Managing Mental Health Challenges Once COVID-19 Pandemic Ends

Social distancing during the coronavirus disease 2019 (COVID-19) pandemic will undoubtably have mental health consequences in the short- and long-term, and these consequences must be considered, according to a viewpoint published in JAMA Internal Medicine.

Authors from Boston, Philadelphia, and Oslo, Norway emphasized the importance of mitigating the mental health consequences of social distancing.

By instituting the practice of social distancing in countries all over the world, there have been changes in national behavior patterns and shutdowns of daily functioning, the authors wrote. And while this may slow the spread and flatten the curve of the disease, the consequences on mental health are unknown.

“Large-scale disasters, whether traumatic (eg, the World Trade Center attacks or mass shootings), natural (eg, hurricanes), or environmental (eg, Deepwater Horizon oil spill), are almost always accompanied by increases in depression, posttraumatic stress disorder (PTSD), substance use disorder, a broad range of other mental and behavioral disorders, domestic violence, and child abuse,” the authors wrote, adding further that 5% of the population affected by Hurricane Ike in 2008 met major depressive disorder criteria a month later.

They also cited the fact that 10% of New Yorkers showed signs of major depressive disorder in the month following 9/11, while 25% of New Yorkers reported increased alcohol use following the terrorist attack.

Specifically, they said, the severe acute respiratory syndrome (SARS) pandemic was linked to increases in PTSD, stress, and psychological distress in both patients and clinicians. COVID-19, of course, is closely related to SARS and the virus has been named SARS-CoV-2.

“For such events, the impact on mental health can occur in the immediate aftermath and then persist over long time periods,” the authors said. They believe after COVID-19, there could be substantial increases in anxiety and depression, substance use, loneliness, and domestic violence (specifically child abuse, as there is widespread school closures).

Mental Health UK has issued “psychological first aid guidance” to combat these increases, and there are 3 main steps to “proactively prepare for the inevitable increase in mental health conditions and associated sequelae that are the consequences of this pandemic,” the authors said.

1. Plan for the inevitability of loneliness and develop interventions. Populations are physically and socially isolating, though some technological advances can help bridge the gap. Places of worship, gyms, and workplaces are creating virtual rooms which can help congregants and employees feel less alone.

“Many observers note that outreach that involves voice and/or video is superior to email and text messaging,” the authors wrote.

“Extra efforts should be made to ensure connections with people who are typically marginalized and isolated, including the elderly, undocumented immigrants, homeless persons and those with mental illness.”

Children who are out of school should be given regular access to programmed work so they can develop routines, the authors added. Children should continue to have structure, learning, and socialization to offset the effects of social distancing.

2. Surveil, report and intervene for cases of domestic violence and child abuse. Those at risk may have limited opportunities to report incidents or get help while social distancing, which can limit travel outside of the home and increase time spent at home.

“Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” the authors wrote.

3. Prepare the mental health care system for inevitable challenges brought on by this pandemic. Stepped care is likely the best approach, as patients can begin with the least resource-heavy approaches and increase their care to as their needs dictate.

“This will require that systems are both well designed and well prepared to deliver this care to patients, from screening to the overflow of mental illness that will inevitably emerge from this pandemic. Scaling up treatment in the midst of crisis will take creative thinking,” the authors wrote.

The authors offered some ideas, including training “nontraditional groups” to provide psychological first aid and giving the public tools to check in on and support each other. Providing stepped care through technology, including mental health visits, group visits, and delivery of care will be important for both acute crisis management and routine support.

While Medicare has expanded their coverage of telemedicine health services to include mental health counseling and virtual visits with psychologists and social workers, public and private sector health care providers still need to develop virtual mechanisms for refill and delivery of essential medicines—including psychiatric medicines.

“This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so,” the authors concluded.

“The worldwide COVID-19 pandemic, and efforts to contain it, represent a unique threat, and we must recognize the pandemic that will quickly follow it—that of mental and behavioral illness—and implement the steps needed to mitigate it.”