COVID-19 & Implications for Behavioral Health Providers in Unprecedented Times

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Acknowledgments: This piece was written by Kim Hazel of Circle Social Inc, a national marketing and consulting firm for behavioral health that works to provide actionable insights for both patients and providers in order to improve addiction treatment and behavioral health outcomes across the US.

An Unprecedented Time

There is much to say about the deaths and physical sickness resulting from COVID-19. These are not matters to take lightly. However, we also need to think about what’s coming next; what will the fallout from this unprecedented time in modern history be

We’re already observing significant challenges to mental health and increases in addiction during lock-downs. Are providers ready? How do providers prepare for the implications of these challenges?

The virus may be new. However, there is extensive data about the impact that other global events such as war, famine, and natural disasters have on mental health. Diving into the data, we provide a guide for providers to prepare for what is sure to be a wave of mental health needs coming out of this pandemic.

We can use past crises to shape and culture an understanding of what comes next for mental health providers to meet their patients’ needs, as we navigate the obstacles of a global pandemic. COVID-19 has come with a plethora of complications. From the high risk of spreading to the individual challenges of rolling quarantines across the globe.

Current events are taking us through uncharted waters. We must use the information and guidance from the outbreaks and disasters that came before. This experience will provide us with the insights we need to provide better mental health facilities, care, and guidance than ever before- despite the novelty of the situation.

How Providers Can Help Individuals Weather the Storm

Across the board, this outbreak has resulted in an increase in mass quarantine and a new approach known as “social distancing.” These have had unprecedented impacts on mental well-being and psychological support. Anxiety has increased substantially across the country as more than 45% of US adults say the pandemic has impacted their mental health. 19% of adults say the epidemic has caused significant mental health impacts.

The world has weathered many storms, from earthquakes and tsunamis to tornadoes and hurricanes. People have lost loved ones, land, livelihoods, and so much more to these natural disasters. And it turns out, these impact our brains much the same way as the crisis of COVID-19 has. As providers, we can use the data and crisis response observed during some significant natural disasters to help us do better when responding to COVID-19 today.

In 2011, the eastern portion of Japan was struck by a massive earthquake caused by shifting the Pacific Plate and the Eurasian plate. This led to an enormous tsunami responsible for 15,984 deaths and over 2,500 still missing today. In turn, the tsunami was partially responsible for another piece of this natural disaster trifecta, as the nuclear power plant in Fukushima experienced a level-7 nuclear meltdown. This series of natural disasters can still be felt today, across the world, as lingering effects and radioactive isotopes continue to migrate.

However, the effects of the disaster weren’t only experienced by the environment. This crisis had a far-reaching impact on mental health in Japan. 42.6% of survivors were found to have moderate or severe mental health problems.((Yokoyama, Y., Otsuka, K., Kawakami, N., Kobayashi, S., Ogawa, A., Tannno, K., Onoda, T., Yaegashi, Y., & Sakata, K. (2014). Mental Health and Related Factors after the Great East Japan Earthquake and Tsunami. PLoS ONE, 9(7), 1–10.

 Those who are younger are more likely to be impacted negatively and have mental health consequences due to being survivors of disasters than older individuals.((Yokoyama, Y., Otsuka, K., Kawakami, N., Kobayashi, S., Ogawa, A., Tannno, K., Onoda, T., Yaegashi, Y., & Sakata, K. (2014). Mental Health and Related Factors after the Great East Japan Earthquake and Tsunami. PLoS ONE, 9(7), 1–10.

 In response to the dramatic toll on mental well-being this disaster had, Japanese organizations implemented various programs to provide mental health and psychological support. 

Each organization involved in attempting to provide support during the aftermath of the 2011 Tohoku Earthquake had different approaches, guidelines, and goals. Therefore, the community’s mental health outcomes were not as dramatically positive as hoped. 

Mental health and psychological well-being are interconnected to experiences surrounding disasters and the survival of catastrophe. To help create a way to help promote growth and support, organizations should implement both bio-psychiatric and non-medical activities and approaches.((Seto, M., Nemoto, H., Kobayashi, N., Kikuchi, S., Honda, N., Kim, Y., Kelman, I., & Tomita, H. (2019). Post-disaster mental health and psychosocial support in the areas affected by the Great East Japan Earthquake: a qualitative study. BMC Psychiatry, 19(1), N.PAG.  

