COVID’s Scars: Psychological Residuals

Managing an emergency within an emergency.

Posted Jun 16, 2020

The inevitable next public health challenge—the mental health residuals of social distancing—is a long-term dilemma. These leftover effects make up an emergency of psychological disorders budding within the COVID disaster. A super-infection is one illness emerging within another. While many heal from both, recovery for some—a subset—is guarded. This natural experiment can unlock “being prepared” for the public and healthcare practitioners.

original oil painting, Frank John Ninivaggi, 2020
Emergency Within
Source: original oil painting, Frank John Ninivaggi, 2020

Are We Living in Fear?

We need social distancing to slow infections. A range of unintended mental health consequences is emerging. Physical distancing has resulted in changes in our social behaviors. Stressful shutdowns of everyday routines have been pervasive, e.g., travel, recreational, medical delivery, and financial resources.

Perhaps, the root of stress is fear. COVID-19 is a new and merciless disease. Lives have been entirely transformed. Acute distress during COVID-19 may transfer to longer-term psychiatric disorders. Stress stems from at least three roots: fear about the virus, changes in daily routines, and financial or resource-related stress. Psychiatric clinics and medical practices have been flooded with COVID-19 questions or empty in fear.

When the entire world faces an unprecedented threat, it is natural to believe that responses must also be unprecedented. Ordinarily, we would not throw multiple unproven drugs at a virus, and we would not try to silence our colleagues in irrational ways. Yet these things are happening.

COVID-19 may someday lead to two sets of lessons for physicians. We struggled to protect the globe from a pandemic, and we fought to defend ourselves, principles, and medical evidence from fear. Yet, the pent-up emotions brewing in the cauldron of fear unleash themselves in inadvertently aggressive ways.

The Budding Emotional Pandemic

New struggles with loneliness, isolation, estrangement, anxiety, depression, substance abuse, domestic violence, and child abuse are appearing. Studies also show cardiovascular problems related to loneliness and social isolation.

Chronic worry, anxiety, fear, and uncertainty upset daily activities. Persistently depressed mood significantly adds to impairment. Suicide enters the minds of some.

Substance use has the temporary effect of dulling malaise. Continued use despite harmful consequences turns into substance abuse—involving impulsivity, risk-taking, and dangers to self and others.

Social distancing and sheltering at home can increase mood instability and restlessness, and an upsurge of domestic violence has become apparent, typically as a spouse or partner abuse. But children are not spared. Damage happens when a parent or caregiver acts or fails to act, causes injury, emotional harm, or risk of serious harm to a child.

COVID-19 is a large-scale natural, environmental, and traumatic disaster. It affects both patients and clinicians. The psychological impact of the COVID-19 pandemic on frontline healthcare workers has yet to be fully understood. This perspective is essential for comprehensive problem-solving and pandemic management.

Pandemic Management Strategies

The new variable during this crisis is the profoundly interconnected world in which we live. Changing old ways of communicating and deciding, building new ways to reduce burnout and encourage professional development, and prioritizing leadership enable health care organizations to transform.

While fear is an automatic reaction, so too is the response of intentional adaptation. The best within people mobilizes. On one level, faced with a viral challenge, antibodies marshal short- and long-term defenses. On another, the mind’s executive functions respond with resiliency to learn responses such as healthy social distancing and using technology to maintain social connectedness. COVID is an opportunity for more rapid learning, seeing negatives earlier, improving, and preparing to grow.

Healthcare Preparation

The cornerstones of a COVID-19 preparedness plan embedded include:

  • mitigating local transmission
  • conserving, supporting and protecting healthcare staff
  • eliminating nonurgent strains on the health system
  • coordinating communication in healthcare, to the public, and via governmental agencies.

1.  New Technologies

Telehealth platforms, including phone, video, text, and email, are becoming routine and part of standardized medicine. Telemedicine allows continued care while reducing unneeded exposure to patients and healthcare workers. The paradox of telehealth is that this “de-personalization” must prepare to meet the personal, emotional, and mental disorders emerging. Therapy strategies must enhance self-esteem, the feeling of accomplishment. Key elements include being present, identifying needs, attentive listening, clarifying emotions, and empathy.

2.  Measurement

Mechanisms put in place for active surveillance, mental health screening, reporting, and direct interventions include testing, contact tracing, and greater ease of accessing medical and psychological support.

3.  Stepped Healthcare Delivery

Enhanced and innovative health services prepare for second waves and resurgences of viral outbreaks. This “stepped care” is delivering care from elemental toward increasingly complex interventions. A layered approach achieves effective treatment while preserving resources until needed. 

Effective Prevention and Treatment

As we emerge from this first wave of the COVID-19 challenge, establishing the foundations for prevention-focused and population-level medical and mental health care is essential.

In reconfiguring care delivery, the status quo must go. Better preparations for future pandemics, more telehealth, virtual care, and payment reform are outstanding challenges. Clinical leaders and the public need a common approach. A central theme is cooperating to establish true population health. Fear causes irrational behaviors. Managing fear constructively is harm reduction that redirects attention toward identifying problems and constructing solutions with mental health in mind.

Health systems cannot wait until they face an emergency within an emergency to implement a response. By acting early, they may avoid crippling crises and so provide proactive care. This emergency preparedness includes dealing with the virus and its psychological trauma, thus minimizing residual COVID scarring. Both providers and the public must prepare for the budding emergency of emotional trauma with attention and intervention—together.

References

Ninivaggi, F.J. (2020). “Physician engagement: mindfulness as part of the pandemic solution.” 

Elsevier.com. Published online May 20, 2020.

Galea, S., Merchant, R.M., Lurie, N. (2020). “The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention.” JAMA Intern Med. Published online April 10, 2020. doi:10.1001/jamainternmed.2020.156.

McGinty, E.E., Presskreischer, R., Han, H., Barry, C.L. (2020). “Psychological Distress and Loneliness Reported by US Adults in 2018 and April 2020.” JAMA, Published online June 03, 2020. doi:10.1001/jama.2020.9740.

Bu, F., Zaninotto, P., Fancourt, D. (2020). "Longitudinal associations between loneliness, social isolation, and cardiovascular events." Heart, Published Online First: 27 May 2020. doi: 10.1136/heartjnl-2020-316614.