Elder Mental Health and Coronavirus - A Conversation with Michael C. Cerullo, Jr., LMHC
On this past week’s Southcoast Seniors Radio Show, we featured a guest who has become a friend of our show and our go-to person when it comes to discussions on mental health issues.
Michael C. Cerullo, Jr., a Licensed Mental Health Counselor practicing in Rhode Island, has a unique perspective on mental health and the needs of our elders in southern New England. One of the most pressing concerns we brought to him was the effect of COVID-19 on the mental health of all adults and how it has suddenly inserted itself into their everyday lives.
“It seems to me, from societal and individual points of view, COVID-19 has arrived as an uninvited, reality-disrupting character in our lives. Its dominant characteristic is uncertainty. With uncertainty, especially sustained uncertainty, comes the anxiety, depression, anger, and sense of powerlessness that often accompany loss and trauma. For some, it takes a dominant and devastating leading role. For others, it is an irritating, complicating, or treatment sabotaging player,” Mike stated.
This explanation reflects what staff has seen at Connelly Law Offices as older adults and elders are more concerned than ever about their futures in multiple areas of their lives. Financial unpredictability, concerns about their loved ones, and thinking about their own mortality has set a course for fluctuating emotions that older adults and elders are struggling to control and have difficulty explaining why they feel the way they feel. How does Cerullo address this?
“COVID has created, both societally and individually, an open-ended period of what might be called cognitive discombobulation,” Cerullo continued. “ That is, what made sense and gave meaning and structure to their earlier realities and hopes no longer makes sense to them. The dots no longer connect. Just as with a mid-life crisis, a therapist’s role is to help patients navigate, accommodate, and manage their unique situations. In a sense, I become their recombobulation coach as they strive to reconnect and reconfigure some of the old dots with the new ones COVID brought to their present moments.”
Many who work in the eldercare field cite that one of their concerns is the disruption in an elder’s routine and the introduction of a "new normal", a common belief that Cerullo does not necessarily buy into.
“To be honest, I’m not so sure I agree with the assumption that elders do not like to experience ‘newness’. In fact, I believe boredom and being stuck in old ways are equal opportunity adversaries when it comes to leading a fulfilling, meaningful, purposeful, and joyful life. As a grandfather of nine who will be 77 in two weeks, I’d hate to think I’m done with adventure, intellectual exploration and adding a few more items to my bucket list … and I’m certain, however troubled they may be at the moment, my patients don’t really want to feel that way either.”
Working with elders presents its own series of concerns when it comes to mental health. Those living in assisted living communities have been under, what is equivalent to, house arrest. This isolation and disconnection from support systems are especially challenging for them. And for those aging in place, not having the social supports of senior centers and even family can prove especially devastating. So how has this pandemic affected this group as a whole?
“It’s difficult, if not impossible, to anticipate or describe how COVID will affect our elders as a whole,” Cerullo stated. “I have found no cookie-cutter presentations or ‘standard’ treatments in my practice. Every elder has her or his own unique narrative into which COVID has inserted itself. For many, however, fear and anticipatory grief can lead to some common psychological reactions and symptoms.” And what are they?
“For example, among the signs and symptoms family members and caretakers should be on the lookout for is anxiety and worry, frustration and irritability, feeling of helplessness and hopelessness, significant and unusual withdrawal from others, feelings of guilt, loss of interest in pleasurable activities, poor appetite, sleep problems (too much or too little), panic reactions, substance misuse, PTSD symptoms (e.g. hypervigilance, startle response, avoidance), and suicidality,” Cerullo explained.
Cerullo also points out that exposure to television news and the incessant coverage of the pandemic including the scoreboard of deaths and increased cases by regions can make underlying problems worse. “[The symptoms] and, very importantly, their emergence may be exacerbated and perpetuated by constant exposure to the uncertainty and intensity presented in 24/7 media coverage of COVID.”
So let’s focus on suicidality, which, by all measures, has shown an increase across all groups and this was prior to the pandemic and loss of employment for nearly 25% of the workforce. Then came COVID with the loss of a business, life savings, and a way of life pushing many to desperation and depression. Has there been a similar period we can look to for some guidance on this problem? During the Great Depression, there were an additional 40,000 deaths by suicide and in the more recent 2008 Recession, there were nearly 5000 more victims of suicide. And in early June 2020, nearby Bristol County, Massachusetts is already experiencing a rise in the number of deaths by suicide compared to this time in previous years, according to the Greater New Bedford Suicide Prevention Coalition. Is this a trend that is concerning for mental health professionals?