It is suggested that employing training and guidelines from experiences from past events during disaster aftermath would’ve been more useful for promoting support for mental health and psychological support.((Seto, M., Nemoto, H., Kobayashi, N., Kikuchi, S., Honda, N., Kim, Y., Kelman, I., & Tomita, H. (2019). Post-disaster mental health and psychosocial support in the areas affected by the Great East Japan Earthquake: a qualitative study. BMC Psychiatry, 19(1), N.PAG.

During the response in the wake of this natural disaster, mental health services were not a steadfast cornerstone. This strategy left a gap in the providers’ ability and care plans. The only new approach to come from this was the introduction of new partnerships and communication channels. 

We know that there is a distinct stigma within seeking care for mental health and addiction treatment. In general, over 57% of those with mental illness do not receive treatment. Taking what worked in Japan, instituting partnerships for mental wellness, and delivering it better, we can hopefully show our crisis response surpasses Japan’s efficacy in 2011. How do we do this?

As providers in the current crisis, we should be sure to learn from their mistakes and victories. We need to be sure to prioritize our services and address partnership opportunities. For example, in Milwaukee, there has been a 70% increase in Emergency Medical Service calls regarding mental health incidence in March and April 2020. 54% have been responses to drug overdose, and there has also been a dramatic 80% increase in response to suicide attempts.

We need to create lasting and meaningful relationships with those who are providing and treating mental illnesses and addiction in our communities who need specialized support. We need to be prepared to meet our patients where they are and begin meeting their needs more promptly. Take Milwaukee; for example, they are finding a considerable increase in EMS responders treating severe events related to mental illness and addiction. Wouldn’t it make sense for us to approach them as a way to provide support and to present ourselves as a resource for patients in a mental health crisis?

By cultivating relationships with EMS rather than focusing solely on relationships with referring hospitals, we can get patients the care they need when they need it. Like Japan, partnerships can pave the way for an improved mental atmosphere, and during a time of crisis, it can be the difference between a system caving in on itself or bolstering itself.

In recent years, Japan was not the only country to experience a record-breaking natural disaster that dramatically shaped mental health. The United States faced its natural disaster in 2012 when Hurricane Sandy, also known as Superstorm Sandy, made landfall in New York City (NYC). This storm affected 24 states in the U.S. as well as the entirety of the eastern seaboard. Compared to historical storms that have impacted the country, Sandy was the fourth costliest storm at $70.2 billion in damages alone. 

Out of the areas most heavily impacted within NYC, 2% of individuals had probable PTSD, and 8.9%  likely had major depression.((Lowe, S. R., Sampson, L., Gruebner, O., & Galea, S. (2015). Psychological Resilience after Hurricane Sandy: The Influence of Individual- and Community-Level Factors on Mental Health after a Large-Scale Natural Disaster. PLoS ONE, 10(5), 1–15. The study that yielded these results also found various significant factors in the prevalence of these mental health impacts like demographic characteristics, disaster-related stressors, exposure to another traumatic event during their lifetime. They also found that being in a cohesive community and in positive economic standing had a negative relationship with significant depressive outcomes when assessed after a crisis.((Lowe, S. R., Sampson, L., Gruebner, O., & Galea, S. (2015). Psychological Resilience after Hurricane Sandy: The Influence of Individual- and Community-Level Factors on Mental Health after a Large-Scale Natural Disaster. PLoS ONE, 10(5), 1–15.

COVID-19, a novel coronavirus, has become a global pandemic, and you’d be hard-pressed to go a day without hearing about it. As it continues to escalate daily, it has begun to outmatch the 1918 outbreak of the flu. All 50 states in the U.S. have reported cases and community spread. The clinical picture of this illness changes rapidly from day to day, and yet strides are being made to research the impacts this global pandemic will have on this generation and generations to come.

When looking at these disasters comparatively to COVID-19, we can glean some critical information as mental health treatment and addiction treatment providers. First, experiences or exposure to trauma, crisis stressors, and demographics can play a significant role in our patients’ mental well-being, which isn’t surprising as most of us work with these factors daily with patients and clients.  The social determinant factors of health are always at play in both physical and mental health aspects with or without disaster or crisis. That being said, it shouldn’t come as too huge of a surprise that we see those same factors causing a stark difference regarding COVID. 

There is already data being published that shows the extent to which the virus disproportionately impacts particular demographics. This isn’t to say that the virus is only going to attack individual races or socioeconomic groups; rather these groups tend to have more outside stressors that they are weathering aside from the virus that play a massive role in their health. African American and Hispanic populations show higher rates of infection and mortality than other demographics across the country.

