If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

ASHEVILLE, N.C. — A few months ago, Waynesville Police Sgt. Paige Shell was about to give up hope of getting better. The daily drip of violence, death, and misery from almost 20 years in law enforcement had left a mark. Her sleep was poor, depression was a stubborn companion, and thoughts of suicide had taken root.

Shell, who works in a rural community about 30 miles west of Asheville, tried talk therapy, but it didn’t work. When her counselor suggested ketamine-assisted psychotherapy, she was skeptical.

“I didn’t know what to expect. I’m a cop. It’s a trust thing,” she said with a thin smile.

Combining psychotherapy with low-dose ketamine, a hallucinogenic drug long used as an anesthetic, is a relatively new approach to treating severe depression and post-traumatic stress, especially in populations with high trauma rates such as firefighters, police officers, and military members. Yet evidence of the efficacy and safety of ketamine for treatment of mental health conditions is still evolving, and the market remains widely unregulated.

“First responders experience a disproportionately high burden of trauma and are often left without a lot of treatment options,” said Signi Goldman, a psychiatrist and co-owner of in Asheville, who began including ketamine in psychotherapy sessions in 2017.

Law enforcement officers in the U.S., on average, are exposed to 189 traumatic events over their careers, a , compared with two to three in an average adult’s lifetime. Research shows that rates of are among police officers than in the civilian population. And in recent years, more officers have died by suicide than been killed in the line of duty, according to the first-responder advocacy group

Ketamine is a dissociative drug, meaning it causes people to feel detached from their body, physical environment, thoughts, or emotions.

The Food and Drug Administration approved it as an anesthetic in 1970. It became a popular party drug in the 1990s, and in 1999, ketamine was added to the list of Schedule III nonnarcotic substances under the Controlled Substances Act.

The death of “Friends” actor Matthew Perry in 2023, which was , further tainted the drug’s reputation.

But starting with a and followed by a landmark , research has shown that low doses of ketamine can also rapidly reduce symptoms of depression. In 2019, the FDA approved esketamine — derived from ketamine and administered as a nasal spray — for treatment-resistant depression.

All other forms of ketamine remain FDA-approved only for anesthesia. If used to treat psychiatric disorders, it must be prescribed off-label.

“This is a situation where the clinical practice is probably ahead of the evidence to support it,” said , chair of the Department of Psychiatry at the Yale School of Medicine and a pioneer of ketamine research.

Krystal has of ketamine on veterans and active-duty military members — a population comparable to first responders in their exposure to trauma. While research shows strong evidence of ketamine’s antidepressant effects, he said further studies are needed on its potential role in PTSD treatment.

The regulatory environment for ketamine also remains a concern, Krystal said. State oversight varies, and federal regulations don’t outline dosing, administration methods, safety protocols, or training for providers.

In this regulatory patchwork, more than have sprung up across the country. At-home ketamine treatments have flooded the market, prompting the FDA to .

Side effects of ketamine can range from nausea and blood pressure spikes to suppressed breathing. The drug can also cause adverse psychological effects.

“Being on a psychedelic puts people in an extremely vulnerable state,” Goldman said. People can get retraumatized as they relive disturbing memories. That’s why it’s critical that a mental health provider guide a person through a ketamine session, she said.

With proper precautions — and when other treatments have failed — Rick Baker thinks ketamine-assisted psychotherapy is a good fit for first responders. Baker is CEO and founder of Responder Support Services, which provides mental health treatment exclusively to police officers, firefighters, and other first responders in North Carolina, South Carolina, and Tennessee.

As a population, first responders are more resistant than civilians to traditional therapy, said Baker, who is a licensed clinical mental health counselor. Ketamine provides a potential shortcut into the trauma memory and works “like an accelerant to psychotherapy,” he said. “It strips away people’s armor.”

When used for mental health treatment, a dose of ketamine — typically half a milligram per kilogram of body weight, less than for anesthesia — creates a mildly altered state of consciousness, Goldman said. It makes people look at their own traumatic memories at a distance “and tolerate them differently,” she said.

The ketamine sessions in her practice are usually two hours long, and clients are under the drug for about 45 minutes. The drug is administered as an IV drip, an intramuscular injection, under-the-tongue lozenges, or a compounded nasal spray. The drug is short-acting, meaning its dissociative effects largely wear off within about an hour.

But most insurers won’t pick up the cost of ketamine-assisted psychotherapy, which can be more than $1,000 per session for the IV drip.

“That’s certainly prohibitive for first responders,” Goldman said.

The Department of Veterans Affairs treatment, including ketamine-assisted psychotherapy, for eligible veterans on a case-by-case basis.

