We’re all working now to safeguard our physical health and “flatten the curve” by staying home and limiting in-person contacts. But what about our mental well-being?
The public health response to the pandemic carries heavy psychological costs. We need to deal with them, especially if measures to protect the public — many of them executed in a slapdash way already — toughen and must be sustained for long time stretches for which people are unprepared.
Are you already feeling bored, anxious, depressed, and sad as you sit at home? Are you obsessing about coronavirus news? Worried about whether you have enough groceries and household supplies? Are you frustrated, grumpy, or angry with roomies or loved ones? Sleeping late and taking too-frequent naps? Do you find yourself going on binges, with snacks and too-big meals, or with excessive TV watching or devouring online content on a screen? Hitting the booze or other intoxicants more than you used to?
Covid-19, in medical terms, may be a viral assault on the respiratory and other body systems. But to defeat it will require our adopting winning ways for our hearts and minds, too. We will need not only physical strength but also mental and psychological resilience. Here are some ways to avoid having the virus grind down your spirit and mental well-being …
Pandemic takes psychological toll on a nation already anxious, stressed, lonely
The leading way that experts want Americans to reduce Covid-19’s harms is for us all to keep our physical distance from each other. That’s a tall order, though, for people who already are struggling with high anxiety and other emotional ills.
Even before the coronavirus, the nation had big issues with too many people feeling on edge, as this newsletter has noted. Slightly less than a quarter of adults and a rising number of young people suffer from anxiety disorders, which have become the nation’s most common mental woes, experts say. They’re as real to those who suffer from them as any physical complaint. The deep apprehension that sufferers feel exceeds the worry or jitters that are part of everyday life. It becomes a dread that patients and experts describe as “deep, persistent, seemingly uncontrollable, overwhelming, excessive, irrational, and disabling.” It’s often accompanied by crushing depression.
Some experts trace the anxiety problems to Americans’ hectic, demanding, over-pressurized modern life, especially with its 24/7, electronic-device-driven, social-media-laden existence.
We’re not alone in coping with the rising mental health challenges of modern life. But more than a quarter of Americans, many in urban areas, also live alone now. This is often their personal choice. It means that singles abound in all age groups, old and young. This affects many aspects of life, including our work, housing, entertainment, transportation, and how, where, and what we eat. It adds billions of dollars to our spending to care for seniors.
As social animals, we’re also struggling with the negatives of being by ourselves so much.
Many of us, with hectic and demanding careers, already march through the day locked up alone in offices or work cubicles, staring at electronic screens. We grab lunch by ourselves and eat at our desks. We gulp down a fast-food dinner in solitude, multitasking all the way, pounding at the laptop with unfinished work chores. Then, it’s off to restless sleep, and too little of it.
The seclusion routine may be even more intense for those striving in the “gig” economy, because even in normal times there may not be a workplace for them to head off to or colleagues to work with day by day.
In many jobs, even our interactions with colleagues or bosses in regular times may be clipped, formal, and with few human — as opposed to business-related — exchanges.
There is, of course, a crucial distinction between solitude and loneliness. People can do fine if they want to be by themselves and are comfortable with it, for short periods or even a lifetime. But too many single people experience social isolation and loneliness. So, too, can people in unsatisfying marriages and unhappy households.
And now, Americans are trying to figure out the best ways to battle the unnerving uncertainty of a novel and exploding disease, while also seeing the economy crater and national leaders veer from one contradictory message to another.
This can be the setup for hard days ahead, as New York Times columnist David Brooks has warned:
“Some disasters, like hurricanes and earthquakes, can bring people together, but if history is any judge, pandemics generally drive them apart. These are crises in which social distancing is a virtue. Dread overwhelms the normal bonds of human affection … Fear drives people in these moments, but so does shame, caused by the brutal things that have to be done to slow the spread of the disease. In all pandemics people are forced to make the decisions that doctors in Italy are now forced to make — withholding care from some of those who are suffering and leaving them to their fate …Pandemics induce a feeling of enervating fatalism. People realize how little they control their lives … Pandemics also hit the poor hardest and inflame class divisions … In her 1976 dissertation, ‘A Cruel Wind,’ Dorothy Ann Pettit argues that the 1918 flu pandemic contributed to a kind of spiritual torpor afterward. People emerged from it physically and spiritually fatigued. The flu, Pettit writes, had a sobering and disillusioning effect on the national spirit.”