For providers, this means we need to be sure that we are working to combat the stereotypes that may form around this data and that we care for patients that are a part of this demographic with specialized plans that focus on their needs. In general, for these demographics, patients first receive care for their mental illnesses from primary care providers. 

With these demographics, in particular, they are less likely to seek help initially and are more resistant to coming into the behavioral health facilities period. That means it is our job to make that transition smooth, affordable, and preferred. One way to do this is to create lasting relationships with primary care providers around our communities. These providers will begin attending these patients even as COVID fades from headlines. Much like we saw with EMS, we must create effective working relationships with these providers to get in front of these populations.

We need to be sure we are providing resources that are the most equitable for our patients. African Americans, Hispanics, and those with lower socioeconomic status are being disproportionately impacted by COVID and various other health factors each day. These patients need unique care that fits their needs and provides them with reasonable accommodations. This may be where further research into integrated interventions and care will come into play, especially in a post-COVID world.

We mustn’t dismiss or ignore the significance of the increase in anxiety due to COVID, either. 

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For example, many patients or clients may benefit from increased sessions in either duration or frequency. A recent article found prescriptions for anti-anxiety medications, specifically benzodiazepines and other antidepressants, have risen 34% and 18%. In Massachusetts, medical marijuana registrations have increased by over 245% during the pandemic as well. 

Looking at this increase from a business standpoint, we can expect an increase in demand for services like behavioral health and addiction treatment. As states begin to reel back regulations and stay at home orders, society will strive to find its way back to normal but, what happens when people start to realize transitioning back to normal is harder than they thought? They begin seeking treatment, meaning that we, as providers, need to be ready to handle an influx of patients. These patients may be inpatient or outpatient. 

Our responsibility is to make sure we are ready, so we need to start preparing now. Facilities can do this by transitioning current qualified staff members and equipping staff ahead of time and optimizing schedule availability in preparation. This can provide opportunities for growth for your team and keep costs low by alleviating the need for new hires. Plus, it can help prevent the need for extensive furloughs of nonessential employees by transitioning their role for a period. This can be an effective method to balance cost with an increasing demand for mental health services while supporting your staff members and displaying their worth to your team.

Aside from prepping your team for an inevitable increase in those seeking care, it is also essential that we champion approaches that are more than medication and that capitalize on the unique situation at hand. One option is providing more accessible care via telemedicine services, something most providers have already implemented. Another is to provide access to a helpline monitored 24/7 for patients to access when needed the most. Current statistics show COVID has increased calls to national helplines by almost nine times their average number of calls. Switching to telehealth and implementing telemedicine strategies can also potentially help lower costs for the facility and decrease the likelihood of community spread of COVID.

When attending patients virtually or in-person, we must be sure they have the resources they need. That means it may be time to create or revamp any existing materials that your team currently provides to patients about where they can access quick care when needed and how they can get in touch with you and your team. This is also a perfect time to be sure that your team is trained on what to do if someone calls seeking help urgently. 

It is not just about physical well-being or mental well-being for patients, as the global economy has taken a downturn. Many patients and clients may be experiencing more financial stress than ever before. We can look to experiences from the economic recession of 2009 to get a more concrete idea of what patients are experiencing and how to better shape mental health and addiction care during and after COVID-19.

It’s About the Money

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Economies are a driving factor in daily life for virtually all of us in the modern world. It shouldn’t surprise that dramatic changes in economics and economic states come with a truckload of baggage and headaches. 

How far those headaches and obstacles go and impact us is, in part, determined by some similar factors as what we saw when looking at the mental health impacts caused by natural disasters. That is to say, mental well-being and psychological health are linked to community and economic strain during times of emergency, whether the disaster is a result of mother nature or not.

There is a significant relationship between mental well-being and economic crises by looking at the data surrounding mental health and economic recessions.((Martone, K. (2012). The Impact of the Economic Downturn on Public Mental Health Systems. (Cover story). Psychiatric Times, 29(2), 1–11.))((Zivin, K., Paczkowski, M., & Galea, S. (2011). Economic downturns and population mental health: research findings, gaps, challenges, and priorities. Psychological Medicine, 41(7), 1343–1348., M., Evans-Lacko, S., Dom, G., Christodoulou, N., Samochowiec, J., González-Fraile, E., Bienkowski, P., Gómez-Beneyto, M., Dos Santos, M., & Wasserman, D. (2016). EPA guidance on mental health and economic crises in Europe. European Archives of Psychiatry & Clinical Neuroscience, 266(2), 89–124., A., Landriscina, T., Amerio, A., & Costa, G. (2018). The impact of the current economic crisis on Italy’s mental health: evidence from two representative national surveys. European Journal of Public Health, 28(3), 490–495. This includes suicide, seeking help for mental health problems, and the onset of mood disorders and distress.

