday how all that went so that's Rosie and the other person just to myself as I said at the beginning I've been feeling quite stressed and quite anxious so my sleep has not been as good so what am I doing in terms of self compassion in terms of managing my fear well I've been meditating for 15 minutes or so every morning on a regular basis I've been going running and exercise I love running I love so I've been doing that three or four times a week I've also been putting into practice the breathing exercise I was telling Rosie about the 478 exercise that does help me get back to sleep it stops my mind wandering in the light so I recommend that one and I've for the last three or four weeks I've been I've been using my own gratitude diary and I've had a lot of and it's wonderful but when you think about when you focus on that all the things you can be grateful for and just the one particular thing I want to share is something I'm grateful to my daughter Claire who sent me a poem by Wendell Berry called The Piece of Wild Things I think you've got that you can put that up on the screen now I just want to read this with you because for me this is I keep on coming back to this when despair for the world grows in me and I wake in the night at the least sound in fear of what my life and my children's lives may be I go and lie down where the wood drake rests in his beauty on the water and the great heron feeds I come into the piece of wild things who do not tax their lives with forethought of grief I come into the presence of still water and I feel above me the day blind stars waiting with their light and for a time I rest in the grace of the world and I'm free very lovely words to finish with Chris I was sure the entire panel were doing the 478 breathing exercises as you described them I'm sure all the participants were as well nice story about Rosie and a lovely poem to finish with so thank you very much indeed now we have a chance to refer to the questions and comments that have been coming in from the participants so I'm going to hand over now to Anna Stavdahl who will let us know some of the questions and she'll direct those to the panel as appropriate so Anna over to you thank you very much we have an interested audience and we have comments on different parts one is on the clinical work with patients I will start with one question from that field but I'll just sum up what the comments in which fields we have comments it's on methodology speaking telehealth home visits get back to that so that's one portion of the questions and comments the other portion is on doctors health and coping mechanisms so I suggest that we start with patients and this could be to several of the panelists maybe to Chris and Sandra first of all looking back at your presentations one of the participants has made this observation that people with severe mental disorders are coping better nowadays maybe because they are used to uncertainties any thoughts and let's say input to how shall we understand this if this is a common experience that I can say from my everyday work it is I can share a couple of examples of that there's one person a patient who suffers from severe agoraphobia and she needs to stay at home all the time so actually she's delighted at the moment because her needs are just the new normal that's what everybody else needs so I understand that she has a lot of empathy for other people we shouldn't overstate the benefits of this current crisis but for some people they're there and a slightly different one, another patient is a patient who uses a lot of street drugs as a young man and he's been finding it very difficult to source his street drugs because there aren't so many, they're getting more expensive and he's unsure about the quality so he's actually asking me for some methadone because he thinks that would be safer that's a very good idea there are some cases where there are some benefits but I don't think we should get too excited about that we should recognise that so another comment to all panellists from managing mental health problems maybe one of panellists would give a few hints on how to make it less stressful Sandra, maybe that's for you we're doing a lot of that in Brazil not only in primary care but also in specialized care because the National Council for Medicine National Medical Council and the National Psychologist Council telehealth consultations and so one important aspect is it's very difficult to deal with a new case through telehealth that's very very difficult but it's not that much difficult if it's somebody you know, if it's somebody you already know and primary care usually know most of their patients then it gets easier because you already know that person the difficulty that they usually face what is going to be more stressful for them and in Brazil we are also doing that by telephone the mental health outpatient unit that works together with primary care in my region what they have done is they have called all patients and make the contact by phone and arranged it for the prescriptions to be available we also allowed to give prescription for a larger time and gave them a special number where there would be everyday somebody there that could attend they could attend if they come and so what happened was most of them were okay and they said that was enough and also giving people support and letting them know that there is somebody around how they can get to help because people are scared of being abandoned by health system and by that office and so if you organize where they can go and who they can look for that's going to help a lot and in the end I am doing some telehealth consultation and I am finding it's not very difficult if I know the person before thanks God we have all this technology so more on counselling with patients in your view sorry Anna did Fami did you want to come in on that thank you God thank you Anna in fact I don't want to comment on telehealth support I want to comment on the stress aspect which I also notice that it also gets repeated in many of the comments including from the good colleague from Spain commenting on stress in relation to stigma and this question also about the stress of telehealth so for all health workers the key message if you look at the messages on stress coping coming from WHO one of the key messages is that in fact during stressful times it is normal to feel stressed it is normal during difficult times to feel stressed try not to make your life focused around COVID-19 because we see many and many health workers and many and many of the populations as well their life all is centered around COVID-19 either dealing with patients of COVID-19 or looking on news on COVID-19 switch off from COVID-19 switch off for some time to do some other things physical distancing does not mean social distancing it is also a time to have more social connectedness through phone calls with friends using technology to communicate with families and loved ones who would need your support supporting others in this time make you also feel better as a health worker so support others they need your support and you need also to be supported from their side and we do what we advise people to do healthy lifestyle we have healthy diet we try to maintain normal routines as much as possible and avoid negative coping methods including benzodiazepines and alcohols