In Shell’s case, a donation made to Responder Support Services covered what her insurance wouldn’t when she decided this spring to try ketamine-assisted psychotherapy with Baker, her counselor.

Revisiting the most gruesome calls in her nearly two decades as a police officer was not something Shell wanted to do. But Hurricane Helene, which caused catastrophic flooding in western North Carolina last year, pushed the 41-year-old “over the edge,” she said.

“Some of the sessions were rough,” said Shell, who is also a member of her agency’s SWAT team. “Things came up that I didn’t want to think about, that I’d buried during my entire career.”

The badly mangled victim in a fatal car crash. A murder-suicide, in which a man cut his pregnant girlfriend’s throat then slit his own.

Under ketamine, the images came to life as still pictures, she said, like a surreal slideshow replaying some of her darkest memories. “Then I would sit there and cry like a baby.”

As of early October, Shell had undergone 12 ketamine sessions. They have not provided a sudden miraculous cure, she said. But her sleep has improved, and bad days are now bad moments. She also finds it easier to manage stress. “And I smile more than I used to,” she said.

She was hesitant to share her experience within her department because of the ongoing stigma associated with seeking help in the hard-charging police culture.

“I just didn’t want my people to think that I couldn’t handle the job,” she said. “I didn’t want them to feel that I’m posing a risk to them.”

The perception of ketamine plays a role as well, said Sherri Martin, national director of wellness services at the , an organization representing more than 377,000 sworn law enforcement officers. Many cops are used to ketamine as an illegal street drug, she said, or think of it as a counterculture psychedelic.

“So, when they are supposed to accept this as a treatment, that’s hard for them to grasp,” she said.

Few if any police departments provide clear guidance on ketamine-assisted psychotherapy. If it were medically prescribed, it would likely be viewed the same as taking an antidepressant, Martin said.

Shell ultimately shared her story with colleagues, most of whom were curious and supportive, and she now encourages other officers to speak up about their struggles. She believes seeking mental health treatment — in her case, ketamine-assisted psychotherapy — has made her a better and safer police officer.

“It’s hard to help other people when you can’t take care of yourself,” she said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

BIRMINGHAM, Ala. — Frank Wampol had a dark realization when he came across some alarming data a few years ago: Over die from suicide annually — the number who die from work-related injuries, according to several studies. That’s considerably more than the in the general population.

“To say this is a crisis would be an understatement,” said Wampol, vice president of safety and health at , a construction company based in Birmingham with over 10,000 employees.

Since then, the company has added mental health first-aid training for on-site supervisors and distributed information about suicide prevention to laborers in the field. The efforts are part of a larger push led by the industry and supported by unions, research institutions, and federal agencies to address construction workers’ mental health.

But initiatives to combat this mental health crisis are tougher to implement than protocols for hard hats, safety vests, and protective goggles. And some of the potential solutions, such as paid sick leave, have drawn pushback from the industry as it eyes costs.

Safety experts have long been concerned about the physical hazards of construction work. The “Fatal Four” hazards are falls, electrocutions, being struck by an object like a brick or a crane boom, and getting caught between two objects, according to the .

Only in recent years have the psychosocial hazards of construction work moved onto the public radar. Studies paint a grim picture, said Douglas Trout, an occupational medicine physician and deputy director of the Office of Construction Safety and Health at .

In addition to high suicide rates, drug use is rampant, especially opioids such as heroin and fentanyl. A from the Centers for Disease Control and Prevention found that construction ranks highest in overdose deaths by occupation.

“Rates of suicides and overdose deaths are some of the worst outcomes related to mental health conditions,” Trout said. “And unfortunately, these are the more measurable ones.”

Less measurable but also prevalent among construction workers are anxiety and depression, which often remain undiagnosed. Almost half of construction workers have experienced symptoms of both, a rate higher than that of the general U.S. population, according to a by the Center for Construction Research and Training, an arm of North America’s Building Trades Unions. But fewer than reported seeing a mental health professional, compared with , according federal statistics.

The combination of high-hazard environments and organizational factors puts construction workers at particular risk for mental health issues, Trout said. Construction is a high-stress occupation involving long hours, extended separation from family and friends, and low job security due to the industry’s cyclical nature.

Even though health insurance and workers’ compensation are offered by some contractors, paid sick leave for laborers, craft workers, and mechanics is not standard. While 18 states and Washington, D.C., have approved laws requiring paid sick leave and federal contractors have to offer it, the mandates don’t apply to many construction workers. And industry advocates are such legal requirements, claiming they don’t fit the transient and seasonal nature of construction work.

If workers get injured, they often “try to tough it out and get back to the job as quickly as possible,” said Nazia Shah, director of safety and health services at the , the country’s largest construction trade association.