In 2009, an economic recession began in the U.S. and led to a reduction in spending across the country. Mental health treatment and other treatment centers also had severe cuts in spending as well. This is inopportune because mental health treatment is a high demand and high needs area during times of recession while funding was slipping away. The financing that State Mental Health Authorities control was estimated to have been reduced by 3.49 billion dollars between 2009 and 2012.((Martone, K. (2012). The Impact of the Economic Downturn on Public Mental Health Systems. (Cover story). Psychiatric Times, 29(2), 1–11.))

Before the recession began, most states were in the middle of revamping their mental health services. Changes including introducing community integration programs and improving accessibility to integrated settings.((Martone, K. (2012). The Impact of the Economic Downturn on Public Mental Health Systems. (Cover story). Psychiatric Times, 29(2), 1–11.)) These came on the heels of the mental health report posted by the U.S. Surgeon General.((Martone, K. (2012). The Impact of the Economic Downturn on Public Mental Health Systems. (Cover story). Psychiatric Times, 29(2), 1–11.)) Once the recession hit, it was clear that most of the mental health services within states were fragile and unprepared to handle another cut in funding. 81% of states reported budget cuts during this time. This led to negative impacts on mental health during a particularly trying time in the U.S.’s economic history.

Economic crises are unique as well in that, regardless of personal wealth, education, and employment status, they dramatically negatively impact mental well-being across the board.((Zivin, K., Paczkowski, M., & Galea, S. (2011). Economic downturns and population mental health: research findings, gaps, challenges, and priorities. Psychological Medicine, 41(7), 1343–1348. The U.S. was not the only country to suffer from an economic downturn; Italy has also experienced it’s own starting in 2008.  Studies across the last ten years have shown these crises impact mental health, specifically depression and mood disorders, anxiety, alcohol-related disorders, and suicides.((Odone, A., Landriscina, T., Amerio, A., & Costa, G. (2018). The impact of the current economic crisis on Italy’s mental health: evidence from two representative national surveys. European Journal of Public Health, 28(3), 490–495.

Work environments are also known to become more toxic and stressful as more people become desperate to remain working no matter the cost to their health. Studies suggest that even during economic crises having a poor quality job and work environment was no more beneficial on mental health than being unemployed.((Odone, A., Landriscina, T., Amerio, A., & Costa, G. (2018). The impact of the current economic crisis on Italy’s mental health: evidence from two representative national surveys. European Journal of Public Health, 28(3), 490–495.

If, as mental health providers, we do not also consider the economic stressors that are compounding with the current outbreak of COVID-19, then we are doing a massive disservice to our patients. When looking at the following research surrounding mental health impacts and economic downturn, we can find various resources shaped to guide us in our community-wide mental well-being treatment during this specific type of crisis. 

The European Psychiatric Association, known as the EPA, created its guidance on the topic.((Martin-Carrasco, M., Evans-Lacko, S., Dom, G., Christodoulou, N., Samochowiec, J., González-Fraile, E., Bienkowski, P., Gómez-Beneyto, M., Dos Santos, M., & Wasserman, D. (2016). EPA guidance on mental health and economic crises in Europe. European Archives of Psychiatry & Clinical Neuroscience, 266(2), 89–124. suggest creating interventions in the areas of:

  • Welfare Provision – 
    • Creation of enhanced social protection systems
    • Maintain income support
    • Fight unemployment
    • Address housing instability
  • Mental Health Promotion and Psychiatric Care – 
    • Improve mental health care
    • Promoting the coordination or integration of primary care and psychiatric care
    • Speeding up care
    • Emphasizing illness prevention and health promotion 

But what does any of that mean for providers?

Taking this research to guide what providers can do today is critical, keeping in mind the significant economic toll isolation has taken on the country while flattening the curve. For example, as providers, we should be clearly and consistently focused on mental health promotion tasks like promotion of coordination between care types and providing regular quality care to patients or clients– even if it is via virtual means.

We can be sure that patients can still get the care they need regardless of the economic situation by creating new initiatives for payer options.