When we feel alone, blue, and afraid, this can be detrimental to our health. The research is building, for example, as to just how harmful loneliness and social isolation can be.
These circumstances have been shown, the New York Times reported, “to impair health by raising levels of stress hormones and inflammation, which in turn can increase the risk of heart disease, arthritis, Type 2 diabetes, dementia and even suicide attempts. Seniors who said they felt left out, isolated or lacked companionship saw declines in their daily ability to care for themselves, with reduced bathing, grooming, and meal preparation. Their deaths increased over a six-year study period relative to people who reported none of these feelings.”
Wired magazine reported this about the damage of isolation and loneliness:
“T]he psychological strain of loneliness manifests physiologically, too. Harry Taylor, who studies social isolation in older adults, particularly in the black community, says that it’s one of the worst things that humans can do to their overall well-being, adding that ‘the mortality effect of social isolation is like smoking 15 cigarettes per day.’ In older people, social isolation seems to exacerbate any preexisting medical conditions, from cardiovascular diseases to Alzheimer’s, but its ill effects aren’t limited to those over 60.
“Alexander Chouker, a physician researcher who studies stress immunology at the University of Munich, has seen radical changes in the bodies of people participating in simulations of manned spaceflight missions like Mars-500. ‘They were young and trained people not in a condition of real threat,’ he says. ‘The pure fact of being confined affects the body. If you change your environment in a quite extreme way, it is changing you.’ Participants, some of whom were only isolated for three months, experienced changes to their sleep, changes to their immune, endocrine, and neurocognitive systems, and alterations to their metabolisms. ‘Being confined and isolated affects the human physiology as a whole,’ Chouker says.
How to rein in obsessive-compulsive behavior
There are good, proven ways to optimize our mental well-being during this pandemic.
Uncertainty can fuel anxiety, and knowledge can be empowering, so dedicate a fixed part of your day to finding credible information on timely topics of concern. Don’t lose valuable time and energy by getting sucked into online warrens of doubt and misinformation. Check yourself because you may be showing classic symptoms of obsessive-compulsive disorder, and you may benefit from professional help for it.
To help deal with your compulsions and fears, develop lists of subjects and even key questions you want to tackle. Put your worries down on paper, don’t let them loop endlessly in your mind and wear you down. You may find it helpful, for example, to at least sketch out your finances for the short term, so you can see how you may need to seek help that soon will be coming from various private and government sources. Even creating shopping lists can be useful, letting you see what you need versus what you want and determining the urgency and difficulty in acquiring goods and services.
With medical and scientific matters, be skeptical and rely on credentialed experts. It may be helpful to limit your social-media exposure and consumption of opinion, as opposed to fact-based material. It may be useful to reduce the attention you give to politicians — unless they are delivering official information that directly affects you and yours. This may reduce your anxiety and help keep your stress and blood pressure down.
Beware of scams, purveyors of bunk, and even well-intentioned friends, colleagues, and family members who may unintentionally be spreading rumors or outright falsehoods. We all can be better consumers of scientific and medical information, and now may be an ideal time to do so.
If you start to feel overwhelmed, pause, listen to yourself, calm yourself, and determine the sources of your anxiety. It may help to take deep breaths, to try to clear your mind of negative thoughts, and to meditate and empty yourself of concerns, if even for a few moments.
Think about this: Experts say Covid-19 is highly contagious and many of us may get infected. For many of us, the cases will be uncomfortable, with fever, aches and chills, and a dry cough. Many of us will fight off the disease after a brief period. Some of us will get sick enough to need hospitalization. Many Covid-19 patients, with intensive medical care, will recover. A slice of the total number of infected patients will not make it. But it is not helpful to you and your mental and physical health to either under- or over-estimate this illness, but rather to take appropriate steps to safeguard yourself and your loved ones.
Human beings, over the millennia, have prospered by becoming creatures of habit, order, and structure. Who knows how long the nation will operate under virus-related strictures? So, build and keep working on a regular, scheduled day for yourself and those around you.
