Dina Goldstein Silverman, Ph.D., H.S.P.P.
Licensed Psychologist (NJ, PA), Associate Professor of Clinical Psychiatry,
Cooper University Healthcare and Cooper Medical School of Rowan University
The COVID-19 pandemic brought forward numerous societal problems to the fore. Among them is the need to address the mental health of frontline healthcare workers and that of patient survivors of critical-level care. To say that the COVID-19 pandemic had grossly affected mental health across the nation would be an understatement. According to the Stress in America 2020 report, 78% of American adults indicated that pandemic stress had overwhelmed them, and Gen-Z teens (age 13-17) and Gen-Z adults (age 18-23) reported particularly high stress and symptoms of depression (American Psychological Association, 2020). Worries about their own health and the health of their loved ones, grief for lives lost or impacted by COVID-19, job loss and prospects of lengthy unemployment, financial distress and uncertainty about the future, were some of the factors contributing to the anxious and depressive symptomology. Concurrently, as many as 20% of COVID-19 survivors with no prior psychiatric history, were likely to be diagnosed with a mental illness within 14 – 90 days of recovery compared to other health events, such as influenza, other respiratory tract infections, cholelithiasis, etc. (Taquet et al., 2021). Hazard ratios in this study were the highest for anxiety disorders, insomnia and dementia (Taquet et al., 2021). Healthcare workers taking care of patients battling COVID-19 were vulnerable to both, a higher risk of infection than the general population, and mental health problems, ranging from anxiety about their own illness or mortality or spreading the virus to their loved ones, post-traumatic stress symptoms, depression and frustration (Xiang et al., 2020). Increased incidents of suicide, both in COVID-19 patients and healthcare providers, has been driven by social isolation, economic recession, fear of contagion, exposure to trauma and social boycott and discrimination, further imperiled mental health (Thakur & Jain, 2020).
In light of the COVID-19 pandemic and its significant impact on American mental health, it seems imperative to utilize health psychologists as providers of swift, impactful mental health interventions to help stem the tide of anxiety, depression and other mental illness. As society moves to its post-pandemic realities, health psychologists are uniquely positioned to be on the forefront of developing timely short-term interventions to support frontline healthcare workers, assist patient survivors and help facilitate support for a beleaguered population in the ambulatory world post-discharge. Beyond reducing anxiety and depression symptoms, psychologists can tailor existing interventions to increase resiliency, reduce burnout and help these vulnerable populations achieve post-traumatic growth in the post-pandemic period.
“Charlotte,” a 54-year-old African-American single female, was referred to the ambulatory psychology service by her primary care provider for symptoms of PTSD following a case of bilateral interstitial pneumonia secondary to COVID-19 in March 2020. At the time, she had required inpatient hospitalization, inclusive of intubation and mechanical ventilation, and after a month-long hospital stay, she would recover at a rehabilitation facility. She reported struggling with racing thoughts, early and middle insomnia, panic attacks, particularly triggered by wearing masks or using a CPAP machine, flashbacks, nightmares, irritability, depersonalization and derealization. She also admitted recurrent anticipatory anxiety around in-person medical appointments that would result in frequent late cancellations or no-shows that compromised her follow-up care.
“David,” a 40-year-old, married European-American physician intensivist, was self-referred for ambulatory psychotherapy due to worsening depression and anxiety symptoms in September 2020. Prior to his self-referral, he had been stable on 20 mg of Prozac for decades, which he had begun taking for depression while in medical school. He reported racing thoughts, early insomnia, poor sleep quality, increased irritability, and numbness, feelings of guilt and shame and inadequacy. He also admitted being short-tempered with family, which contributed to his feelings of guilt. He noted a preoccupation with self-defeating thoughts of making a critical error that would cost a patient’s life. Working with these patients and many others led this writer to examine how to tailor existing interventions to unique pandemic stress.