That could look like increasing awareness that you accept Medicaid or Medicare. As we continue to observe COVID-19 dramatically impact employment rates, we will recognize changes in increased patients relying on Medicaid. This shows a complicated shift in the market, and it can be critical that we prepare for this moving forward. Medicaid reimbursements are generally lower than other forms. So as we make to pivot to a market in which Medicaid plays a more significant role, we must find ways to maximize the support Medicaid provides by lowering operational overhead.  

An example of this can be reevaluating the clinical timeline for your patients. As a clinical team, it is our number one priority to ensure that patients get the care they need for as long as they need it. However, something to consider during this time is that some of our timelines may be going a little long so, perhaps instead of having your patient stay for residential care for an extended period, we find a way to shorten their inpatient stay and lengthen their outpatient sessions. To combat the changes we see coming soon from COVID-19, we need to think outside the box while still cultivating unparalleled care. We suggest gathering your clinical team to assess the possibilities of altering patient timelines to provide more opportunities for more patients at a lower cost. 

Alternatively,  ensuring patients get the care they need may look like creating a team that guides each client through payment options, so they don’t have to stress about affording their care. We are witnessing an increase in patients lacking the workplace provided insurance or care plans as the country’s unemployment rate continues to increase. More than ever, patients are looking for clear and beneficial guidance for how they can pay for their care without it costing them an arm and a leg. 

It is the perfect time to revisit your uninsured discount policies and care policies. We believe you can capitalize on this time by leveraging your team’s expertise to create a plan that works for your specific patient community. After creating a new program or revamping an old policy, you will want to provide clear and explicit guidance for your patients. Perhaps you mandate a financial wellness visit with your billing cycle team members for patients and families. Maybe you create a series of branded informational content that displays the information families want to understand the most. This can include the payment schedule, the total cost of care, repayment options, timeliness of care and costs, etc. 

Also, as providers, we can work to streamline the process of care. Think back to the discussion we had about building meaningful relationships with EMS based on Japan’s experiences in crisis response. If we genuinely cultivate effective partnerships, we can provide our patients with a reliable and lasting care pipeline. From EMS to behavioral or addiction care can sometimes be a prolonged and confusing process for patients. 

Some patients’ journeys are filled with trips to and from their primary care group that are not prepared to handle their mental illness aside from prescribing medication adequately. Some patients’ journeys feature multiple EMS visits that leave them feeling helpless and without a reliable solution to their problems. During an epidemic, like COVID, it is more important than ever to create an active pipeline for these patients as the incidence rate of mental illnesses related to COVID increases.

Sick and Tired of Being Sick and Tired

Throughout time there have been various types of outbreaks and illnesses that have shaken the world. Some of these include the Spanish Flu (1918), H1N1 (2009), Ebola (2014), Zika virus (2015), and now COVID-19 (2019). Each of these outbreaks led to their responses and aftermath. However, they all have one thing in common that surpasses the rest- their impact on the mental health of survivors and those impacted. 

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From No News to Fake News 

In 1918, the U.S. was hit with its second, and much more intense, wave of the Spanish Flu. Newspapers had published stories on the impending epidemic, but there was no sense of anxiety or worry on an extensive scale.((Dicke, T. (2015). Waiting for the Flu: Cognitive Inertia and the Spanish Influenza Pandemic of 1918–19. Journal of the History of Medicine and Allied Sciences 70(2), 195-217. There has been virtually nonstop coverage of the global pandemic and economic downturns taking place across the world in recent days. 

While this allows us to become informed, it also increases community anxiety exponentially.10 So, while most communities received less news and treated the outbreaks with disregard in the past, now communities have access to a constant barrage of news and information.

The outbreak of Spanish flu and COVID is not the only outbreaks that faced challenges in disbursing information to the public. In 2009, H1N1, also known as Swine Flu, had begun to spread across the world.

The WHO warned of a phenomenon known as “public pandemic fatigue” that occurs when the public becomes exhausted and desensitized to the hype surrounding outbreaks. ((Isaacs, D. (2010). Lessons from the swine flu: Pandemic, panic, and/or pandemonium? D Isaacs Lessons from the swine flu. Journal of Paediatrics & Child Health, 46(11), 623–626.

This can be as dangerous “no news” as it will lead to the same careless behaviors that caused the flu of 1918 to continue to wreak havoc in four separate and distinct waves. 