To manage pain from injuries, workers often resort to prescription opioids. Some then develop a dependency and turn to street drugs. “It’s a vicious cycle,” Shah said.

If a worker is fatigued, distracted by pain or personal issues, or impaired by some type of substance, the results can be catastrophic, said Wampol, a 20-year industry veteran who went into construction after retiring from a career as a firefighter and paramedic.

The biggest step, Shah said, is “breaking the stigma and normalizing conversations around mental health.”

The hurdles are particularly high in this male-dominated field, where harassment and bullying are common and speaking up about emotional hardships is often considered a sign of weakness, Shah said.

Several organizations, including , have created short “toolbox talks” to review the signs and symptoms of mental health issues, the risks of self-medicating with drugs and alcohol, and the resources available through health insurance and employee assistance programs.

Some, such as the , hand out hard-hat stickers, cards, and “hope coins” — small tokens that symbolize support. They all serve as conversation starters and include information on the in English and Spanish.

Many contractors hold regular stand-downs, with supervisors halting work at a construction site to provide on-the-spot training related to a specific mental health issue. Others, such as BL Harbert, offer health education fairs and team with local health clinics for lunch-and-learn events.

But Stanley Wheat, an on-site safety manager at BL Harbert, said that even the best policies, procedures, and training materials won’t stick without making an effort on the ground. “A PowerPoint presentation alone won’t cut it. You’ve got to know your people, and you’ve got to engage them.”

Wheat, a military veteran who has worked in construction for over two decades, said it’s important to make rounds several times a day at a job site — getting to know the workers and observing changes in their behaviors.

“You start noticing the guy who’s isolating himself, sitting alone at lunch, not talking with anybody,” he said.

Wheat can relate. His uncle died by suicide, but his family would never talk about it. During his time in the military, Wheat said, he went to rehab for drug and alcohol addiction. He dropped out of college to work in construction.

“I’ve been there,” he said. “I skinned my knuckles. I pulled my back. I worked injured.”

Wheat tries to strike up conversations with workers who he thinks are having a rough time. He listens, sometimes shares his personal story, and suggests resources for help.

Peer-to-peer support is among the more promising concepts in the effort to curb the mental health crisis in construction. Workers often don’t want to talk with management or outsiders, Trout said, “but they usually trust each other.”

One successful model is , a program for mental health and suicide prevention that originated in Australia in 2008. The idea is to train on-site personnel — workers, foremen, superintendents — to spot and support co-workers in crisis, offer a confidential space to talk, and guide them to help if needed. The volunteers, called “connectors,” are typically identified by green hard hat stickers. Efforts are underway to bring a formalized Mates program to the U.S., Trout said.

Other, often small and local initiatives are being implemented, too. Some contractors have hired full-time wellness coordinators or bring mental health care providers to construction sites so employees can start appointments immediately. A few companies have put dedicated trailers on their job sites that serve as quiet rooms, with lounge chairs, board games, and video consoles, so workers can take a moment to decompress.

Many contractors also have added naloxone — an emergency medication used to reverse opioid overdoses, often known by the brand Narcan — to on-site medical kits.

Going forward, as President-elect Donald Trump takes office next week, the industry faces major uncertainties, including possible ripple effects from tariffs, mass deportations, tax cuts, and deregulation.

No matter what comes, Wampol said, the construction industry needs to understand that the investment in mental wellness and suicide prevention programs creates “a healthier, more productive workforce” — and, ultimately, a better bottom line.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

“It’s the worst that I’ve seen in my career,” said Beyer, co-founder and CEO of Enhanced Recovery Center, a private mental health and substance use recovery and treatment center for first responders in the waterfront Maryland town of Havre de Grace. Established in 2015, Harbor of Grace is one of only six treatment centers in the U.S. approved by the , the world’s largest organization of law enforcement officers.

Public safety is a profession plagued by high rates of mental health and addiction problems. Considering the unrelenting pressures on first responders, Beyer said, the treatment centers can’t keep up with the demand.

Specialized recovery facilities like Harbor of Grace focus on treating law enforcement officers, firefighters, emergency medical technicians, and dispatchers — people who regularly encounter violence and death at work. In the past two years, Beyer said, the number of police officers admitted for treatment at his facility alone has more than tripled. “And we always have up to 20 cops in the queue,” he said. Other treatment centers for first responders reported a similar spike in patients.

Anger at police and policing practices soared after a Minneapolis officer murdered George Floyd in 2020, and it put additional strain on officers’ mental health, said Dr. Brian Lerner, a psychiatrist and the medical director at Harbor of Grace. “Officers feel disparaged by the public and often, they also feel unsupported by their agencies,” he said.