where there are also reports that there is increased use as a stress coping coping mechanism and finally access help try to access help if support is needed and make sure that all health workers in all facilities have access to mental health and psychosocial support about social stigma we need also to get more involved with communities by disseminating messages big part of the stigma is related to misinformation among the communities so I think disseminating messages to the communities in a way that can understand them got also a benefit for reducing stigma thank you good so I guess you have already answered questions that I won't get back to concerning healthcare workers themselves or ourselves but let's stick with patients for another question here is one in your view should we systematically advise among mental health patients at this stage the risk of alcohol use suicide and family violence who wants to reflect on that one Christos do you want to have a go at that one to start off with you can start and I follow okay so will you just repeat that question should we systematically advise or address among people with mental health problems the risk connected with alcohol use or drugs I presume suicide family violence as we know that the risk is increased during a crisis like this I okay my response is that we should have those things in our minds most certainly when we're talking with patients with mental health problems whether we discuss it with a patient I think will depend on the situation and on the particular patients with some patients it would be helpful some patients it might not for sure always thinking about suicide ideas in every consultation and discussing those that's fine I think if you're discussing misuse of alcohol or drugs with patients it can be a bit patronizing I think it depends on the patient and the issues of family violence again those are ones to be very aware of if it's a patient who is likely to be a victim of family violence yes to give them the opportunity to talk about that but I think with all of those it requires a degree of sensitivity and a degree of yeah I would say no to routine but yes to having them in my mind and thinking about them sensitively thank you thank you very much Gris I think that in primary care is not only the issue what type of questions or information we're asking but how we can ask questions and I think that especially in our working party we have already stressed that a motivation that motivational interview and many other style of encouraging people in changing the behavior or taking into account things is very very important that means it's not only that of course we can ask about the lifestyle or alcohol use etc when we are asking or open questions just at the same time is motivated and people I think that is the critical and the key feature and characteristics of the consulting styles of primary care practitioners thank you to more on doctors I think Donald had his hand up I was just going to say this is what we talk about anticipatory care and also opportunistic screening I think as family doctors we don't limit to mental patients in general that's how we are trained in normal conversations just asking how are you, how's the family, everything is working what have you been doing, are you having a glass or two before you go to sleep this sort of thing I mean in a casual way I think it covers as something that we teach family doctors to do even if they come with a symptom we should always think about providing this kind of holistic care so those are good points I wouldn't be so direct to say how many a day are you thinking of food conversation with the patients I really like calling Rosie, I was there for you and this is the whole thing the continuity, we ask about the patients just call them if you feel that they are slightly depressed or whatever the next week how are things, are you sleeping alright, are you doing anything to help I think not just for mental patients but all patients this is what we think holistic, comprehensive, continuous care that's my comment, thanks. Thanks Donald. Anna do you want one more question? Yeah, we have time for one more I think and this is to all of us you already addressed the health workers health and coping strategies in this situation here's the question it's adaptive learning networks to address secondary psychosocial, the secondary psychosocial pandemic but also for coping strategies for health care workers, will Wonka do that? WHO just showed us some of the material you have created, is this an issue for Wonka to take on for this working party or for us in the leadership to follow up on so comments? Just briefly, yes I think that's a challenge and opportunity and something that the working party with Wonka Executive and with many other groups can and must do so I think that's very important going forward I think we have covered the main fields and there from the questions and inputs Sandra has a quick comment I think very quick looking at the chart the Brazilian medicine society that from the society have started several violent groups to support professionals during these periods and I think this is a good alternative Thank you and somebody else in chat mentioned groups as well so right thank you very much Anna and thank you to your team of monitors for monitoring all those questions and a special thanks to the panelists for some really great presentations thanks to the participants for some good chat and some good questions and I'd like to hand over now to our president for his final comments, Donald and you're muted. Thank you again panelists for wonderful presentation very stimulating and I think we really reached out to our fellow family doctors and thank you all for tuning in but before I make concluding remarks I want to do some advertising for next webinar which is next Sunday this will be on education and training led by our chair of the working party VauWars basically we will be thinking about a few questions how can medical schools evolve to deliver in a virtual context how can you adapt postgraduate training and assessment and how can you address diverse CPD needs globally online so these are a few things that we will be exploring next week so with that I would like to conclude next Harris please so this is a pandemic with an unknown end game I wish each and every one of you our family doctors well during this time we are here for you and that's why these webinars have proven to be a good platform for us to share on special subjects and for people to ask so use the best advice available work collaboratively with your teams do the best you can for your patients and you should stand proud of your contribution to tackling this world crisis next please no one knows what we will face in the weeks and months ahead but everyone knows enough to understand that COVID-19 will pass our capacities to be kind and generous and to see beyond ourselves and our interests our task now is to bring the best of who we are and what we do to a world that is more complex and more confused than any of us would like it to be may we all proceed with wisdom and grace thank you very much thank you Donald and again thanks to all the panel for some great presentations we'll meet again next week for the education and training webinar and in the meantime everyone please stay safe thank you and good afternoon