Interventions, preparation needed to address psychological fallout from current COVID-19 pandemic, potential next wave

During the COVID-19 pandemic, psychiatrists, health care professionals and organizational leaders should utilize evidence-based population mental health interventions to augment clinical care, according to a presenter at the American Psychiatric Association Spring Highlights Meeting.

“The psychological and behavioral impacts of disasters are experienced by more people over a greater geography across a much longer period of time than all other medical effects combined,” Joshua C. Morganstein, MD, chair of APA’s Committee on the Psychiatric Dimensions of Disaster, said during the presentation. “This is important for disaster resource planning... The reduced utilization of [ED] inpatient psychiatry beds in some areas has paralleled the significant increase in crisis hotline utilization, representing a shift in how distress is expressed throughout the population during a time of physical distancing requirements and stay-at-home orders. If history is any predictor, we should expect a significant tail of mental health needs that extend for a considerable period of time after this event.”

Psychiatric disorders comprise a significant proportion of the morbidity and mortality associated with disasters, according to Morganstein. Before disorders occur, the public may experience distress reactions and engage in or exhibit health-risk behaviors, such as substance use, family conflict and insomnia. Morganstein highlighted other responses that often arise among the public during pandemics, including fear and uncertainty, the potential for isolation and quarantine, shortages and scarcity, a rapid spread of misinformation, faltering confidence in government/institutions and a surge in health care demand.

Although distress reactions and health-risk behaviors typically show up in primary care emergency settings, they are also relevant for other sectors, including law enforcement and social services.

“This really underscores the importance of building and sustaining partnerships among health care specialties, as well as other professional disciplines, to more effectively support public mental health in disasters,” Morganstein said.

During the pandemic, significant proportions of individuals will experience disorders related to trauma and loss, as well as those related to heightened stress and decreased access to care, and most individuals will be impacted in some way by uncertainty and loneliness, according to Morganstein.

Children and adolescents may face a specific set of mental health challenges during the pandemic, including parental distraction and preoccupation, disruption in schedules and routine, induction of fear, and erosion of safety and helplessness.

“Children often express distress differently than adults and in ways that can easily be misinterpreted as misbehavior,” Morganstein said. “Educating families on how children and adolescents respond differently to trauma can help them respond more effectively.”

Morganstein noted that the media play a significant role in overall response to the pandemic in that they may both enhance dissemination of timely and accurate information while also transmitting fear and distress.

During most disasters, community response typically happens in several phases — pre-disaster, impact, heroic, honeymoon, disillusionment and reconstruction. The unique characteristics of these phases can inform timing of resource allocation and disaster mental health education, according to Morganstein; however, pandemics disrupt these phases. For example, the community cohesion typically observed during the honeymoon period may not happen because of social distancing and quarantine orders.

The ongoing pandemic has also led to increased focus on societal disparities.

“Public health emergencies often open the fault lines in our society and expose divisions across race, religion and socioeconomic status,” Morganstein said. “Stigma after disasters is common. Leaders and institutional elements within our communities play an important role in shaping community response and behaviors.”

Morganstein highlighted pandemic-related “tipping points,” which he defined as events that would have a more modest impact under other circumstances but now have an exaggerated effect. Current factors that promote tipping points in the health care system include the death of a beloved staff member or a child, a perception that responsibilities or risks are being unfairly distributed, and a belief that leadership is failing to take reasonable and realistic protective measures.

“These are all factors that can promote tipping points, and when they occur, organizational trust and participation in recommended health and other behaviors may diminish rapidly,” Morganstein said.

Health care workers face challenges unique to COVID-19, including working outside the scope of practice, navigating evolving policies, experiencing illness stigma from family, friends and neighbors, and anticipating a future wave of the virus.

“The duration and severity of exposure to various traumatic aspects of this pandemic are an important aspect of increasing risk, particularly for our frontline health care workers,” Morganstein said. “Those overseeing or advising health care systems should consider methods of surveillance that consider duration and severity of exposure as one important factor to inform on things like work-rest cycles, as well as helping supervisors determine which personnel may benefit from temporary modification to their duties or additional peer and organizational support.”

Morganstein highlighted several public health approaches that foster community and workplace resilience, including early intervention, public health education, leadership, mental health surveillance, and workplace and community preparedness.

“As the curves flatten and perhaps warmer weather reduces disease transmission and the strain on our health care systems, there will be many forces at work vying for our attention,” Morganstein said. “Avoiding complacency and remaining vigilant will allow us to more effectively prepare for the anticipated next wave. Creating an organizational framework to address psychosocial areas of risk in pre-, during and post-event periods is often helpful for planning.”

Morganstein also noted the importance of psychological first aid.

“Following exposure to trauma, we can reduce the stress and improve functioning by enhancing a sense of safety, calm, self or community efficacy, social connectedness and hope or optimism,” Morganstein said. “These elements form the basis of psychological first aid, which is an evidence-based framework for supporting resilience in individuals, communities and organizations. As with all interventions, these are most effective when delivered with consideration of the unique cultural and contextual factors of a given community.” – by Joe Gramigna

Reference:

Morganstein JC. Preparing for a marathon: Health care worker & organizational sustainment during COVID-19. Presented at: American Psychiatric Association Spring Highlights Meeting; April 25-26, 2020 (virtual meeting).

Disclosures: Morganstein reports no relevant financial disclosures.