That’s part of the reason “we’re looking at a significant rate of burnout among police officers,” said , a clinical psychologist in Kansas City, Kansas, who focuses on helping law enforcement personnel.

The poor state of many officers’ mental health, combined with low morale, has contributed to an exodus of police across the country that has and the remaining officers overworked and exhausted. Atlanta, Seattle, Phoenix, and Dallas are hit particularly hard by officer shortages. “That’s creating enormous stress on the system,” Prohaska said. “It’s a perfect storm.”

Even before the most recent stressors, and were up among first responders. Rates of post-traumatic stress disorder are . Some that as many as 30% of police officers have a substance use problem. is at the top of the list.

Last year alone, — more than the number killed — 129 — in the line of duty, . A suggests that police suicides are often undercounted because of stigma.

Harbor of Grace has a small campus of eight single-story brick buildings with light blue and yellow accents and looks more like a seaside inn than a clinical setting. The center can treat 47 patients at a time. It has seven acute care beds, mostly for detox.

It offers help for a wide range of mental health conditions, including addiction, sleep disorders, anxiety, depression, suicidal ideation, and PTSD.

To date, more than 500 law enforcement agencies — federal, state, and local — have sent employees to Harbor of Grace. The center has 45 full-time clinical staffers, including an emergency physician and several psychiatrists, nurses, and counselors. Many have previously worked as first responders — from Army medics and firefighters to police officers.

On a recent morning at Harbor of Grace, the sun burned hot over the Chesapeake Bay. A group of patients, mostly men and a few women in their 30s, gathered on the small patio. Some sat alone, while others stood in small groups chatting.

“We get all types, from all backgrounds, and at all stages of brokenness,” said Beyer, 66, a former firefighter and EMT who overcame a problem with alcohol several decades ago. “All our patients and most of our staff know what it’s like to hold a dead or a dying child,” he said.

Sgt. Ryan Close has held several dead children. The 37-year-old police officer works as a patrol supervisor for a small law enforcement agency in New England that he did not want to identify to protect the identities of his colleagues. He has been a police officer for 15 years and has worked for several departments. When he started, he said, officers did not receive psychological training or have access to designated peer support programs.

He said that almost every time he was involved in a critical incident — like a shooting or an accident with burnt and disfigured bodies — “my supervisor ordered me to the bar afterwards.” One incident in particular has stuck in his memory — when a young boy shot himself in the head with a rifle. Washing down the horror with alcohol “was the culture back then,” he said.

But Close didn’t drink much at the time and was mocked by his peers for ordering only small beers. It wasn’t until years later, when memories of his experiences at work reemerged and he had trouble sleeping, that he started to self-medicate with alcohol. He developed social anxiety, and his marriage suffered.

His department pushed him to get help, and he entered Harbor of Grace in April 2021 for a 28-day treatment cycle. There, he learned to let go of his hardened veneer and his impulse to always be in control. He saw many other cops struggle with that too when they got to the center. “I witnessed grown men have a fit like a 6-year-old because a staff member wouldn’t let them use their cellphone.”

Many first responders develop heavy defense mechanisms and are “insecure, non-trusting, controlling,” Beyer said. They often wait way too long before they seek help, he added.

Police officers tend to be “very closed, very unwilling to be vulnerable,” Lerner said. But he finds that most first responders make model patients after they take the first steps. “At that point, they’re all in,” he said. “They don’t do anything halfway.”

At Harbor of Grace, the communication style mirrors the tone at a police station or firehouse, said Beyer. “We don’t waste time on the feel-good stuff,” he said. “We’re blunt. We call people out if necessary.”

Psychologist Prohaska said it’s important that specialized behavioral treatment centers for first responders exist. But, she said, there must also be better investment on the front end — for hands-on initiatives that teach resiliency to public safety employees, like the one she developed .

Robust mental health training needs to be part of the academy curriculum and embedded in police culture, she said. “Just like we teach officers safety, we need to teach them resiliency,” she added. “A two-hour PowerPoint course won’t do it.”

Beyer expects the situation to get worse before it gets better. Over the past two years, he has seen more police officers resign while they’re in treatment. Previously, most went back to work. “Now, once they gain clarity, many say, ‘I want to stay healthy, and the way to stay healthy is get out of police work,’” he said.

Ryan Close decided to return to work in law enforcement. He has become an advocate for peer-to-peer support in his agency and beyond. He said his own mental health journey has made him a better police officer, with more empathy and improved communication skills.