Experts from the “gig economy” can share hard-won knowledge about optimizing your WFH, as the kids call the practices of working from home. It may start with simple stuff, such as: rising at a set time, making that bed, getting showered and dressed (yes, it doesn’t have to be a suit but think hard about getting out of those sweats, and, for sure, put on shoes, so you’re less inclined to sneak off to a nap), taking regular breaks, and ending the day at a time certain, too. If you can, set up a separate work space. If you live with others who also are working, see if you each can have your own space. If not, well, your work boundaries in the house will be part of several matters you will benefit from hashing out, immediately. More on that in a second…
If you’re working from home, talk with colleagues and supervisors to ensure you are communicating, being realistic and setting boundaries about objectives for what you and your enterprise can accomplish in the difficult days ahead. Be aware that the people you deal with may be experiencing great stresses (personal, financial, and more) about which you may not know. Prove columnist David Brooks wrong: Try to be more patient, empathetic and concerned for others during this pandemic.
Under normal circumstances, crucial items of self-care would top many of our to-do lists. In these unfamiliar and even scary times, it will be more important than ever to eat well, exercise, get plenty of rest and sleep, and minimize consumption of intoxicating substances. Because Covid-19 attacks the respiratory system with ferocity, it may be more crucial than ever, please, to not smoke or vape.
As matters stand, not even the toughest virus-related restrictions lock people in their homes. Experts say you can and should get outdoors, if you can. Take long walks, keeping the recommended distance from others. Get the dog on a leash and saunter around the block. Work in the yard. If you’ve got exercise equipment or appropriate personal workout facilities in your residence, using them may be a real boon to your physical and mental well-being.
The panic buying of groceries and household items appears to be easing. This may allow you to take advantage of your home time by eating better — as a well-known expert has described it: “Eat food. Not too much. Mostly plants.” Try to avoid excessive snacking all day long. If circumstances allow, dine old-school, meaning take in a good breakfast, a light lunch, and an early dinner that aims to be a show-off meal for the day. It need not be big. But if prepared with care, a simple, home-cooked meal can be a small celebration — by ourselves or with those whose company we share at home. If time and budgets allow, and if local authorities permit it, support hard-hit restaurants by ordering take-out meals, including by delivery. Here’s hoping that many of us, down the road, will remember some pleasure we experienced with quiet, relaxed dinners in the house with a salad, a veggie, a taste of carbohydrates, and a bit of protein.
There will be ample causes for consternation in the days, weeks, and months ahead. So, after dinner — and, of course, as empty time in your day allow — consider resolving to use this odd interlude to explore your interests and find diversions. You’ll have enough on your mind without revving it up before bedtime with violent, noisy entertainments, whether gore-soaked TV or movies or violent video games. Dive into that stack of novels or nonfiction books, instead. Start your own novel or play, or jot down memories of this unique period in a diary that, yes, historians or loved ones may value and appreciate years from now. Rather than lamenting the absence of televised sports or getting mired in poor-quality network dramas, try streaming comedies, stand-up acts, international dramas, musicians and singers, or nature and science programming. If you’ve wanted to improve your culinary capacities or polish your conversation in another language, check out online educational sites for yourself and the kids. Or support artists and the arts by taking in special productions they are offering through online services, some of which may be available to you with nothing more than a card from your local public library.
It may be tempting to stay up late, blanking out the day with a glass of beer or wine or a tumbler of scotch, all while glued to the glare of a blue electronic screen. Avoid this, please. Instead, to protect your physical and mental health, make a priority of getting lots of rest and decent sleep. Shut things down well before keeping your regular bedtime. And don’t sleep in. Get up at a fixed, respectable hour, so you don’t feel you’ve lost the day from its start. You have challenges to face, and they will be tough to escape because many of them will now be shut in with you at home.
Human Relationships: A key to resilience
Even as experts warn us to keep physical distance from each other to protect our physical health for now, our well-being — especially our mental health — will depend in the longer term on how close we can stay to our colleagues, friends, family, and other loved ones. Relationships may make or break us, experts caution.
Friends (roommates) and couples may not have planned to spend so much time in the close confines of a home or residence. Now that circumstances demand they do so, they need to take the time to figure how to make their needs clear and how to work together to keep each other as happy as possible.
If you have set up schedules, you can put them side by side to see where they click — or don’t. If you’re living with someone whose work requires frequent phone or online discussions, maybe you need the best noise-blocking headphones that you can lay hands on. You may need to dedicate space and set up flags or markers if your spouse or flat mate participates in video conferences — social-media sites are filling up with stories of kids or partners caught in embarrassing situations in the background of online business sessions.