Not to mention, social media has become a significant staple in our daily lives and has taken a more massive chunk of the pie chart of our time during the increase in social distancing. Currently, social media engagement has increased by over 61% during the pandemic. As that happens, it also works to fuel the fire that is community anxiety for isolation, death tolls, negative news, and more.1

There has been research regarding COVID-19 that has shown a high prevalence of mental health problems occurring during the novel outbreak. These problems have also been positively associated with the frequency of social media exposure during the outbreak.2

 As providers, it is our responsibility to ensure that quality, accurate information is being distributed to our patients. This will also allow our patients to feel better about the situation, the news they witness, and the anecdotes they hear from friends and family.

Patients and clients may be finding themselves feeling a bit lost at sea in the flood of information about and surrounding COVID. As professionals, we need to be prepared to help them navigate the tides. That means creating an effective strategy for staff members to implement to start the conversation about how news and social media are causing a client to feel. It is also essential that we create a stable and agreed-upon process to help them learn to filter and cope with their viewing information. 

For example, maybe for your overly anxious patient, you recommend limiting time on social media during this time so that they do not feel overwhelmed by the news and “fake news” on their timelines.

Aside from adding increased anxiety in patients flooded with news via social media, the increase in social media use can be an advantage for providers. In the industry, there is a gap that can be filled during this time that may gain more ground while providing better access to care for patients, and it is known as Direct To Consumer (DTC) marketing. 

Our piece on what behavioral providers can learn from pharma marketing seriously takes on this issue. For times like COVID-19, the need for care is increasing. If you provide your local community with the information they need by showing them directly who you are and what you do, it can alleviate some entry barriers that patients may be experiencing during this time.

Speaking of social climates during outbreaks… each outbreak has featured its unique response to pull best practices out of to provide better care.

Outbreak Response

During the Spanish Flu outbreak, multiple waves lasted from mild waves during the 1918s to larger waves leading up to the 20s. Epidemiologists believe approximately 30% of the world’s population contracted the flu before 1920.((Dicke, T. (2015). Waiting for the Flu: Cognitive Inertia and the Spanish Influenza Pandemic of 1918–19. Journal of the History of Medicine and Allied Sciences 70(2), 195-217. During this time, the organization and response to treating this outbreak looked much more like disaster relief than typical public health practice. Responses varied by location, but the answer was largely to close down schools, churches, and public gatherings. Some places went as far as to criminalize acts like coughing in public.((Dicke, T. (2015). Waiting for the Flu: Cognitive Inertia and the Spanish Influenza Pandemic of 1918–19. Journal of the History of Medicine and Allied Sciences 70(2), 195-217.  Temporary hospitals quickly became a new routine, and volunteers provided support to doctors and nurses worldwide. 

Today, we recognize much of the same activities: self-isolation, statewide closures, limited business opportunities, and more. We also see many temporary hospitals, drive up testing, and demanding that pre-screening take place before visiting any medical facilities. There has been increased vigilance by stores and shops, both locally and nationally, from limiting customers’ numbers to fashioning homemade place markers to maintain a safe and cushy 6 feet between patrons. COVID-19 is continuously changing our everyday lives, and it is impossible to ignore it.

In general, epidemic outbreaks can create a vast amount of mental health challenges for individuals.1 For example, these can include ongoing challenges to mental well-being during recovery, anguish from family members of those impacted or who have passed away due to disease, stigmas, fear, anxiety, detachment, etc. Communities may also experience their unique challenges like fear, isolation, confusion, and an increased rate of risky behaviors.1

The Spanish Flu survivors reported an increase in sleep disturbances, depression, difficulty concentrating, suicide, and more mental illness-related issues and symptoms.  H1N1 was unique as it was one of the first outbreaks that led to a significant amount of research and concern for the psychological toll something like a global epidemic can cause. 

A novel study used the ability to track electronic medical records of patients who recovered from H1N1 to monitor their mental health status.3

 It found that children and teens were more likely to have expressed serious concern about the flu and the possibility of getting it. 

Most studies do not include children and adolescents when researching the impact of disasters on mental health for ethical or logistic reasons. However, they are a significant part of the population known to express extreme anxiety and worry over outbreaks.4 This may be in part due to their proximity to friends via education and school. As schools close for outbreaks among their peers, students may begin to suffer anxiety and worry about themselves and their friends.

For adults, most of the anxieties that arose came during the first three months of the outbreak.((Page, L. A., Seetharaman, S., Suhail, I., Wessely, S., Pereira, J., & Rubin, G. J. (2011). Using electronic patient records to assess the impact of swine flu (influenza H1N1) on mental health patients. Journal of Mental Health, 20(1), 60–69. lingered for a time before their concerns moved onto other topics. Other disease outbreaks like the outbreak of Ebola and Zika had different mental impacts on survivors and indirectly impacted individuals. 

