From the Editor

This week’s Reading – like the last few – focuses on the latest in the literature on COVID and mental health care with three selections. As life with the pandemic continues, more and more journals have published about it, with some discussing the implications for mental health services.

In the first selection, we consider a paper on mental health services and the pandemic. In a NEJM paper, Drs. Betty Pfefferbaum (of University of Oklahoma Health Sciences Center) and Carol S. North (University of Texas Southwestern Medical Center) argue for an integrated and measured approach. In responding to COVID, they advocate that: “already stretched health care providers have an important role in monitoring psychosocial needs and delivering psychosocial support to their patients, health care providers, and the public – activities that should be integrated into general pandemic health care.”

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How can we help health workers? In the second selection, we consider a new CMAJ paper by Dr. Peter E. Wu (of the University of Toronto)and co-authors. They write: “Taking care of ourselves is vital so that we may continue to take care of others.”

Finally, in the third selection, we look at a news article from The Globe and Mail. Reporter Erin Anderssen describes how “caring contacts,” a psychiatric intervention, is used by volunteers to connect with the elderly. “The spontaneous initiatives expanding now are prompted more by what we instinctively know: Human contact motivated purely by compassion is essential to our well-being.”



Selection 1: “Mental Health and the Covid-19 Pandemic”

Betty Pfefferbaum and Carol S. North

The New England Journal of Medicine, 13 April 2020


Uncertain prognoses, looming severe shortages of resources for testing and treatment and for protecting responders and health care providers from infection, imposition of unfamiliar public health measures that infringe on personal freedoms, large and growing financial losses, and conflicting messages from authorities are among the major stressors that undoubtedly will contribute to widespread emotional distress and increased risk for psychiatric illness associated with Covid-19. Health care providers have an important role in addressing these emotional outcomes as part of the pandemic response.

So begins a paper by Drs. Pfefferbaum and North.

They note the stresses of the moment.

These effects may translate into a range of emotional reactions (such as distress or psychiatric conditions), unhealthy behaviors (such as excessive substance use), and noncompliance with public health directives (such as home confinement and vaccination) in people who contract the disease and in the general population.

They are careful, however, to note that many aren’t at risk of developing mental disorders. “After disasters, most people are resilient and do not succumb to psychopathology. Indeed, some people find new strengths.”

Some groups may be more vulnerable than others to the psychosocial effects of pandemics. In particular, people who contract the disease, those at heightened risk for it (including the elderly, people with compromised immune function, and those living or receiving care in congregate settings), and people with preexisting medical, psychiatric, or substance use problems are at increased risk for adverse psychosocial outcomes. Health care providers are also particularly vulnerable to emotional distress in the current pandemic, given their risk of exposure to the virus, concern about infecting and caring for their loved ones, shortages of personal protective equipment (PPE), longer work hours, and involvement in emotionally and ethically fraught resource-allocation decisions. Prevention efforts such as screening for mental health problems, psychoeducation, and psychosocial support should focus on these and other groups at risk for adverse psychosocial outcomes.

The authors call for a response – but advocate for being strategic.

On the milder end of the psychosocial spectrum, many of the experiences of patients, family members, and the public can be appropriately normalized by providing information about usual reactions to this kind of stress and by pointing out that people can and do manage even in the midst of dire circumstances. Health care providers can offer suggestions for stress management and coping (such as structuring activities and maintaining routines), link patients to social and mental health services, and counsel patients to seek professional mental health assistance when needed. Since media reports can be emotionally disturbing, contact with pandemic-related news should be monitored and limited.

They also note the particular importance of incorporating mental health considerations into the identification of COVID cases.

Given that most Covid-19 cases will be identified and treated in health care settings by workers with little to no mental health training, it is imperative that assessment and intervention for psychosocial concerns be administered in those settings.

They also advocate that: “The mental health and emergency management communities should work together to identify, develop, and disseminate evidence-based resources related to disaster mental health, mental health triage and referral, needs of special populations, and death notification and bereavement care.”

This paper reads well, and makes good points. Little here is particularly earth-shattering or novel.

That said, the authors make a solid point about responding to the psychological needs arising from the pandemic. Not everyone needs care; as they note, “many aren’t at risk of developing mental disorders.” Indeed, they argue for a stepped-care model, which makes sense for this unique situation – and for many others perhaps.


Selection 2: “Mitigating the psychological effects of COVID-19 on health care workers”

Peter E. Wu, Rima Styra, and Wayne L. Gold

CMAJ, 15 April 2020


Although tremendous efforts are being made to investigate the pathophysiology, clinical outcomes and treatment of coronavirus disease 2019 (COVID-19), the psychological effects of this pandemic on health care workers cannot be overlooked.

Experience from the 2003 severe acute respiratory syndrome (SARS) outbreak and early reports related to COVID-19 show that health care workers experience considerable anxiety, stress and fear. The psychological effects related to the current pandemic are driven by many factors, including uncertainty about the duration of the crisis, lack of proven therapies or a vaccine, and potential shortages of health care resources, including personal protective equipment. Health care workers are also distressed by the effects of social distancing balanced against the desire to be present for their families, and the possibility of personal and family illness. All of these concerns are amplified by the rapid availability of information and misinformation on the Internet and social media.

