Although medical literature has largely focused on the acute, physical manifestations of the coronavirus, it is also important to consider the impact of stress for medically vulnerable patients
A recently published article by physicians Betty Pfefferbaum and Carol North in the New England Journal of Medicine discusses mental health and the COVID-19 pandemic highlighting how public health emergencies, like the current one, can affect the health, safety and emotional well-being of both individuals and communities.
Although the preponderance of the medical literature has focused on the acute, physical manifestations of the virus while searching for effective treatment options, it is also important to consider the impact of stress for medically vulnerable individuals. While they are worried about contracting the virus, they are also feeling the economic distress the pandemic has caused, and the isolation that comes with social distancing measures for individuals who don’t have a robust support system, which may either cause or exacerbate depression and/or anxiety.
Primary care physicians, psychiatrists and other mental health professionals should expect to eventually see increased mental health-related visits and need to be prepared to discuss how patients with pre-existing mental health conditions are coping during this time.
Weighing the Pros and Cons of Telehealth for Mental Health Visits
Allan Giesen, DO, a psychiatrist practicing in Massachusetts is seeing “more anxiety across the board,” in patients, direct care workers, nurses and even fellow psychiatrists. Although health care providers and other health care workers have heroically provided medical care to patients infected with COVID-19, Giesen says many practitioners providing care in hard hit communities are still anxious.
A senior practicing military psychiatrist that I talked with said that even in a lower acuity, higher functioning population, patients are fearful of coming to health care facilities due to COVID-19. This psychiatrist said telehealth offers a convenient solution to provide consultative advice, therapy and treatment, especially for the younger, working population that is comfortable with technology and is concerned with potentially being exposed to someone carrying COVID-19.
While both psychiatrists highlighted the pros of using telehealth for mental health concerns, Giesen, noted his “concern about the non-verbal aspects of empathy being properly conveyed through the video.” Although the video connection between patients and physicians may be quite good, he still feels in-person visits provide helpful information to holistically treat patients.
For providers, it will be important to decide which services can be offered in person or remotely and to also have a process in place to determine which patients prefer and can receive appropriate levels of care via telehealth visits. Patients who are using telehealth for the first time to discuss mental health issues should be reassured that privacy and security are preserved.
Younger, less medically complex patients who feel comfortable with technology may want to increase the use of telehealth for their care. Elderly patients, and those with several comorbid medical and mental health conditions, and who may not feel comfortable with technology, may feel more at ease with in-person visits with social distancing measures in place.
Primary care physicians must also plan for the possibility of obtaining an immediate consultation with a mental health professional, or referral for an emergency psychiatric hospitalization, if suicidal ideation emerges during telehealth consultations with their patients.
Other mental health considerations from COVID-19
Both Giesen and the authors of the New England Journal of Medicine article highlight that excessive anxiety increases the risk for relapse of mood disorders, anxiety disorders, psychotic disorders and illicit substances use. The development or worsening of sleep disorders may also occur which can contribute to irritability and a decreased quality of life.
An important question for health care providers to ask is whether the patient has a family member or close friend who has suffered a significant health issue from COVID-19. This is important because many hospital visitation policies have restricted family members from being physically present at the patient’s bedside. Those who otherwise could be counted on to provide comfort and support are not able to be present. As a result, fear and anxiety about contracting the virus, as well as the bereavement period should someone close pass away, may become even more daunting under these circumstances.
An Rx for Mindfulness
In these uncertain times, Dr. Giesen suggested that practicing “mindfulness,” for both health care providers and patients may alleviate some of the stress and anxiety. Mindful.org defines mindfulness as “the basic human ability to be fully present, aware of where we are and what we’re doing, and not overly reactive or overwhelmed by what’s going on around us.” Some of the key aspects of mindfulness include setting time and space aside to pay attention to the present moment, and to let your fears judgements pass, before returning to observe the present moment.
The American Psychological Association reports that in addition to reducing stress, mindfulness can improve focus, working memory and reduce emotional reactivity. These are active skills anyone can practice so that the anxiety and fear of COVID-19 doesn’t overwhelm either patients and/or health care providers’ ability to remain resilient for their friends, families and colleagues.
Joseph M. Geskey works at Vizient as a Principal, Data Sciences & Member Insights. He is currently working on a book about the healthcare experiences of patients with limited health literacy and challenging social determinants of health in the digital and technological era medicine is embracing.