With such a massive impact on the health of the world on a global scale, it isn’t surprising that outbreaks like these drastically impacted the world’s mental health. It is something to consider as we create care plans and relapse prevention plans for our clients and patients. When we create new care plans for patients, we need to ensure that we are creating care that can be implemented into their schedules as things progress. 

For example, a patient may have more time for visits on a regular schedule now, but as things transition from stay at home or shelter in place orders to the latter phases of state reopening, their time for care may decrease substantially. We mustn’t let these patients fall off our radar and create flexible options for them to utilize. Another example is a patient who is a long-term patient receiving outpatient care at your facility for a little over a year. COVID has undoubtedly impacted this patient as well, and they may need an adjusted plan or a plan that fits around their new schedule of homeschooling and telecommuting for work. 

When it comes to planning care for patients during COVID, it is critical that as a provider, your team puts patient needs first and has flexibility during scheduling. As plans and guidance changes, we need to support our patients to be sure that they don’t have added stress from the ever-changing atmosphere that COVID-19 has left us.

Quality Care Above All Else

As is familiar with outbreaks of illnesses, the priority is control of infection and spread while mental impacts and treatment take a distinct backseat. The Inter-Agency Standing Committee of the WHO crafted guidelines for a four-tiered intervention structure. The tiers focus on a pyramid type approach that builds off of one another.1

  1. Restoring essential services and security
  2. Strengthening networks for families and communities
  3. Providing psychological and mental support for distressed individuals (particularly those in acute stages of illness)
  4. Specialize in mental health interventions for affected survivors

We fit into tiers 3 and 4 of this type of pyramid response based intervention structure. In the past, care for the survivor’s mental health was virtually nonexistent during outbreaks. It showed as the psychological impacts of survivorship and the spread of illness had deadly consequences in the areas most heavily impacted.5

This suggests more resources and time need to be focused on mental health treatment, care, information and education, and policies during times of crisis. 

The lessons from the mental health crisis sparked from the Ebola outbreak specifically were mainly focused on improving access to care. Care was not widely found or easily accessed during the outbreak, and it had substantial consequences for the communities. Studies suggest an approach supported by strong leadership and affordable medications is the appropriate approach to resolving and working through a mental health crisis during a public health emergency.((Kamara, S., Walder, A., Duncan, J., Kabbedijk, A., Hughes, P., & Muana, A. (2017). Mental health care during the Ebola virus disease outbreak in Sierra Leone. Bulletin of the World Health Organization, 95(12), 842–847.

 Let’s start by discussing the leadership piece of this puzzle then move into providing more accessible and affordable care.

During times of crisis, most people are looking for a solid structure of leadership. This applies to all aspects of their lives, including in their mental health and addiction care settings. Utilizing a strong leadership structure clear to patients is relatively simple, especially if there was already a solid structure. 

Start by providing precise and concise messaging that comes from the top down. Patients must recognize those in charge of the facility or clinic, taking the time to address concerns and needs regarding COVID specifically. The things you can do to ensure you are creating a clear communication strategy with patients and staff are:

    • Develop communications about how your group is meeting or exceeding the CDC guidelines to prevent the spread
    • Create a process for screening patients, clients, and guests before they enter the facility
    • Producing bulletins on facility rules or guidelines in response to COVID and the statewide changes that impact your facility. 
    • Provide opportunities for patients to discuss their concerns and then respond to them appropriately
    • Ensure adequate social distancing by either staggering entrance to the facility or doing extended phone screenings before attending treatment
  • This piece is especially crucial for behavioral health centers, as many patients with severe anxiety may have significant apprehension about waiting in close or crowded waiting rooms with others.

Some state-wide rules frequently changing can be a significant source of anxiety for patients, clients, and their families. We suggest creating informative sessions or documents that help explain the changes taking place in your state to address this. It can help designate one team member to monitor the statewide situation to provide quality guidance for the team and patients. Also, verifying that staff is trained and ready should COVID symptoms pop up in your facility. Creating a readiness plan and having it posted is an excellent way to ensure that team members are prepared to take action. Still, also it will provide patients with a strong sense of confidence in the team, helping monitor their safety. 

Accessibility and affordability are other factors that COVID-19 is yet again, providing challenges of its own. This has cultivated all-new challenges, including:

  • How do we provide care without contact? 
  • How do we remain accessible to patients/clients without in-person clinic time?
  • How do we promote the continuation of our services during this time?
  • How can we provide the best care to the most vulnerable patients?

