This article originally appeared in the July/August 2020 issue of the Ontario Medical Review magazine.
by Stuart Foxman
Consider the impact of the pandemic: increased cases of depression and insomnia, difficulties coping at work, and a seven-fold increase in psychiatric admissions. That’s not the aftermath of COVID-19. It was the reality after the Spanish flu a century ago, notes Dr. Janet Ellis, Director of Psychosocial Care in Trauma at Sunnybrook Health Sciences Centre in Toronto.
COVID has taken a physical toll, but experience tells us that its effects will ripple far wider. What’s the mental health burden, and how can doctors help to alleviate it?
Dr. Ellis was among the Canadian and U.S. experts who explored that at the third annual Psychiatric Dimensions of Disasters (PDD) conference, supported by the OMA. The CME-accredited program was organized by Dr. Frank Sommers, founding chair of Disaster Psychiatry Canada/University of Toronto Psychiatry, and the Canadian Psychiatric Association’s Section of Disaster Psychiatry.
With the inability to hold the event live, PDD streamed for free on June 6, drawing an audience of close to 2,000 registrants from 19 countries and four continents.
Dr. Sommers and Dr. Benoit Mulsant, chair of psychiatry at the University of Toronto, took a few moments to discuss the importance of disaster mental health training in medical schools and postgraduate programs. Acknowledging the residents and medical student registrants in attendance, Dr. Mulsant exclaimed, “You are the next generation … and we welcome your energy and participation.” Dr. Sommers echoed the sentiment, saying, “You are the future, and we welcome your interest.”
Dr. Sommers reminded all attendees that: “As physicians, we aspire to the highest ideals of healing the sick and relieving suffering.” In the shadow of COVID, he said there’s an opportunity to do that by treating mental health issues and reinforcing resilience in individuals and communities.
That’s true after any natural or human-made disaster. Canada has seen many in recent years, from the Fort McMurray wildfires of 2016, to the Humboldt Broncos bus crash of 2018, to violence like the Toronto van attack of 2018 and the Nova Scotia mass killings of this April. This pandemic is a different order of magnitude.
Start by recognizing the broader damage of an outbreak like COVID, advised PDD presenter Dr. Joshua Morganstein, Assistant Director of the Center for the Study of Traumatic Stress at Uniformed Services University of the Health Sciences in Bethesda, Maryland.
“Historically, the psychological impacts of disaster are experienced by more people, over a greater geography, across a much longer period, than all other medical effects combined,” said Dr. Morganstein.
He added that we should expect a “significant tail of mental health needs” for some time post-COVID.
In the post-Spanish flu days, said Dr. Ellis, big chunks of the population were gripped with feelings of helplessness, anxiety, guilt and anger. As for doctors? “Years later, health professionals were found to be haunted by a sense of frustration and grief,” said Dr. Ellis, a founding member of Disaster Psychiatry Canada, and a member of the Ontario Mental Health Response Team.
Surveys already reveal high levels of COVID-related stress among the Canadian population. It’s no surprise given the pressures of lockdown and distancing, the loss of social contacts or jobs, and the shock of personal, community and global upheaval.
We also see a unique public response to pandemics—fear and uncertainty, misinformation, anger and scapegoating, said Dr. Morganstein. He suggested that public health emergencies open fault lines in society and organizations, which we think we’ve solved.
Dr. Ellis said doctors face many tasks in helping their patients (and themselves) to live with uncertainty and loss of control, adjust to a change in roles, accept some degree of physical suffering and moral distress, and cope with anticipatory grief.
People can feel acute stress in the early days of a disaster (which might require short-term psychotherapy), while post-traumatic stress can persist for months or years. Those hospitalized for COVID have a high chance of developing PTSD symptoms. Isolation and quarantine increase the risks too, as does inequality.
PTSD can include fear of re-experiencing the trauma, intrusive or negative thoughts, an inability to recover from the traumatic event, hyperarousal, being “jumpy and grumpy,” changes in mood and behaviour, and a numbing detachment.
“The emotional brain and fear circuitry overrides the thinking brain,” said Dr. Ellis.
It’s easy to miss PTSD, even for psychiatrists, she said. Patients might present with multiple symptoms, including anxiety, anger, insomnia, depression, substance use, missed appointments, and an excessive fear of routine procedures.
If needed, PTSD treatments can include long-term psychotherapy, as well as anti-depressants, Trazodone and Mirtazapine (but not Benzodiazepines). But allow for a natural recovery—Dr. Ellis said 44% of people will recover without specialized help.