His advice to fellow officers is to learn about the possible effects of trauma before they develop a serious problem. Also, he said, “establish a good dialogue with your family, your supervisors, your peers. Know what your limitations are. And learn healthy coping skills. Alcohol isn’t one.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

On days like these, Winn, who lives south of Atlanta, is haunted by the memory of her 6-by-9-foot prison cell, where she spent eight months in solitary confinement more than 10 years ago. She said she now feels “safest when I’m by myself.”

It’s a common paradox of solitary confinement, said , a professor of social psychology at the University of California-Santa Cruz. Instead of craving the company of others after release from social isolation, many former prisoners want just the opposite.

“Solitary forces prisoners to live in a world without people,” he said. “And they adapt to it.”

Research has long shown that solitary confinement — isolating prisoners for weeks, months, years and sometimes decades — has devastating effects on their physical and mental health. Once released, either to the general prison population or to the outside world, they can face a suite of problems, like and . They’re often hypersensitive to light, sound, smell or touch. Like Winn, they may struggle to read social cues. People, Haney said, “become a source of anxiety rather than support.”

And the coronavirus pandemic may have made the situation worse.

Before the pandemic, the estimated number of people in solitary confinement in the U.S. ranged from 50,000 to 80,000 on any given day, though many advocacy organizations believe counts are underestimated. The Centers for Disease Control and Prevention states that medical isolation — the separation of people with a contagious disease from the rest of the population — should not hinge on solitary confinement. Yet, at the height of the pandemic last year, up to 300,000 incarcerated individuals were in solitary, according to estimates from , non-profits focused on criminal justice.

“Jails and prisons, like many organizations, acted in fear,” said , deputy director of the American Civil Liberties Union’s National Prison Project. “They thought the way to keep people from infecting each other was to simply put them in solitary.”

Solitary confinement can serve many goals, from punishment to protection. And it is called many things — protective custody, restrictive or secure housing, administrative or disciplinary segregation, or simply “the Hole.”

“The conditions are essentially the same: It’s the extreme deprivation of any meaningful social contact,” Haney said.

In the so-called Mandela Rules, named for South African leader Nelson Mandela, who was imprisoned for 27 years, the associates solitary confinement lasting longer than 15 consecutive days with a form of torture. More than half of all U.S. states have introduced or passed some type of legislation restricting or regulating the use of solitary confinement — like limiting the practice for juveniles, for example. But it is still widely used in American jails and prisons.

Inmates in solitary typically live in a small cell for up to 23 hours a day. They have little sensory stimulation, like sunlight. Access to reading materials, educational programming and personal property is limited or nonexistent. Prisoners may get one hour in a recreational yard, an equally isolated area typically enclosed or surrounded by concrete walls, with a secured high window that opens for fresh air.

An analysis suggests that more than half of all prison suicides occur in solitary confinement. A found that the rate of self-harm among those in solitary is 10 times that of the general prison population.

The isolation can be particularly destabilizing for people with preexisting mental health conditions, often exacerbating underlying issues that cause people to end up behind bars in the first place. “It’s a downward spiral,” said Haney.

A study published earlier this year found that prisoners with mental illness, especially bipolar disorder, severe depression and schizophrenia, were up to 170% more likely to be placed in solitary for extended periods. In many prisons, experts worry, mental health treatment is nonexistent, making matters worse.

But even among people without a history of mental health problems, it may be impossible to predict who is susceptible to the harmful effects of solitary confinement, including suicide.

Pamela Winn, a registered nurse by training, was incarcerated in 2008 and later convicted to a 6½-year federal prison sentence for . As the now-53-year-old African American woman with red-colored curls sits in her ranch home, her mind goes back to what she said was the darkest time of her life.

When she entered a federal holding facility south of Atlanta, she said, she was a healthy woman. She was also six weeks pregnant. One day, she fell as she was trying to step into a van while shackled. Three months later, she miscarried and was put into solitary confinement for what she was told was medical observation.

After a few months, she was transferred to a municipal prison, where she was placed into solitary again, this time for protection. For a total of eight months, at two facilities, she lived in tiny cells, with iron beds, thin foam mattresses, and metal sinks with toilets attached.

“No window. No mirror. No clock. No concept of time,” she said. She was allowed to leave her cell for one hour a day. She could shower three times a week if staffers were available.

In the beginning, she replayed the traumatic memory of the night she lost her baby. Eventually, she joined in when other inmates screamed in their cells.

“I acted out. I threw stuff against the wall. I was angry,” she said. Before she went to sleep, she prayed for God to take her. “But I kept waking up.”

In Haney’s experience, prisoners who develop a strategy to withstand the excruciating loop of idleness have a better chance of surviving. Some individuals force themselves to maintain a routine, to act as if there is a coherence in their life, “even though there isn’t,” he said.