“This [question] is about deaths of despair and whether they will increase significantly due to COVID-19. 'Deaths of Despair' were originally described by two economists during the steady increase of deaths in the US from suicide, overdose, and alcohol in the decade before COVID-19 showed up,” said Cerullo.
“There are two points of view, one is exemplified by the Well-Being Trust projections that as many as 150,000 of these deaths may occur depending on how quickly unemployment rates go down. The other is reflected in a paper in Statistics News by Brown Medical School Professor and ER physician Megan Ranney and a psychiatrist colleague that suggests we cannot simply map Great Recession stats onto the many unique aspects of what is happening today, such as how new technologies make possible increased virtual social connection and support, or the evidence-based treatments we know work on the assumption we will commit the funding and resources. And I would add that it is widely accepted among mental health professionals, that funding has been woefully inadequate for decades.”
“Regardless,” Cerullo continued, “both perspectives acknowledge that we may not really know for years whether any increase is simply an extension of previous trends or substantially related to COVID itself.”
When we do look at the previous trends, one thing is certain, elders have shown up as one of the groups with a significant rise in suicide that continues to move upwards. Cerullo is also concerned about these numbers.
“Recent CDC national death by suicide rates per 100,000 for age 65 & older are 30 for men and 7 for women. Significantly, for women, between 45 to 55 the rate of 10 is actually 40% higher, probably because as research is now showing about 42% of women in perimenopause have clinical depression, and, depression is clearly suicide’s most lethal partner,” said Cerullo.
But there is positive news when it comes to suicide in the Ocean State according to Cerullo. “In RI, we are in much better shape. According to Jeffrey Hill -- who heads up the Department of Health’s suicide and mental health prevention programs as well as Governor Raimondo’s partnership initiative with the VA to end suicide among veterans – Rhode Island actually has the third-lowest suicide rate in the country!”
With suicide, the choice of means obviously increases the lethality of the act. Overall, for elder males, guns are involved 78% of the time while for elder women, 40% involve the use of poison, and guns are used 37% of the time. These stats do not refer to what is called passive suicide among elders, which includes neglect of one’s personal safety, stopping medication, or refusing to eat. And, Cerullo cites some other important data when it comes to suicide.
“Over half who died by suicide had mental health conditions and less than half had been in treatment and a majority of these elder’s had seen their Primary Care Physicians within a few weeks of their death. So, educating and providing Mental Health screening tools to PCPs is an important prevention strategy. This is a major focus of our South County Zero Suicide Program which is headed up by Dr. Rob Harrison, a retired ER doctor with extensive experience in family medicine.”
"A study of 90 deaths by suicide also found that just 1 victim lived in a supervised residential setting," said Cerullo. "So elders living in the community and those aging in place are clearly at greater risk.”
How would someone spot an elder’s desperation that may be heading for a crisis and possibly ending in suicide? Cerullo said that in the Mental Health First Aid course (which we will discuss later), he cites 22 risk factors and warning signs that those who work with or socialize with elders should be aware of. They are:
Living in suburbs or in rural areas as opposed to core cities;
Marked feelings of hopelessness;
Pain and/or medical conditions that significantly limit functioning or life expectancy;
Co-morbid general medical conditions that significantly limit functioning or life expectancy;
Social isolation;
Family discord or losses (the recent death of a loved one);
Inflexible personality or marked difficulty adapting to change;
Access to lethal means (firearms);
Previous attempts;
Impulsivity in the context of cognitive impairment;
Threatening to hurt or kill oneself;
Seeking access to means;
Talking or writing about death, dying, or suicide;
Feeling hopeless;
Feeling worthless or a lack of purpose;
Acting recklessly or engaging in risky activities;
Feeling trapped;
Increasing alcohol or drug use;
Withdrawing from family, friends, or society;
Demonstrating rage and anger or seeking revenge;
Appearing agitated.
Why would living in the suburbs be a risk factor? After all, isn’t this what many elders seek, to retire and move out of the hustle and bustle of the city to the peace and quiet of the country? Not necessarily.
Cerullo explained, “Rural living can lead to social isolation, resulting in less intimate face-to-face contact with family and friends, lack of access to health services, which, in turn, increases the risk for suicidal behavior. Plus, rural dwellers have easier access to lethal means (firearms), which increases their suicide risk.”
Cerullo also points out that using certain words and phrases during this pandemic can also be counterproductive, and not just with elders. As has been said many times by many people, “words have consequences” and he wants to see us move away from words and phrases with negative connotations.