It also may be true that all the occupants of the house seem to run on conflicting schedules, with some taking early times while others work or study late. Talk through the problems, seek workarounds, and do what you can to not only preserve the peace but also make everyone feel understood, even if that takes more effort.
Friends and couples also may need to realize that they need their own time and space. Make the offer, but don’t insist on doing everything together all day and all night. Take separate walks. Shop, as is allowed, separately — unless help is needed.
This cooped-up time also may be evolutionary or revolutionary for many relationships when it comes to determining how vital chores get taken care of. It may be past time for a sexism check, with plain talk due about how household work gets apportioned fairly so no one person does all the cleaning, washing, cooking, and other domestic labor. Again, self-awareness, lots of talk, and compromise can be valuable — if you’re the Odd Couple, figure out who is Oscar (the slob) and who is Felix (fussy and fastidious) and negotiate how your idiosyncrasies can be made to mesh.
The domestic bargaining gets more freighted, of course, when some of the parties involved are pint-sized or only a bit bigger. Young people need their own special care to deal with difficult times. It’s a safe bet, too, that before this pandemic gets resolved, many parents may be clamoring to increase teacher pay and grant schools whatever they want — just so they take charge of the youngsters again.
Many schools, as much as they can, are making yeoman efforts to assist parents in home-schooling kids, offering lessons, activities, and sound counsel, notably through evolving online initiatives. Educators are taking advantage of public broadcasting systems (TV and radio) to provide instruction, too. Still, moms and dads will find themselves spending big chunks of their day not only with unplanned pedagogy but also in dispute resolution and other normal kid-rearing activities.
This will be tough on everyone involved, especially because children may be on edge, their emotions raw and their feelings tender. They may not understand. or be comfortable with, the fear and uncertainty created by the pandemic. And they lack the maturity to handle the difficulties of their situation. They will want to be with friends, doing kid stuff, and, particularly depending on their age, separate from — ugh — parents.
Youngsters need their space, too, but they also require varying levels of supervision, structure, and boundaries (which they will push hard against). When some kids find themselves online already for learning, they may want to stay for inappropriate time with video games or other cyber activity, including chatting and meeting others online. This can be risky and needs to be monitored.
Grownups will find themselves doing lots of conversing, cajoling, and scolding as they take on 24/7 care for their kids. All concerned, looking back, may find this a special and rewarding time. It also will be frustrating and exhausting for the grownups juggling in close quarters their kids’ needs, their own jobs and careers, household duties and finances, and their own needs and stresses. Single parents may find themselves, frankly, pushed to the breaking point. It may be important, too, to keep an eye and ear out for friends, neighbors, and loved ones who may be locked into abusive situations that may require law enforcement or other interventions.
Technology may provide some assistance in keeping connected with others — with email, texting, and video conferencing But let’s also not forget the virtues of hanging out over the front yard or back fence — maintaining that 6-foot distance, of course — to chat with neighbors. Or the relief that can be found in old-fashioned telephone calls with colleagues, friends, and loved ones.
Covid-19 is proving to be a fearsome parasite, attacking men with greater severity than women, and older people with underlying health conditions perhaps more than young people. The disease has become opportunistic enough to fell patients aged 20 to 50, such that they represent roughly 40% of hospitalization, so everyone needs to follow the recommended cautions to prevent infections’ spread.
That said, it may be important for us all to reach out to older adults (and they to us, too), particularly those who may be debilitated and isolated already. They may need someone to help shop for groceries and household goods or assist with filling prescriptions or getting to medical appointments. They also may need human contact to ease their worry that they may be forgotten and alone. The public health guidelines about the coronavirus have chagrined many Americans who have found themselves deemed in an “older and higher-risk” group, starting at age 55. Do remember this: Roughly 60% of us are at higher virus risk because we have “underlying health conditions” ”These can include obesity, diabetes, high blood pressure, asthma, and immune systems compromised, for example, by treatment for many different kinds of cancer and other chronic conditions.
Translation: Covid-19 puts us all at risk for many different reasons, including our health or because of our always precarious personal and financial situations. This, in turn, can crank up the individual struggles we all may have with our mental well-being.