There is a robust body of literature regarding the impact of Acute Respiratory Distress Syndrome (ARDS) on the cognitive and psychological health of survivors. ICU survivors may struggle not only with physical sequelae but with cognitive and psychological distress for years following their hospitalization (i.e., Herridge et al., 2011; Marra et al., 2018). One-fifth of ICU survivors experience clinically-relevant PTSD symptoms, and many endorse marked anxiety and depression in the first year of post-ICU recovery (Bienvenu et al., 2015; Tingley et al., 2020). Early pandemic research suggested that those survivors of COVID-19 that required intensive care were also more susceptible to PICS (Post-Intensive Care Syndrome,), inclusive of cognitive and psychological impairment (Tingley et al., 2020). Such impairment may include difficulties with memory, comprehension, and executive functioning, as well as worsening anxiety and depression due to contact precautions and reduced access to rehabilitation services and spiritual care (Hosey & Needham, 2020; Turnbull et al., 2022). Several recent studies have suggested that a third to a quarter of COVID-19 survivors, including those that did not experience ICU-level care, met clinical criteria for PTSD (Chamberlain et al., 2021; Janiri et al., 2021). Another study proposed that up to 30% of COVID-19 survivors would meet criteria for PTSD due to increased risk of trauma associated with witnessing the demise of other patients, high rates of delirium, hallucinations and delusions in ICU-level patients, breathing difficulties associated with severe COVID-19, deeper sedation and longer rates of ventilation than typical critical care treatment. Isolation from loved ones and continued contact precautions as well as PPE usage by healthcare workers further reinforced limited communication (Green et al., 2022).
Treatment of Charlotte presented its own unique challenges, as it took place entirely by telemedicine with the exception of the in-person termination visit. In the initial intake session, Charlotte was introduced to the Prolonged Exposure Therapy model of treatment of PTSD (Foa et al., 2019) to address her symptoms via in-vivo and imaginal exposure. Charlotte was able to identify areas where she would engage in phobic avoidance, and she was able to notice that she was particularly triggered by news coverage. In-vivo exposure required some creativity as Charlotte’s medical history made her a particularly high-risk patient for re-infection and complications, so she would attend grocery stores during off-peak hours, practice going to smaller stores at strip malls with outdoor spaces and would wear a clear face shield in addition to a face mask during her outings. Imaginal exposure was facilitated with the use of various television medical dramas to imitate the sounds of the ICU in addition to reviewing her ICU experiences. Charlotte was also able to create a calming ritual, where she would meditate upon the words “calm” and “safe” as she donned and doffed her PPE prior to her shopping trips and medical appointments. Over the course of 10 sessions, Charlotte’s scores on the PHQ-9 and the GAD-7 decreased, and her primary care physician reduced her dose of antidepressant medication in response to a marked reduction in her symptoms.
Working with David included using a mindfulness-based approach to reduce his symptoms. Like 78% of Americans, David was overwhelmed with pandemic stress in 2020 (APA, 2020), with the pandemic exacerbating his symptoms of burnout such as depersonalization, emotional exhaustion, cognitive fatigue, disengagement and anxiety (Hurst et al., 2022). David also struggled with moral distress, worrying about infecting his young family and about not being able to do enough to help his patients. A recent study suggested that moral distress experienced by many frontline healthcare workers would exacerbate burnout symptoms and imperil psychological functioning (Norman et al., 2021). David found relaxation training and meditation, as well as grounding techniques helpful. He was also engaged in cognitive restructuring around his self-defeating negative thoughts and engaged in behavioral activation strategies that helped him focus on meaningful time spent with his family and physical exercise to help with self-care.
As the world emerges from the pandemic, and emerging research points to the impact of Long COVID-19 on mental health, psychologists are uniquely positioned to deliver efficacious short-term trauma-informed interventions, particularly in medical settings, where high acuity is prevalent. Behavioral health integration, where multiple systems can work together across multiple disciplines and organizations, can be an avenue of delivering necessary care, as society positions itself to cope with the aftermath of the global pandemic.
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