“In the case of ‘social distancing’, why not ‘physical distance while fostering social connection’? And instead of emphasizing ‘isolation’ or ‘quarantine’ rightly used in their technical sense for people who are COVID positive or exposed, why not refer to sheltering in place as offering opportunities for ‘periods of solitude’? Solitude is something toward which one is drawn, often in the hope, whether consciously or sub-consciously, of finding ways forward in the midst of change, crisis, or perhaps to recharge and heal. It is, in fact, an important time for meditation, mindfulness, and other well-proven means of maintaining emotional well-being.”
And when it comes to elders and the word "geriatric" being used, Mike shares this personal anecdote;
“On April 1st I had my periodic check-up with my PCP. We checked in quickly, he dutifully went over my COVID safety protocols and so on. Then, out of the blue, he used the word “geriatric” in referring to me and I immediately burst out - half in jest - with 'Don’t use the G-word with me Doc … I’m in my Elderhood stage of life. You can call me an Elder.' On reflection, I realized my clearly automatic reaction to the word geriatric was because it can suggest that someone is worn out, decrepit, failing, and somehow ‘used up’ and helpless. Wouldn’t a person referred to with that word feel offended, disrespected, disempowered, and stigmatized? It may be true that one’s body is failing, but that doesn’t mean one’s spirit is. In fact, most elders will tell you they won’t let anything get their spirits down.”
This is important to Cerullo, who feels that using such words to group all elders together into one category is not a positive contributor when it comes to the mental health perspective of older Americans.
“We are individuals who have worked really hard to grow into one (an elder). We’ve earned our stripes and the status of “Elder”. Think about how much esteem the term elder holds in many cultures. Shouldn’t we do the same, even though their bodies may be more vulnerable to an adversary named COVID-19? And what nuclear-powered survival weapon do Elders use and can bring to their communities? Wisdom!"
"And you cannot just go out and buy that. Right? So, as both a therapist and someone living into my 8th decade, I think we might want to look to our elders and, literally ‘mind them’ and their store of Wisdom as we all struggle in an intergenerational effort to defeat this disrupting and deadly character called COVID-19. I think this perspective will do wonders for not only the mental health of individual elders but also for the well-being of people of all ages,” Cerullo emphatically stated.
Finally, what about those who care for aging parents or grandparents, they too are subject to the COVID burnout. What does Cerullo see in this group and are there any suggestions he can offer on self-care?
“With the parents of the adolescents and emerging adults who are also caretakers for a parent, I see the same effects of COVID-19 stress as their parents may be experiencing,” Cerullo states. “These parents are often under enormous simultaneous pressure to work remotely, make certain the kids are seriously engaged in remote schooling and at the same time feeling they should be more involved in monitoring and caring for isolated parents who often have underlying medical conditions.”
“Self-care skills such as mindfulness, periods of solitude, and accessing well-informed therapy is vital for everyone involved. I always remind caretakers to remember what the cabin attendants tell us when we are sitting next to someone who needs help when the oxygen mask pops out. They tell us, 'Make sure you put yours on first, or you will be unconscious by the time you try to help them.' The only difference is that in our case, the mask is very likely to pop out,” said Cerullo.
Mike is a tireless advocate for training everyone in spotting someone struggling with mental health issues. Because of this, he is dedicated to teaching Mental Health First Aid to the community. Just what does that entail?
“Mental Health First Aid, (MHFA) for Older Adult’s helps caretakers, professionals, and elders themselves to understand the unique challenges to elder mental well-being, to overcome widespread stigma involved in seeking professional help, and to develop confidence that as a layperson they can be helpful,” Cerullo explained. “These 8- hour courses do not train First Aiders to diagnose or treat mental health challenges, rather how to help someone who may be experiencing a mental health or substance use challenge. The training helps them identify, understand, and respond to signs of addictions and mental illnesses.”
Unfortunately, due to COVID, MHFA training in South County is unlikely to resume till Fall at the earliest. Until then, Cerullo has included the following resources for those who may be experiencing a crisis:
The National Suicide Hotline at 1 (800) 273-8255;
Your local Police Department or EMS Service by dialing 911 … (every sworn police officer and licensed EMS First Responder in RI is required to be certified in Mental Health First Aid);
BH Link at (401) 414-5465 (for any mental health crisis);
The Samaritans at (401) 272-4044.
Plus, anyone interested in learning more or being put on a notification list for future MHFA training should contact Cerullo directly at 401-286-0804 or at Mike.Cerullo@verizon.net
To listen to the podcast of the show with Mike Cerullo, click on the photo below
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