From the Editor
What now? COVID is part of our new reality. But as we move forward – as a nation that is past peak, and slowly beginning the task of reopening – how do we understand the mental health needs, challenges, and opportunities of the post-pandemic world? This week, we have three selections considering that question.
The first is a new editorial. In The Canadian Journal of Psychiatry, Dr. Daniel Vigo (of the University of British Columbia) and his co-authors note that “epidemics & pandemics have long been known to impact mental health: The mental problems triggered by viral outbreaks have been described as a ‘parallel epidemic.’” Understanding that subpopulations have different needs, they argue for an approach that focuses on those at greater risk. They make specific recommendations in an impressive paper that includes 52 references.
Will our digital moment continue? In the second selection, we look at a new JAMA Psychiatry paper by Dr. Jay H. Shore (of the University of Colorado) and his co-authors, who argue that it should. They note that many clinics and hospitals have embraced telepsychiatry. He argues that, with the right approach, we could have “a golden era for technology in psychiatry in which we are able to harmonize the benefits of telepsychiatry and virtual care while maintaining the core of our treatment: that of human connectedness.”
Finally, in the third selection, Dr. Jessica Gold (of the University of Washington in St. Louis) considers stigma around mental illness. In this time of COVID, she wonders if it will fade further, providing some evidence from social media. She sees opportunity for better: “Instead of looking at the post-COVID-19 mental health future through a lens of inevitable doom, we can, and should, use this moment as the impetus for the changes that mental health care has always pushed for.”
Selection 1: “Mental Health of Communities during the COVID-19 Pandemic”
Daniel Vigo, Scott Patten, Kathleen Pajer, Michael Krausz, Steven Taylor, Brian Rush, Giuseppe Raviola, Shekhar Saxena, Graham Thornicroft, Lakshmi N. Yatham
The Canadian Journal of Psychiatry, 11 May 2020 Online First
In addition to various physical distancing measures, isolation of cases, and contact tracing, most Governments are trying to scale up COVID-19 testing and their capacity to deliver acute and intensive unit care, while at the same time providing economic help to the millions of people left out of work. Despite such measures, in the context of grave threats to everyone’s health and livelihood, combined with the inconsistency of governance efforts, widespread adverse mental health and substance use outcomes seem likely to occur, both directly from the pandemic and indirectly from the related economic downturn. Epidemics and pandemics have long been known to impact mental health: The mental problems triggered by viral outbreaks have been described as a ‘parallel epidemic.’ These mental health problems (which may follow but also precede local outbreaks) can be broken down into four subtypes based on the subpopulation affected: (a) the general population, (b) people with preexisting mental or substance use disorders, (c) people who provide essential services and are at increased risk of infection, and (d) people who are infected by the pathogen.
So begins a paper by Vigo et al.
They focus on the following four population groups.
They note that many may have health anxiety. They also note that: “the general population can be expected to bear the brunt of traumatic experiences associated with the virus and the social response: the inability to attend and adequately care for sick family members due to contact restrictions; the death of relatives, friends, and acquaintances; the inability to hold funerals, bury, and mourn the dead.” The authors also describe the psychological weight of quarantine, as well as the mental health problems associated with economic downturns.
Intervention: “Scaling up psychosocial supports to people undergoing overwhelming stress or trauma.”
People with Mental and/or Substance Use Disorders
“People with preexisting disorders may become more vulnerable during an epidemic. They are at increased risk of medical comorbidities in general, more likely to smoke, more likely to be immunocompromised, and are therefore specifically at greater risk of respiratory symptoms. In addition, those with serious mental illness are at increased risk of infection when admitted to psychiatric inpatient units.” They also note disruptions of care to those who need service, including those with substance problems.
Interventions: “The transition to online delivery of psychoeducation, psychotherapy, and psychopharmacology should be facilitated and evaluated.”And they advocate: “Attention to physical health should be enhanced to prevent undetected spread of the virus and worsening of chronic physical conditions.”
People Delivering Essential Services
“People who provide essential services during the pandemic in doing so put themselves at significantly increased risk of exposure to the virus. One unique characteristic of this pandemic is the massive and open-ended nature of physical distancing measures, which leads to an expansion of what can be considered essential services.”
Interventions: “Psychosocial support should be widely available to provide information, validation, and support while they develop their tasks under increased stress and risk.” And for those with exposure to trauma, they recommend specialist care.
People Infected by the Virus
“The emotional and neuropsychiatric impacts of COVID-19 in people who have recovered will be highly variable, depending on multiple factors including preexisting vulnerabilities or resilience, the severity of illness, the provision of social support, and the experience of care.”
Interventions: “Targeted outreach through online and mass media offering information and psychosocial supports for people who may undergo stress or trauma while symptomatic or difficulties adjusting afterward. Again, these are nonspecialists delivering psychological first aid.” For those with more severe forms of COVID, they prevent online/telephone support to address the isolation.
Overall, this is an excellent paper.
Breaking up the population into different groups is a reasonable appoach to the daunting challenge of trying to address mental health needs. After all, it’s popular to talk about providing mental health services, but the authors push past this rhetoic, and note that different groups will be effected differently, and require different interventions. The general approach – matching increased need with greater resources – seems appropriate, and echoes a point made by others, such as Drs. Pfefferbaum and North in The New England Journal of Medicine (their paper was considered in a past Reading).