Winn said she developed a strategy: She would start the day by praying. She would picture what her two teenage sons were doing. She would do sit-ups and mental exercises, like remembering street names. After solitary, she served most of her sentence in a federal prison in Florida and was released in 2013.

Her time in solitary scarred her for life, she said. To this day, she has high blood pressure. Paranoia is a constant companion; her house is surrounded by a solid wooden fence with a security gate, and she has two Rottweilers. Small spaces make her anxious, and she can’t tolerate strangers getting too close, such as in a coffee shop line.

While she struggles to connect with her granddaughter, Winn keeps a journal, hoping that one day, when her granddaughter is old enough, she’ll understand.

“She can read it and learn about everything that’s in my heart and on my mind … if I’m still here, if I’m not here, wherever I am.”

Both Haney and Gregg said jails and prisons have alternatives to long-term, extreme isolation. Mentally ill prisoners who engage in disciplinary infractions should be put into a treatment-oriented unit, said Haney.

For someone who acts violently, solitary confinement should be only a short-term solution aimed at acutely de-escalating the outburst, said Gregg. Afterward, those individuals should go to units that provide programming to address the root cause of their behavior. This may mean separation from the general prison population, but less time in total isolation.

A similar model could also apply to prisoners in solitary for their own safety, such as former Minneapolis police officer Derek Chauvin, who is serving a 22½-year-prison sentence for the murder of George Floyd. They could be placed in smaller units with individuals who have undergone a thorough risk assessment, and with access to education and training, Haney said.

Prisoner advocates are hopeful that solitary confinement in the U.S. will eventually be a concept of the past. In April, New York became the first state to codify the U.N.’s Mandela Rules that ban solitary after 15 consecutive days, when the was signed into law. The legislation will take effect next April.

After Winn’s release from prison, she founded , a nonprofit that advocates to end the mass incarceration of women of color, and pregnant people, in particular. She also helped enact laws in Georgia and North Carolina that bar the shackling of pregnant women.

“What I’m doing now gives me some redemption,” she said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

ATLANTA — Robin Hancock gently worked her steel tongue drum with a pair of mallets, producing a set of soothing, mystical tones. They blended with the soft sound of chirping birds and bubbling creeks pouring from a Bluetooth speaker. Her warm voice invited the two visitors in the dimly lit room to slip into a nature setting of their choosing.

The 20-minute guided meditation took place at an unlikely location: , which until 2020 was the world’s busiest passenger hub. The airport interfaith chapel’s executive director, Blair Walker, introduced the meditation sessions last fall in the midst of the covid-19 pandemic.

People were noticeably more stressed during the past year, Walker said as he stepped out of his office onto the second-floor gallery, which overlooks the airport’s main atrium. Walker is an ordained minister who previously worked in higher education and public health. He said people have been quicker to lose their temper, lose their patience or lose it altogether.

“There was a tightness that I’ve never seen before,” he said.

That’s why he brought on board Hancock, a , to join his team of 40 volunteer airport chaplains. She said her goal is to provide people with “a piece of calm in whatever storm is going on at that moment” and leave them with a tool to use the next time they’re feeling overwhelmed.

“Traveling is tough,” said , a clinical psychologist and assistant professor at Atlanta’s Emory University School of Medicine. Airports, in particular, trigger panic and anxiety because of the frenetic pace, noise and glaring screens, she said, but covid amplifies travel anxiety.

Airport chaplains have become close witnesses to people’s worsening mental condition. “No doubt, the pandemic has accelerated the need for our services to a new level,” said the Rev. Greg McBrayer.

McBrayer, an Anglican priest, is the corporate chaplain for American Airlines and director of the , the world’s largest airport chapel. During the pandemic, he said, he has seen depression, anxiety and addiction increase among the travelers and workers served by him and his staff of 20 chaplains.

“We have encountered a tremendous amount of grief and fear,” McBrayer said, especially among airport employees. In the past year, he logged over 300 counseling sessions via Zoom and more in person.

Many struggled not only with economic woes, health concerns and covid deaths, but also with feelings of guilt for being well and employed when some of their former colleagues weren’t. “We’ve seen a lot of workers come up to the chapel because they need a quiet space to sit, chill and maybe cry,” said Walker.

In the early months of the pandemic, Hartsfield-Jackson also became a refuge for up to 300 homeless people per night, many with mental health conditions such as addiction and schizophrenia. They were redirected to hotels rented by the city. Now, the  is conducting a $400,000 study of homelessness at airports, including how to stage mental health interventions.

“We will put together best practices of what airports can do to assist these vulnerable populations,” said Steve Mayers, the airport’s director of customer experience who is chairing the panel guiding the study.

