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Published On April 2, 2020

CLINICAL CARE

In the Shadow of the Pandemic, a Mental Health Crisis

The dangers of COVID-19 go beyond the physical risks, especially for those with psychiatric health needs.

The physical symptoms of COVID-19 have by now been well mapped. But the mental health effects of the pandemic, which affect the infected and the uninfected alike, are only beginning to take shape. Lock-down policies will bring the dangers of social isolation. Economic unrest and worry about older relatives will be deeply stressful. And familiar coping mechanisms may be hard to come by or unhealthy in themselves.

This poses a danger for everyone, but especially for people who are already in a vulnerable place. “People with mental health issues or substance abuse are susceptible to any kind of change, stress, or anxiety-provoking events,” says Asim Shah, professor and chief division of community psychiatry at Baylor College of Medicine in Houston. Shah directed Houston’s mental health care for victims of Hurricane Harvey in 2017. He says that nearly all those who were seeking psychological treatment following that event had pre-existing psychiatric diagnoses. “We have evidence from previous disasters that anxiety and depression may get worse and, in fact, these events might precipitate anxiety, depression, bipolar episodes and psychosis,” he says.

A wide spectrum of mental health conditions may get worse, and people might find it hard to keep an even keel. Those with anxiety disorders, whose thoughts often jump to the worst-case scenario, may now “have discovered that their worst fears are, in fact, legitimate,” says Nidal Moukaddam, associate professor of psychiatry at Baylor College of Medicine. Moukaddam says that some psychotic disorders can manifest as an extreme distrust of medicine and providers, and they may find that confirmed by what will undoubtedly be a slow and uphill fight to control the pandemic. Individuals who misuse alcohol or drugs have seen in-person 12-step programs disappear, and weekly drug screens that promote accountability have stopped. Those with post-traumatic stress disorder (PTSD) may see a flare up or new symptoms showing up months from now. As part of her work, Moukaddam is also enrolling the public in a study on the psychological effects of the pandemic.

While it’s too early to determine if suicides will increase as a result of COVID-19, Massachusetts General Hospital resident emergency physician Clayton Dalton has already treated patients “who indicate that fear and panic over coronavirus has led them to make the impulsive decision to attempt suicide,” he says. There may be a wave of attempted suicides within a few months from now if the economic recovery from Covid-19 is particularly severe, says Moukaddam. “Those with pre-existing mental illness are already in treatment, so we can check on them,” she says. She is more worried about a mounting desperation in the general population. “This crisis will push a lot of people over the edge, not just those we are already seeing.”

Psychiatry does have one advantage over other medical fields: For years psychiatrists have been using telepsych visits. These can extend care to people who don’t have access to the office or whose condition, such as agoraphobic or severe anxiety, prevents them from leaving their homes. Psychiatrists also don’t need to physically examine their patients, so using telemedicine for psychiatric problems has presented fewer barriers than for other specialties.

Telemedicine has its own challenges, reimbursement from insurers being one of them. But during this emergency, Medicare and private insurers have announced that they will cover all telemedicine visits as if they were in-office visits. The federal government has also waived some Health Insurance Portability and Accountability Act (HIPAA) rules governing the confidentiality of patient information. This frees clinicians to conduct visits via FaceTime, Zoom or Skype if the patient consents. The Drug Enforcement Agency is also now allowing physicians to use telemedicine to prescribe controlled substances to patients, such as methadone to treat opioid addiction, instead of requiring an in-person evaluation.

“Normally we have thousands of outpatient psychiatric visits at MGH each month and now they’ve essentially all been converted into virtual video visits or phone calls. That lets us maintain contact with patients and provide support,” says psychiatrist Jeffrey Huffman, associate chief of psychiatry for clinical services at MGH.

Telepsych visits can also reveal important information about how patients are living and coping, says Moukaddam. “We can see if patients are hoarders, whether they have beds, how inviting or depressing their homes may be,” she says. It’s important to note, however, that virtual visits may exclude poor patients without Internet access or older patients who lack digital know-how. And patients with psychosis who distrust or are paranoid of the Internet or the phone may end up in the emergency room. “I fear that we’ll see a large number of patients who won’t get care and end up in worse shape,” says Moukaddam.

Unfortunately for those patients who do wind up in the emergency department and need to be admitted, COVID-19 is making beds very hard to find. “During normal times, it’s not uncommon for psychiatric patients who aren’t safe to themselves or others to stay in the ED for days because there aren’t enough inpatient psychiatric beds available,” says Dalton. “Now patients with a little cough or slightly elevated body temperature are being turned away from psychiatric hospitals for fear of COVID-19. The ED is a terrible place to stay for days if you are in psychological distress. If the ED is filled with COVID-19 patients and psychiatric patients, who can’t leave, that will be a disaster within a disaster.”

The coronavirus is also changing how psychiatry wards and psychiatry hospitals can deliver care to those admitted patients, says Huffman. “Normally, patients attend group therapy sessions much of the day and eat together, but now we have to deliver more one-on-one treatment,” he says. Instead of putting patients in double-bed rooms, which is the norm, psychiatric facilities are isolating patients who test positive for COVID-19 in single rooms, further decreasing capacity. Or patients with the virus may have to be treated on a hospital’s medical floor.

The best plan now is to plan ahead. Mental health care professionals are encouraging everyone to reach out to one another before problems arise. “Research shows that loneliness and social isolation are potential exacerbators of PTSD, and loneliness is a risk factor for suicide,” says David Benedek, chair of psychiatry at the Uniformed Services University in Bethesda, which treats active and retired military personnel and their dependents. He says that social distancing doesn’t have to mean a lack of social connectedness. “Connectedness can actually be improved during times of distress. We can use technology and telephones, and we can see increased efforts by providers, family members and other social-support networks to reach out,” he says. Twelve-step communities, for example, have always relied on telephone communication to support their members. “These communities know that stressful situations exacerbate underlying conditions. They know how to create opportunities for more social connectedness,” says Joshua Morganstein, associate professor of psychiatry at the Uniformed Services University.

It will be helpful, says Huffman, for everyone to accept that “coronavirus is our new reality right now and to take steps to mitigate the stress.” He says that this should include maintaining social contacts, eating well, limiting exposure to media, keeping a healthy sleep schedule and making sure to engage in pleasurable activities, all of which can help maintain mental well-being.

“It’s important to remind people—especially people with mental health conditions—that most of us will rise to the occasion and do well,” says Morganstein. Adds Benedek: “Previous disasters have taught us that people, including those with mental illness, are resilient during tough times. Despite our very justified worries and concerns, people will get through this current crisis.”

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