At a time like this, psychological first aid is crucial, said Dr. Jodi Lofchy, interim chief and medical program director at St. Joseph’s Health Centre in Toronto.
She defined the goals as reducing initial distress and fostering adaptive functioning and coping. Psychological first aid isn’t a single intervention or treatment, but an approach. The option of doing nothing increases the risk of PTSD, said Dr. Lofchy, who is also the service head of adult acute care psychiatry at St. Joseph’s.
Psychological first aid offers safety and calm, reminds people of their sense of self and self-efficacy, promotes connections with families and friends, and instills hope.
The latter can involve a delicate balance. “What is hope during an event like this?” asked Dr. Morganstein. The pandemic will eventually end, and most people will be okay. Yet the challenges are real, problems need to be managed, pain needs to be felt, and grief needs to be honoured, he said.
What skills are needed for psychological first aid? Recognize affective states, know how to de-escalate, practice active listening, show empathy and realize when to refer.
Understand the difference between stress and distress too, said Dr. Robert Ursano, a professor of psychiatry and neuroscience at the Uniformed Services University of Health Sciences School of Medicine in Bethesda. “Stress is the demand put on us to respond. Distress is our response when something is burdensome, frightening or concerning to us,” he said.
Dr. Ellis described how the psychological effects of disasters can extend over time: warnings and threats, the impact, heroic and honeymoon phases (featuring community cohesion), disillusionment (e.g., with family stress, job loss and home schooling), trigger events and anniversaries (anything that brings back the event) and reconstruction.
She noted that COVID can also affect various ages differently. Members of each group can experience the pandemic in distinct ways and struggle to manage their unique challenges.
For instance, older adults have borne the brunt of the dying, which brings a specific worry.
Adolescents and young adults, at the age when mental health conditions typically develop, have seen their future shaken (e.g., loss of academic progression, peer supports, and ceremonies like graduations).
And young children find themselves in the midst of stressed families—restless, powerless, perhaps afraid, and possibly witnessing parental distress or conflicts.
Consider the millions of young people affected by the pandemic. “Children are particularly vulnerable due to limited communication skills, immature cognition and high dependency, as well as their developmental stages,” said Dr. Frederick Stoddard, a professor of psychiatry at Harvard Medical School.
When screening and assessing children, look at several factors: their development; psychiatric and medical histories; the effects of health disparities; exposure to COVID; past traumas; quarantine; eating, sleeping and mood patterns; screen time; peer and family relationships; and virtual school participation.
What do children need most from parents now? Dr. Stoddard’s advice:
Some factors that affect resilience are biological (hormones, neurotransmitters), and others are psychological (social supports, moral compass, exercise, hardiness), said Dr. Stoddard, co-editor of the book Disaster Psychiatry: Readiness, Evaluation and Treatment.
Typical acute reactions include distress, sleep problems, regression, clinginess, worry about safety and separation, new fears, mild behavioural dysregulation, re-experiencing and re-enactments. Still, “Children are resilient—roughly 80% are likely to do well,” Dr. Stoddard reported.
Anyone can be vulnerable during COVID, and that includes doctors and other health care workers themselves. How can we reduce the harmful mental health impacts of COVID on these professions?
Doctors were already dealing with the chronic background of “ordinary” health care stress and high occupational risks, said Dr. Robert Maunder, deputy psychiatrist-in-chief and head of research in the Department of Psychiatry at Mount Sinai Hospital in Toronto.
And now? The OMA has seen increased stress levels and more calls for help to the Physician Health Program (PHP). “We know that before COVID more than half of our members struggled with burnout. That’s an epidemic in and of itself,” said OMA President Dr. Samantha Hill. The pandemic only compounds the load.
For health care workers, said Dr. Ellis, signs of PTSD can include compassion fatigue, and a doubt of whether you are right for your job.
After the 2003 SARS outbreak, Dr. Maunder said relatively few new cases of PTSD, depression or anxiety disorder emerged among health care workers. But there was evidence of burnout, increased sick day use and interpersonal problems. He said mitigating harms for doctors and others in health care comes down to resilience, psychological first aid, coping skills, and controlling the determinants of perceived risk.
What helped during SARS was feeling well-trained; optimizing interpersonal skills; balancing reflection and problem-solving; tolerating uncertainty; and increasing personal control. When that happens, said Dr. Maunder, “resilience is greater, and stress is less.”
Medical professionals should practice self-care too, said Dr. Lofchy. “We have to think about our own infrastructure of support.”