We’re always, though, in this pandemic together. We’ll pull through, with the appropriate physical distance and by helping and supporting each other. Remember that research increasingly shows that when we exercise humility and gratitude and show others kindness, this also benefits our health and well-being.
Many of you who read this newsletter already have battled serious illness or injury. Many of you have fought to remedy wrongs in medical practice with sometimes arduous cases in the civil justice system. You, and we, know about common sense, moxie, and resilience, as well as the power of reciprocal altruism. Keep those chins up. And here’s hoping you stay healthy throughout 2020 and beyond!
PTSD a heightened risk for those hit by high demands
It won’t happen to everyone, but for many people the pandemic will be shocking and scary. These are all ways that may trigger some individuals to suffer post-traumatic stress disorder (PTSD).
Health care workers and first responders may be especially subject to PTSD, as they toil in life-and-death conditions with long hours, great uncertainty, serious risk to themselves and those around them and with sadness, sickness, and death surrounding them.
Doctors, nurses, and other medical personnel, as well as police, firefighters, and paramedics, may force themselves to push through their high-demand situations, telling themselves that they are trained to help others and they will take care of themselves later.
But they may need to watch for signs later that they have psychological trauma. They may have PTSD if they experience scary flashbacks, bad dreams, and frightening thoughts. They should check if they find themselves avoiding specific sites or objects that increase their anxiety, or if they find they keep summoning back or rejecting memories. They may need to be aware if they are easily startled, always tense or on edge, can’t sleep, and have problems controlling outbursts.
These are the symptoms of PTSD, and they may wish to seek professional counseling, with the prospects of therapy and medication to help.
As federal experts have suggested in a special memo on this issue:
“A strong service-orientation, a lack of time, difficulties in acknowledging or recognizing their own needs, stigma, and fear of being removed from their duties during a crisis may prevent [health care] staff from requesting support if they are experiencing stress reactions. Given this, employers should be proactive in encouraging supportive care in an atmosphere free of stigma, coercion, and fear of negative consequences. Self-care for health care workers can be complex and challenging, given that people in these roles may prioritize the needs of others over their own needs. Therefore, a self-care strategy should be multi-faceted and phased properly to support the sense of control and contribution of health care providers without making them feel unrealistically responsible for the lives of patients.”
It will be important for colleagues, friends, and loved ones to keep watch for PTSD in people besides health care workers or first responders who also have been stressed by the pandemic in big and bad ways.
Might we see mental health issues among workers in grocery or big box stores or with the over-burdened folks delivering many kinds of needed goods to our doors? Will folks who clean up and maintain areas where Covid-19 cases have occurred start to feel overwhelmed? What kind of extra psychological care might benefit those who must maintain vital services to shut-ins, seniors, the poor, or the homeless?
Some of these individuals may not be paid much, and they may not have the education, training or background to process psychological injury. They may have been forced to work long hours with suddenly great responsibility, and in unpleasant and uncertain circumstances.
Employers also may need to think ahead and be prepared to offer psychological support if workplace colleagues in numbers fall ill with the coronavirus or die from it. These will be surprising and shocking events, with hard-to-forecast effects on people throughout an organization.
That said, the experts at the National Institute of Mental Health have offered solace about PTSD, writing:
“It may be very hard to take that first step to help yourself. It is important to realize that although it may take some time, with treatment, you can get better. If you are unsure where to go for help, ask your family doctor … Caring for yourself and others is especially important when large numbers of people are exposed to traumatic events.”
Don’t let therapy lapse
Let’s not stigmatize mental health issues and their care in this stressful time.
Patients may find in the days ahead that they will receive help more online and less in person. That may mean that therapy sessions, individual or group, may be conducted via phone, apps, or video conferencing (telemedicine). Providers are racing to adapt to these high-tech options, and patients should discuss them fully with their therapists or counselors.
Alcoholics Anonymous long has emphasized the importance of sustained, repeated application of its well-known 12-step intervention. The organization — and others helping those with substance-abuse problems — has spread the word that its programs will go on, in a fashion, online. AA groups, for example, may work together through the video conferencing service Skype:
“Skype AA meetings operate similarly to face-to-face meetings. Our purpose is to carry the message of recovery to the alcoholic who still suffers. We use a Skype conference call, audio only, no video. Like AA meetings everywhere, there are a wide variety of members. Being Skype based, participants log on from all over the world. We have AA meetings every day. All meetings are open meetings (anyone may come and listen, but please do not share if you are not an alcoholic).”