Health care workers may experience psychological distress from providing direct care to patients with COVID-19, knowing someone who has contracted or died of the disease, or being required to undergo quarantine or isolation. Mitigation strategies for all scenarios are vital to ensure psychological wellness and in turn ensure a healthy and robust clinical workforce.

So begins a paper by Wu et al. If Drs. Pfefferbaum and North touched on health care workers, Dr. Wu and his co-authors focus on them.

Not surprisingly, providers caring for patients with COVID-19 are among those at greatest risk of psychologic distress.

They review recent studies:

  • “A survey of 1257 nurses and physicians caring for patients with the disease in China found that these providers (41.5% of respondents) had significantly more depression, anxiety, insomnia and distress than providers who did not care directly for patients.”
  • “Another observational study of 180 health care workers providing direct care for patients with COVID-19 found substantial levels of anxiety and stress that adversely influenced sleep quality and self-efficacy. Importantly, those who reported a strong social support network had a lower degree of stress and anxiety, and a higher level of self-efficacy.”
  • “A qualitative study of medical residents during the 2003 SARS outbreak in Toronto showed that anxieties around personal safety and risk of contagion to loved ones conflicted with their professional duty to care.”

They also note the effects that quarantine can have on mental health, highlighting the Brooks et al. paper featured in a past Reading.

They offer practical recommendations:

  • “Strong leadership with clear, honest and open communication is needed to offset fears and uncertainties.”
  • “Provision of adequate resources (e.g., medical supplies) and mental health supports will bolster individual self-efficacy and confidence.”
  • “Leveraging online technology will allow delivery of psychosocial supports while preserving physical distancing.”
  • “Emphasizing the altruism of working in health care and serving of the greater good will help health care workers to be reminded of their purpose in a time of crisis.”

They conclude: “Supporting health care workers in all aspects is vital to sustaining a healthy workforce during the pandemic in Canada.”

This paper is clear and concise, providing practical suggestions. It also offers a timely review of the literature.


Selection 3: “Caring contacts: a compassionate grassroots response to COVID-19 that is based on science”

Erin Anderssen

The Globe and Mail, 16 April 2020


Canadians are writing letters, sharing family stories and pet pictures in cheerful dispatches to lonely seniors at nursing homes. Others are making regular calls to people they have never met, just to check in.

In the midst of a pandemic, a grassroots movement of compassionate contacts has emerged – the very approach advocated by many experts as an essential part of mental health care.

Even before COVID-19 further isolated people, “caring contacts” were seen as an important touchstone to the outside world for people struggling with depression and loneliness. In suicide prevention research, these brief check-ins have been found to save lives.

So begins an article by Anderssen.

She notes that “caring contacts” has been used in psychiatric settings:

  • “Versions of caring contacts have been successfully tested in countries around the world; a new mental health program in France aims to provide a caring contact to every person, young and old, who visits an emergency department after a suicide attempt.”
  • “In Canada, a few pilot projects have also been under way, most geared toward those deemed at high risk of suicide.”

Anderssen notes the origins of the program:

The original idea for caring contacts is credited to an American psychiatrist named Jerome Motto, who was inspired by the letters he received in the trenches during the Second World War. Between 1969 and 1974, Dr. Motto and his team started sending typed letters to patients at risk of suicide who had turned down treatment, and compared their outcomes with a control group of similar patients. In all five years of the study, the group receiving the letter had significantly lower rates of suicide.

The article focuses on volunteers who are reaching out to the elderly. For example, Family Services of the North Shore in British Columbia connects hundreds of Vancouver seniors with volunteers. The article also describes a similar effort where letters are written to the elderly. One young volunteer has written more than fifty letters.

Anderssen mentions one elderly person:

Ms. Ancic, who takes oxygen for a lung condition, is especially vulnerable to COVID-19. The seniors in her apartment building are all self-isolating, and before her regular chats with Ms. McMillan, with her family living on the other side of Toronto, she worried about dying alone, with her Chihuahua mix, Moe, left to fend for himself.

Asked about the contact, she notes: “I sleep better knowing she is calling…”

The article closes with information for potential volunteers.

With the heaviness of this moment, this story is a nice break – a reminder of the decency of Canadians. Of course, there is a twist. The organizers have drawn from “caring contacts,” which originates from the suicide prevention literature. The effort isn’t a mental health service – they are targeting loneliness, not mental disorders – but they have learned from psychiatry, a comment on the influence of mental health care on our culture. While our work used to be in the shadows, we hear more and more about celebrities describing their mental health problems, etc. But we also see a larger influence of mental health care on our culture. Corporate retreats tap mindfulness gurus, as an example. And the expansion of “caring contacts” – past suicide prevention into the realm of connecting the disconnected – is another example. Nice.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.