Develop a personal resiliency plan, she said. Take breaks. Meet your basic needs. Be mindful of HALT – knowing when you’re hungry, angry, lonely or tired. Get sleep. Have a buddy system with another responder. And be flexible, patient and tolerant.
COVID will be a marathon, added Dr. Ursano. He said it’s essential to try to recover mentally during any pause, so you can best be prepared for the next series of events.
Resilience has many facets. Organizational resilience can include preparation, whether for reserves of material, training or contingency planning. Resilience is also supported by visible and responsive leadership, clear communication (explaining the “why” of changes and decisions), and enhanced support (from coaching to counselling).
At Sinai Health System during COVID, an ad hoc group of resilience coaches took shape. The group included about a dozen psychiatrists, three psychiatric residents, an advanced practice nurse, a social worker and a bioethicist. Dr. Maunder described them as peers with expertise caught in the same struggle, offering guidance.
Any individuals, units, or departments can request the presence of the resilience coaches in-person or via Zoom. The coaches don’t act as therapists. Instead, they are facilitative – listening, surfacing feelings and issues, validating and supporting.
Sometimes, the coaches can offer a crisis response after a particularly stressful event; other times, they might help colleagues to self-advocate or communicate concerns to senior management. Staff can feel they have a greater voice, said Dr. Maunder.
What have the resilience coaches heard? Fears and concerns vary with context, i.e. anticipation versus acute events, or frontliners versus sideliners. There’s some anger about being put in harm’s way, i.e. inadequate PPE and conflicting advice. Staff also report fatigue in running this marathon, as well as some moral distress (are we offering sub-optimal care?).
Dr. Maunder said staff wish for recognition from leaders and the public but have some ambivalence about the hero narrative. Will personnel, doing the same work as always, have to give their capes away as that narrative fades?
Dr. Morganstein offered a word of caution to health care workers. As the curve goes down, “The process of reintegrating can be challenging,” he said.
That can include a loss of meaning and purpose. Tight knit teams dissolve, so there is no longer a shared experience. Previous life problems can seem trivial. Others don’t understand what you’ve been through.
Potentially, all of it could be even more distressing than working on the frontlines during COVID, said Dr. Morganstein.
Doctors aren’t the only ones on the frontlines. During a PDD panel, representatives from the Toronto Police Service, Toronto Paramedic Services and Toronto Fire Services reminded attendees about the stress on other first responders. That includes anxiety about possibly bringing COVID home, the elaborate routines just to re-enter their home, and sometimes living apart from family. Doctors can relate.
Count the Canadian Armed Forces among the responders too, said Dr. Andrea Tuka, clinical leader, Operational Trauma Stress Support Center at the Royal Canadian Navy Base in Victoria, B.C. She noted that in addition to their own protection efforts, the Forces have sent members to assist in places like long-term care facilities at governments’ requests.
Consider some unique issues when planning treatment for first responders, said Dr. Tuka. Those individuals face a risk of repeated trauma exposure and of moral injury. The occupational culture can also lead to delays in seeking care.
As doctors grapple with the pandemic, Dr. Morganstein says it’s vital to differentiate between feelings of guilt (I did something bad) and shame (I am bad). How do you prevent someone from experiencing something that’s morally injurious?
Dr. Hill said it’s critical to help each other manage through this crisis. “We’re not superheroes. We all need to be kinder to ourselves and others during this challenging time,” she advised.
Peer-to-peer support and collegiality can be a huge boost. For one, it helps to normalize feelings, said Ted Bober, director of clinical services for the OMA Physician Health Program. But it’s more than that, he said: “It helps to build a community and a sense that we’re in it together and allies. It also creates an opportunity to discover ways to advocate to make structural changes.”
As PDD highlighted, the challenges of supporting people through the pandemic and beyond are enormous and complex. “The coronavirus environment, just as other types of disasters, also offers the opportunity for development, change, and transformation at the individual, familial community and organizational levels,” said Dr. Tuka.
She said that COVID brings a chance for positive changes and transformation, right alongside the pain and distress caused by the trauma.
“Post-traumatic growth is a valuable concept,” agreed Dr. Ellis. “To be able to come out with a sense of shared experience, and mutual support, to feel an appreciation for being alive and gratitude for each day, leaves us in a much stronger position than being angry against fate.”
View the full webcast of the Psychiatric Dimensions of Disasters training day, which is also accessible on Disaster Psychiatry Canada. An extensive list of resources is also accessible on the “COVID-19” page of the Disaster Psychiatry Canada website.
Stuart Foxman is a Toronto-based writer.