May 2020, Volume XXXIV, Number 2
Addressing patient stress during a pandemic
How physicians can help
inding ways to balance the physical risks and emotional distress caused by COVID-19 is important for both health care personnel and patients. The mental health needs of entire communities are on the rise. The best practices that we are promoting to keep people safe from the virus are completely contrary to the practices we rely on to stay mentally well and emotionally resilient. “Social distancing,” the pillar of these efforts, has led to fear and isolation for many people. The reality is that COVID-19 is not a “social” disease at all, since it is transmitted by respiratory droplets among individuals who may have never had any social interaction. The inadvertent side effect of trying to keep physically safe through social distancing has in fact created emotional distress and removed us from the usual comforts of life and means of support. These necessary measures are our best defense in fighting infectious diseases, but many patients are now reporting an increase in emotional distress as a result.
Health care providers around the world are now tasked with providing exams and treatments to patients who are fearful of clinics and hospitals. In addition, the added stress of dealing with this pandemic is interfering with preventative visits, and the costs of care for patients dealing with comorbid conditions will likely increase even more. The challenge for our health systems and clinicians will be to provide necessary care while addressing the added complexity of the impact to the mental health of patients and providers alike.
Social distancing ... has led to fear and isolation for many people.
Keeping physically safe
We need to begin by encouraging patients to prioritize basic efforts to stay physically safe from contracting coronavirus, especially those with chronic health conditions, older people, or those with multiple health conditions or weakened immune systems. Luckily, most health systems now have the necessary telehealth infrastructure to deliver basic care and education remotely. The goal is to help patients adopt habits that simply eliminate or avoid situations in which they may encounter the virus. These efforts have been prominent around the globe since the start of this year, initially with diligent handwashing, avoiding physical contact with others, and staying away from crowded areas.
These practices have been forcefully encouraged under government shutdowns of nonessential businesses and covered extensively in the media. They become far more credible when they are reinforced by one’s physician or care provider. Patients can be reminded that individual hygiene is critical, as are public efforts such as our socially acceptable 6-foot physical distance from others and wearing facemasks when outside of the home. Many vulnerable patients, or those with high anxiety, can find additional comfort in formal efforts such as shelter-in-place that enforce these behaviors. Businesses are also making great efforts to keep us safe through heightened sanitation/cleaning protocols, barriers at retail counters, and visual reminders about distancing.
When individuals feel more comfortable in these physical precautions, they are less likely to be socially isolated. They can more freely shop for essential items such as groceries. They will be more apt to go on walks outside, visit parks and trails, and even attend a small backyard event.
Interestingly, early trends show that extroverted individuals are coping with reduced social interactions better than introverted individuals. Extroverts tend to capture energy and emotional input through more brief interactions, such as small talk (even via online and social media), while introverts tend to be more emotionally fulfilled through longer and more steady social input—which has proven difficult in these times of brief and distant interactions.
Spending extra time with patients can help them take control of their own behaviors to keep themselves and those around them safe. This is empowering for many patients, and it provides a greater sense of control over the situation, helping them avoid feeling helpless. During times of helplessness, mental health clinicians have long encouraged individuals to “control what you can.”
Mental wellness and resiliency
This unprecedented pandemic-related stress adds barriers to receiving health care, including mental health care. According to a poll conducted by the American Psychiatric Association in late March, “more than one-third of Americans (36%) say coronavirus is having a serious impact on their mental health and most (59%) feel coronavirus is having a serious impact on their day-to-day lives. Most adults are concerned that the coronavirus will have a serious negative impact on their finances (57%) and almost half are worried about running out of food, medicine, and/or supplies. Two-thirds of Americans (68%) fear that the coronavirus will have a long-lasting impact on the economy.”
Most healthy individuals receive emotional support from their family, peer groups, and social circles, which are physically distanced and, at best, moved online. Many individuals are fearful to visit clinics, and especially hospitals, for fear of contracting coronavirus. Most health care systems have quickly adopted telehealth for these patients. PrairieCare Medical Group, one of the region’s largest providers of psychiatric health care, now provides close to 80% of visits by telehealth, including group therapies. Patients feel much safer not having to leave their home for care. While not all psychiatric services can be done using telehealth, this method of care delivery will help thousands remain connected to their supportive services. When patients experience a psychiatric crisis, such as panic attacks, a suicide attempt, or a drug overdose, they most often end up in a hospital or emergency room.
More than one-third of Americans (36%) say coronavirus is having a serious impact on their mental health.
Many patients struggling with a previously diagnosed mental illness have likely been able to retain access to their psychiatrist or therapist through the use of telehealth. PrairieCare Medical Group experienced an initial dip in patient visits at the onset of the pandemic, but now, as a result of the increased efficiencies of telehealth, is able to offer a greater number of appointments with more flexibility.
Many individuals who may have been more predisposed to an illness, especially anxiety disorders and depression, may now be experiencing diagnosable symptoms, due to the pandemic, that warrant mental health treatment. In addition, many individuals struggling with job loss, social isolation, financial distress, and more may be experiencing general stress-related conditions such as an adjustment disorder, alcohol/drug use disorder, or post-traumatic stress disorder (PTSD).
In general, kids will be far more resilient to the impact of this pandemic on their mental health than adults, who will struggle with profound feelings of self-worth, insecurity (exacerbated by job loss, feeling out of control, helplessness, etc.), and existential angst. Basic screening tools such as the PHQ-9 (depression), GAD-7 (anxiety), and the AUDIT (alcohol use) can quickly identify a potential diagnosis and then help refer a patient to a mental health clinician. All of these tools are easy to administer and can be found free online. A referral to a mental health clinician will prevent worsening of symptoms as we continue to endure this pandemic and avoid the need for higher levels of care, including the need for hospitalization, if symptoms go unattended. Some of the more serious warning signs of mental illness are irritability, becoming withdrawn, outbursts, and thoughts of harming oneself. If patients express any of these signs, they should be referred immediately to a mental health clinician.
During routine check-ups, physicians should also ask about the impact of some of the smaller disruptions to one’s daily routine, marked by changes in behavior, sleep, diet, and general activity levels. These subtle changes can add up quickly and lead to mental and emotional distress. Even minimal disruptions of circadian rhythms can have a drastic impact on the quality of restorative sleep, health, and well-being. As more of us adapt to working from home, helping kids with distance learning, having groceries delivered, and cancelling weekly social events, our rhythms are unwittingly impacted, leading to symptoms such as headaches, fatigue, and irritability, and all the way up to more serious conditions such as weakened immune system functioning, insomnia, depression, mania, and more. The compounding effect of these disruptions to our daily lives can manifest as noticeable stress. Over time, and without proper intervention or rationalization, this will lead to mental illness.
It is critical to care for both the physical and emotional needs of our patients during this tough time, and also to look ahead to the future. As experts in health care, the way that we message information about dealing with this pandemic is important. When we convey positivity, our patients and communities respond accordingly. Helping our patients have a sense of agency when things seem out of control will build resiliency.
Many people are dubbing the current state as the “new normal,” which can be misleading, since this state is merely temporary, and far from normal. If a marathon runner develops blisters on mile 20, rationalizing the discomfort as a new normal may help them cope until they reach the finish line, since blisters are only temporary and will heal. Don’t confuse this current state of discomfort as the future state; this is merely a phase we are experiencing on a journey to a brighter, more resilient future. Sharing positivity and tending to both physical and emotional needs helps to refuel ourselves and those around us for the ongoing journey of life.
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