Chaplains typically encounter people in distress as they walk the concourses in what they call “the ministry of presence.” Walker and McBrayer said they’ve seen more breakdowns and panic attacks during the pandemic. Many of these events are triggered by the contentious issue of wearing masks, said Walker. A few weeks ago, a gate agent called when a passenger furiously refused to wear a face covering and then broke down as the airline took her off the flight.

“It was obvious there was much more going on than just the mask issue,” Walker said.

The guided mediation at Hartsfield-Jackson is designed to “help people breathe, recenter, step away,” said Hancock, who inherited a love of flying from her pilot father and volunteers at the airport once a week. On a busy day, each session has up to five participants to accommodate physical-distancing guidelines.

“I can read people pretty well,” she said. “Many of them carry a lot of vulnerability and angst right now.”

Most people are quiet when they come in, and their bodies are tense. Hancock remembers an older couple who were on their way to Texas for a family emergency. After the meditation, the couple became more talkative. “They were fearful about what to expect. They were fearful about traveling,” Hancock said. “They were fearful just being among people.”

Cattie, the clinical psychologist, said practices such as mindfulness, meditation, yoga and controlled breathing can be very effective at thwarting anxiety triggers that are inherent in air travel.

Mental health and well-being were on the radar of airport administrators long before covid, but some services were paused because of the pandemic. Now, though, they’re making a comeback. Several airports have yoga, stretching and silent meditation areas. Live music and therapy pet programs are also intended to calm stressed-out travelers.

As more people get vaccinated, passenger volumes continue to rise and more trips are for vacations and other joyous occasions. Still, Cattie expects the pandemic’s mental health fallout to last a while longer. “Covid has seeped into every crack and every foundation and created so much loss and change and fear,” she said. “There will be a huge echo.”

In her clinical practice, she’s seen many patients who are anxious about rejoining life, with its crowded places and people on the move. “This past year, many of us have been living in a safety bubble,” she said. For most people, traveling is a social muscle that hasn’t been exercised in a while. “It’s OK to be scared,” she said. “It’s normal to feel uncomfortable.”

[Correction: This article was revised at 10:15 a.m. ET on April 23, 2021, to fix an inaccurate description of the ’s study of airport homelessness and the Hartsfield-Jackson airport’s role in the research.]

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

“It doesn’t look like a hospital, and it doesn’t feel like a hospital,” Kristy Nations said on a recent visit to pick up medications at the pharmacy. “It actually feels good to be here.”

Profits from the tribe’s casino have helped the 12,000 members of the Eastern Band of Cherokee Indians opt out of the troubled U.S. government-run Indian Health Service. They are part of an expanding experiment in decentralization, in which about 20% of federally recognized tribes in Oklahoma, California, Arizona and elsewhere have been granted permission to take full control of their health care.

For the North Carolina Cherokee, self-governance has meant adopting an integrated care model designed by Alaska Natives to deliver care that not only improves patients’ health, but also is tailor-made for the needs of the tribe. It has meant the opening of a 20-bed state-of-the-art facility in 2015 and the construction of an 18-bed mental health clinic scheduled to open in October 2020.

The hospital is a “medical home for our people,” said Casey Cooper, the hospital’s CEO who is a member of the tribe.

Half of the Indian Health Service budget is now managed by Indian tribes to various degrees. But while full control has worked out well for tribes with resources like the Eastern Cherokee, they are one of just a few bright spots in an otherwise dire medical landscape. It remains to be seen how widely this model can be applied.

“Not all tribal communities have access to the economic opportunities that we have,” Cooper said. “Some tribes are in these desolate, remote locations where there are no natural resources or economic development opportunities. I get that.”

Self-Governing To Change The Narrative

The U.S is legally obligated to offer health services to all members of the 573 federally recognized tribes. Yet the federal Indian Health Service, which currently provides direct care to about 2.2 million out of the nation’s estimated 3.7 million American Indians and Alaska Natives, is chronically underfunded. The current IHS budget is about $5.4 billion, yet the National Indian Health Board estimates the total .

American Indians are more than twice as likely to get diabetes and six times as likely to get tuberculosis than the average U.S. population. Mental illness, and especially substance abuse, runs high in Indian Country. Native Americans are than any other ethnic or racial group.

Health disparities are particularly harsh in the Northern Plains region. In the Dakotas, average life expectancy among American Indians is 20 years less than among white Americans.

“You do not have to cross an ocean to find Third World health conditions,” said Dr. Donald Warne, a professor of public health at the University of North Dakota and an Oglala Lakota tribesman. “You can find them right here, in the heartland of the United States.”