Even before the pandemic, tech innovation had created a boom in online services and apps targeting users’ mental health and well-being. NPR has reported on the giant rise of Headspace, an app with revenues exceeding $100 million and providing guided meditation materials to users in more than 190 nations. Headspace and Sanvello, an app self-described as offering mental health services, both have content and materials to help users cope with Covid-19’s psychological challenges.
John Torous, the director of digital psychiatry at the Harvard-affiliated Beth Israel Deaconess Medical Center, told the MIT Technology Review that apps and “teletherapy” services like Talkspace can be helpful, with caveats:
“These apps help augment care or extend it. When they’re used as standalone tools as single interventions, there’s good evidence from meta-analyses that they might not be as effective, or not enough as treatment alone.”
Caveat emptor. Please discuss with mental health experts you know and trust, as well as your health insurer, if you decide to use apps or online services, which may have various charges for their offerings.
Recent Health Care Blog Posts
Here are some recent posts on our patient safety blog that might interest you:
- The opioid-overdose crisis has not disappeared, not by a long shot, and there’s a new warning about its toll: A blue-ribbon expert panel has urged doctors to expand testing for hepatitis C to all adults, ages 18 to 79, and no longer limiting the screening to those born between 1945 and 1965. That’s because the risky conduct that goes with abusing opioids also bumps up the risk of this potentially deadly but treatable liver infection. Hepatitis C is growing as a significant health concern, the New York Times reported
- Cold, hard facts — not hunches, arguments, or theories — matter most when tough health care decisions must be made. Americans have been reminded of this by painful headlines on the opioid and overdose crisis, the rise of lung injuries and deaths due to vaping, and, yes, now the rapid spread of a new coronavirus. Doctors, hospitals, insurers, Big Pharma, and other major parties in the U.S. health care system aren’t always as candid as they need to be, especially in disclosing how they harm and even kill patients. That’s a truth (with a small “t”) that readers can discover quickly in the Center for Justice and Democracy’s latest edition of its annual “Briefing Book: Medical Malpractice by the Numbers.” The center, at New York Law School, provides evidence about a field that has become the bogeyman for politicians, policy makers, and medical practitioners eager to hide egregious errors with extreme counter factual assertions.
- Although federal experts estimate that alcohol abuse leads to 88,000 Americans’ deaths annually and economic costs of almost $250 billion, one of the nation’s oldest and best-known programs to deal with this problematic behavior has long been surrounded by doubts. Critics have questioned its effectiveness, criticized its “irrationality,” and focused on its stepped regimen, desperate and self-enrolling participants, and core tenets, including its spiritual appeals to higher and external powers. But after a deep dig into the building and rigorous evidence about it — including scrutiny of 27 studies, (some of them randomized clinical trials) with more than 10,000 participants — researchers from Harvard, Stanford, and Europe have concluded in a published, research review for the respected Cochrane Collaboration that Alcoholics Anonymous, indeed, can be beneficial for many but not all excessive alcohol users.
- It sounds like a good idea. Have primary care doctors learn about older patients’ cognitive health by putting all of them, during routine office check-ups, through a few minutes of tests in which they are asked to recall lists of words, draw a clock face, describe the day and date of their appointment, talk about current events, and take on other simple tasks. Such screenings, some advocates for the aged say, can be an important way to diagnose early and try to provide for help for patients with dementia and its most common affliction, Alzheimer’s disease. But a blue-ribbon panel of experts that advises the nation on medical testing and procedures isn’t buying the argument: The U.S. Preventive Services Task Force (USPSTF) has given such screenings the group’s letter-grade rating of I, meaning the evidence is incomplete that a test or procedure is harmful or beneficial.
You also may be interested in this Covid-19 information provided by our law firm:
- Practical tips from a virus expert on how to protect yourself from Covid-19. My special newsletter edition (click here)
- What are viruses, anyway, and why should we care? My March 2020 newsletter (click here)
- And these recent blog posts on topic: As pandemic grips the globe, outbreaks, too, of ‘What were they thinking?’ Or: Trump storms into medical-ethics minefield by flogging drugs’ untested use. And: Life grinds to a halt as Americans start to deal with gravity of Covid-19 spread.
Patrick Malone & Associates