Vigo et al. talk more broadly of change. I highlight their comments on a particular change that is “effective and cost-effective:”
“This is the time to invest in the development of virtual stepped care platforms that include psychoeducation, self-guided-, AI-, peer-, and specialist-supported e-therapies, as well as telepsychiatry. Such innovations should occur in the context of integrated electronic health records and platforms, and their impact should be systematically evaluated.”
Selection 2: “Telepsychiatry and the Coronavirus Disease 2019 Pandemic – Current and Future Outcomes of the Rapid Virtualization of Psychiatric Care”
Jay H. Shore, Christopher D. Schneck, Matthew C. Mishkind
JAMA Psychiatry, 11 May 2020 Online First
Telepsychiatry, in the form of videoconferencing and other technologies, was uniquely positioned to push the field of psychiatry to the forefront of these efforts. Prior to the pandemic, telepsychiatry had built a strong scientific foundation and real-world evidence base, demonstrating its effectiveness across a range of psychiatric treatments, populations, and settings. Although previously leveraged temporarily in disaster response, telepsychiatry’s use in the COVID-19 pandemic has been distinctive and will have long-lasting and wide-ranging effects on the field of psychiatry, including mental health care delivery and configuration and patient experience and expectations.
So argues a paper by Shore et al.
Historically, full implementation of telepsychiatry, especially in large organizations, could take months to years. Rapid virtualization has shown that clinicians, patients, and systems can quickly adapt to telepsychiatry, although not without challenges and lessons learned. Previous barriers including regulatory constraints, system inertia, and general resistance to telepsychiatry have disappeared, at least temporarily; technical innovations abound as clinicians and organizations work to best configure telepsychiatry to current clinical needs and environments.
But the reality of the pandemic, coupled with relaxation of various government regulations, means that many use telepsychiatry. As an aside, a new Psychiatric Services paper details the results of a survey of 20 psychiatrists; all are using telepsychiatry now, but the majority hadn’t prior to the pandemic.
The authors ask: “Will the current regulatory and structural changes stay in place, or will they also change in a parallel, sporadic, and episodic manner?”
What the psychiatric care environment will look like is currently unpredictable. Psychiatry is well-positioned to prepare for the transition to a post-COVID-19 health care world. Pre-COVID-19, many in psychiatry and other mental health disciplines were already working with digital technologies and leading efforts to advocate for more widespread use and deployment of telehealth to support broader access to quality psychiatric treatment.
But will it maintain its dominance? They ask a series of questions.
What will the lessons of the COVID-19 pandemic be, in terms of what can vs should be done in person or through telepsychiatry or other technologies? How much virtual care is too much? Is there a virtual saturation point, at which the benefits of a virtual relationship decrease or patients request more in-person interactions? What data need to be captured now to better understand this and identify current lessons learned?
They don’t answer these questions, but note the opportunity:
The regulatory and system changes wrought by the COVID-19 crisis present the opportunity for the field to gather lessons learned to strategically shape the post-COVID-19 world of psychiatry and telepsychiatry. This work could usher in a golden era for technology in psychiatry in which we are able to harmonize the benefits of telepsychiatry and virtual care while maintaining the core of our treatment: that of human connectedness.
This is an excellent paper. Dr. Shore is a long-standing advocate of telepsychiatry, and this paper is well-balanced and thoughtful.
I will repeat one of the questions posed: “How much virtual care is too much?” Today, we don’t ask that question, because there is limited alterative to virtual visits. But in the coming months, the challenge will be to find the right balance.
When is telepsychiatry appropriate? When should it be combined with in-person care? What populations should be treated with more conventional care?
Selection 3: “Could COVID-19 Finally Destigmatize Mental Illness?”
Time, 13 May 2020
As a psychiatrist, I understand the realities of the mental health stressors that exist from this global pandemic and the potential for an increase in psychological care needs now and in the aftermath. However, it’s possible that we emerge from this with innumerable positive mental-health outcomes.
So argues Dr. Gold.
She notes the progress that has been made on reducing stigma. Still, she argues, stigma is real and persists. She gives examples, including the way physicians are required to disclose mental health problems as part of state licencing requirements. “This not only equates mental illness treatment to felonies, it makes physicians, who have some of the highest rates of suicide of any profession, fear seeking treatment because of what it might mean to their license and any other possible repercussions at work.”
“The COVID-19 pandemic is a sort of equalizer.”
She gives two examples. First, she notes our common experience. “Nearly everyone is self-isolated at home, trying to work while managing a household, and dealing with uncertainty and grief. To some degree, everyone is experiencing what life with anxiety is like. This includes those in management, who are dealing not only with their employees’ stress but also their own.”
Second, she looks to social media. “Some students maintain a ‘finsta’ (a ‘fake-Instagram’ account) they share with a select group who have ‘earned’ seeing their true selves. However, during COVID-19, nearly all people – from influencers to celebrities to students – are finally being vulnerable about their lived experiences and emotions. They are removing the perfectly curated images, in part, because they have to, without makeup or stylists or even access to haircuts and shopping.”
She closes with a call to action.
This essay is nicely written and argued. But is it persuasive?
Will our collective anxiety lead to more understanding of the struggles of those with mental illness? Will our post-pandemic world merely revert back to form, as people move past this moment?
Readers can decide for themselves, though I suspect that we are all hoping that Dr. Gold is right.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.