One particularly grim example is the Rosebud Indian Reservation in South Dakota. In 2015, the Centers for Medicare & Medicaid Services found so severe that they shut down the emergency room for six months. During this time, at least five patients died en route to other hospitals located sometimes 100 or more miles away. , the situation has only slightly improved.

“The Indian Health Service respects tribal sovereignty and is committed to tribal self-governance,” said IHS spokesman Joshua Barnett. “IHS recognizes that tribal leaders and members are in the best position to understand the health care needs and priorities of their communities.”

Self-governance also allows tribes to be eligible for Medicare, Medicaid, private-sector health insurance, partnerships with larger health systems and even federal grants that are designed for underserved communities — all which can be limited for the IHS.

“Generally speaking, tribally operated health care systems tend to run more efficiently, more effectively and with higher quality of care than IHS-managed systems,” said Warne.

Money Makes A Difference

The Cherokee Indian Hospital is lucky to be supported by a tribe that’s economically thriving due to gambling revenues, according to Cooper. The Qualla Boundary is home to Harrah’s Cherokee Casino Resort. It’s a unique situation, said Indian health expert Warne, as most reservation casinos don’t make huge profits.

The hospital’s annual budget has grown from $20 million to over $80 million within the past 17 years. The largest sources are third-party reimbursements, mostly from Medicaid and Medicare, at $27.4 million, followed by IHS contributions and tribal funding.

In 2012, the hospital decided to implement a new, patient-centered approach called the , created by the Southcentral Foundation, a nonprofit health provider owned and led by Alaska Natives. A Cherokee delegation visited a Nuka program to see how it could be tailored to their culture and health needs.

“An integrated approach is more consistent with traditional healing,” Warne said. Since “we don’t separate our physical, mental, spiritual and emotional health the way we do in modern specialized health care.”

At Cherokee Indian Hospital, patients are assigned a team, which typically includes a primary care physician or a family nurse practitioner as well as a nutritionist, a pharmacist and a behavioral health specialist.

Rebuilding their health care prompted the need for the new hospital. Gambling revenue covered most of the costs for the $82 million facility. “The old building was outdated and inefficient,” said Cooper, “a constant reminder of the paternalistically provided Indian Health Service.”

The new hospital’s main concourse — called Riverwalk — tells stories from Cherokee legend through graphics of a winding river, fish and turtles inlaid in the terrazzo floor. Signs are written in English and Cherokee. A literal translation of the emergency room sign is “Get better in a hurry,” and the dental suite is “the place that gives you a big smile.”

Patients can receive dialysis, acupuncture, massage therapy and chiropractic care. The ambulance bay, surgical suite and in-patient unit are located out of patients’ view to reduce anxiety and stress.

“The building really is one big strategic tool,” Cooper said.

Nations, the patient visiting recently, remembers the old days when she and her family, many of them dealing with diabetes and some on dialysis, used to wait for hours in the former hospital, a dark space dubbed “the bunker.”

The 46-year-old said that she’d typically see different providers every visit. “And every time I would have to tell my story over and over and over.” Now, she feels somewhat accountable to her care team — and more motivated to make and keep appointments.

“Back then, if my provider had wanted me to see a nutritionist, for example, I would have probably said, ‘Whatever,’ and forgotten about it,” she said.

“We’re trying to build a relationship with our patients,” said Richard Bunio, the Cherokee Indian Hospital’s clinical director who is Canadian and married to a tribe member. He noted that Native Americans generally have suffered a lot of historical trauma, leading to deeply rooted mistrust of mainstream medicine.

By quality measures, including the , the hospital has recently performed in the top quartile for blood pressure control, blood sugar control and several cancer screenings. Also, Cooper added that in the past four years the diabetes rate in the community has leveled.

Could It Work Everywhere?

It is uncertain if self-governance would work for tribes such as the Rosebud Sioux or the Oglala Lakota on the Pine Ridge Indian Reservation, where geographic isolation, poverty and a lack of resources make new health care investments difficult.

“It’s a huge challenge, but it’s possible,” said Warne, adding that philanthropy or partnerships with an academic health system might help finance such projects.

Not too long ago, tribal officials from South Dakota visited the Cherokee Indian Hospital. Despite their geographic and socioeconomic challenges, Cooper said, he believes self-determination is essential for their future. “Self-determination works. Self-determination is the right thing. And self-determination is the catalyst to restoring the health of our communities.”

Yet many of the South Dakota tribal leaders remain skeptical. They are concerned that self-determination would let the federal government off the hook from its responsibility to provide health services.

Therefore, the Rosebud Sioux took a different route. Instead of just parting ways with the IHS, they sued the federal government for violating treaties. The case is pending in court.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .