A thought occurred to me -and it relates to the implications of COVID-19 on mental health. I noticed that several bodies had noted these consequences as well. I found the take on the issue in the Psychiatric Times interesting and therefore decided to share with you, dear reader. It is by Liebermahn et al, titled “Meeting the Mental Health Challenge of COVID-19 Pandemic” and published in the Psychiatric Times of April 24, 2020.
The piece notes that the public is gripped by fear of the novel coronavirus of 2019 (COVID-19). The worry is whether the health system will be able to treat them or their loved ones should they become ill. As a result, clinical and public health efforts have focused on acute medical care needs of those who are severely affected, while containing the virus’s spread in the population. Measures have included expanding hospitals’ capacities to care for sick patients and equipping health care providers to meet the unprecedented medical demands while keeping them safe. Others are efforts to validate diagnostic tests and bring them to scale while developing effective acute and preventive treatments, including vaccines.
It is important to look at the mental health consequences of the pandemic. While the urgent emphasis is and should be on containing the virus and its physical threat, when the pandemic has subsided and we begin to resume normal life, it is the psychological effects of COVID-19 that will emerge and persist for months and years to come.
During the acute crisis, everyone, to varying degrees, will experience fears of infection, somatic concerns, and worries about the pandemic’s consequences. Compounding personal distress are the disruption of usual daily routines and the social isolation imposed by the “stay at home orders” measures. Longer periods of physical isolation, especially if experienced as involuntary, without an adequate and convincing explanation, or accompanied by financial losses can compound risks of adverse mental health consequences of physical isolation.
People with pre-existing or constitutional vulnerabilities to psychiatric disorders including anxiety, depression, obsessional symptoms, substance use, suicidal behavior, and impulse control disorders will be especially vulnerable to stress-related symptom exacerbations.
While admitting the possible existence of these psychological effects in the population, we do not yet know their extent or impact. There have been previous natural and man-made disasters, but nothing in our lifetimes compares to the scope of the COVID-19 crisis. The last comparable event was the Spanish Flu Pandemic of 1918. Subsequent epidemics including polio, HIV, Ebola, MERSA, SARS, and Swine Flu, though in some cases more virulent, were much smaller in scale, shorter and less disruptive to society.
While the polio and HIV epidemics may bear some similarities to COVID-19, they did not approach the magnitude of population-wide psychological impact. Therefore, studies of the mental health effects of recent epidemics offer limited guidance about after-effects of the COVID-19 pandemic. One could compare COVID-19 to the Great Depression of the early 1930s. In a variety of contexts, economic crises have been found to be associated with an increase in depression. Increased rates of depression, anxiety, substance use, and post-traumatic stress disorder (PTSD) have been found to follow natural disasters, such as earthquakes, hurricanes, tsunamis, or floods. If similar patterns hold for the COVID-19 pandemic, long after the physical threat of infection has subsided, psychological effects will induce or worsen mental disorders in vulnerable people. Behavioral effects of persistent distress within the general population will also be a major consequence.
The expected increase of various mental disorders and cumulative psychological stress on the population will further strain the mental health and primary care systems and expose the limitations of its infrastructure, work force, and accessibility.
To stem this tide, efforts should begin with those who are at increased risk of adverse mental health outcomes including patients with pre-existing mental disorders vulnerable to such stressors. Such persons may need adjustments in their treatment and increased frequency of contact with their mental health providers.
Others include people who reside in high COVID-19 prevalence areas, who live with someone affected by COVID-19, who have a family member or close friend who has died of COVID-19, who are socially isolated and who have little available emotional support. In our setting, concerns have been raised about stigmatization. Adverse mental health consequences of social isolation can be mitigated by keeping the period of isolation as short as is consistent with personal and public health safety, providing accurate information concerning the rationale and personal and public health benefits of physical isolation, and improving social communication. On the flipside, there may also be some countervailing positive mental health effects of living through a pandemic. One study of the SARS epidemic found that most individuals reported caring more about their family’s feelings during the SARS period than before it.
Health care professionals, especially those whose work brings them into close contact to patients infected with COVID-19, are also vulnerable to adverse mental health consequences. Feelings of futility, extensive involvement in end-of-life care without being able to connect patients and their families, and practicing outside their areas of confident clinical expertise can result in psychological stress.
Health care professionals world-wide have been hailed for their bravery and commitment to patient care during COVID-19 pandemic. Yet the pandemic has also created a sobering moral dilemma as an innate desire to preserve their own lives and awareness of their vulnerability to the disease conflicts with their call to duty and identity as healers. Thus, stress management and counselling may need to include discussions of ethical principles and practices.
Increased primary care mental health surveillance through routine screening for depression, anxiety, coupled with greater availability of mental health services within primary care will enable larger numbers of affected individuals to receive mental health treatment within a familiar primary care context.
Psychiatry is particularly suited to use of virtual methods of providing mental health services. While telemedicine technology has existed for almost three decades, it took the advent of the COVID-19 crisis to overcome the inertia of practitioners and health systems, and relax the regulatory and legal barriers to utilization. Effecting the changes needed to sustain the use of telemedicine coming out of this pandemic should be a priority. I will add that it should be done without compromising safety and quality.
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DR. EDWARD O. AMPORFUL
CHIEF PHARMACIST
COCOA CLINIC.