Research backing telehealth options is reassuring. Telehealth options have been gaining steam as the outbreak has progressed and led to a prolonged amount of time under Stay-At-Home orders from states. From Zoom to Skype to more specific telehealth provider options, there has been a substantial learning curve to providing patient care with no in-person contact while keeping it accessible, affordable, and timely. 

The Office of Civil Rights at the U.S. Department of Health and Human Services has even provided unique guidance for HIPAA compliance for providers during these times as well. They created a unique discretionary set of guidelines and information for providers seeking to use or making use of telehealth services during the COVID-19 pandemic. This is a big win for providers as it gives us more options to help our patients without compromising ourselves or our practices. It also allows for a big push in support of telehealth solutions in the future.

Photo by Edward Jenner from Pexels

That is not to say that telehealth’s transition for mental health services and addiction treatment will be painless. It is well-known that there is an adjustment being made by both providers and patients across the nation. 

Some practitioners have struggled with the technical aspects related to virtual visits. This can include poor sound or video, problems maintaining connection, poor security control, and limited access to critical medical information or clinical notes. Although, in general, some practitioners seem to prefer the advantages of virtual visits to care for their patients and clients during the time despite the issues surrounding the fickle nature of some technologies. Benefits can include: visiting specialists previously out of reach, the convenience of care, more direct oversight from providers for patients, current guidance is supporting a massive push for telehealth options.

However, patients have some different experiences and expectations of care when it comes to virtual health. Like we said above, there is an adjustment being made for everyone during this time. There have been some reports of individuals experiencing delayed or inadequate care, but more importantly, the occurrence of “telehealth bombing.” Recently, an article was published highlighting a severe problem of care visits being hosted via the internet (by Zoom in particular for this case, although they are not the only platform with this issue) hacked by outsiders. 

This is more common for addiction treatment as many support groups have transitioned to an online setting where they are open access and can drop in and drop out as they please during a session. While this promotes accessibility, it can also hurt the intimate and trustworthy relationships built and maintained through group meetings. Especially as some courses can host up to 300 people per virtual room, the private close atmosphere and comfort level can be dramatically reduced for participants.

When providing care for our patients and clients, we need to be sure that we are providing accessible care that is also secure and as comfortable as in-clinic care. The advantages heavily outweigh the disadvantages of virtual visits in mental health services and addiction treatment if done correctly. It also gives us an avenue to answer all those burning questions listed above, as best we can. 

Ultimately, it is likely that telehealth will still be in second place when compared to brick and mortar services. As providers, some changes need to be shaped to accommodate and account for the changing landscape COVID-19 has created. 

As we’ve stated before, slowing the spread and having an action plan are two significant facets that patients and their families will be actively looking for when considering treatment. These two criteria will continue to be relevant long after COVID-19 has faded from the media headlines. 

When considering ways to provide accessible and safe care, one method is to create staggered timetables. Creating certain times for several individuals in the facility will help combat the spread of the illness. It will also allow patients to feel at ease in the facility whether they are there for therapy, an initial consult, or MAT. 

Another massive benefit of a staggered schedule is that it gives staff and team members enough time to spotless rooms, common areas, and workspaces between each client without feeling rushed. This will give the team more time to focus on providing quality care in a way that makes the most significant difference for your patients.

Many patients are feeling uncertain if now is the ideal time to leap to start care. Giving your team the support and guidance they need to provide better phone screenings and follow-ups can make a big difference in whether your patients stay committed to treatment and create concrete plans or renege. Allowing staff members to do what they do best with increased support will enable them to provide better support and reassurance to patients and families that aren’t sure that now is the correct time to seek care. Plus, encouraging and setting more robust follow-up call schedules can also remind patients that you are still there for them when so many other aspects seem uncertain.

The final aspect of providing quality and compassionate care to those who count on us is something that providers often overlook: ourselves.

Don’t Forget to Take Care of Yourself and Your Team. 

Responders and professionals are also impacted in an additional way. We saw this during the Ebola outbreak studies, and we continue to see it today in response to COVID-19. Responders and providers face the potential for PTSD and other stress disorders on top of all the other potential mental health issues that are posed to individuals and communities alike.1

Secondary traumatic stress is also common in providers during this time. Whether responders are on the “frontline” in hospitals or “in the trenches,” providing any types of care to those with COVID or impacted by COVID, PTSD, and secondary traumatic stress are real possibilities. 

The CDC has these suggestions for providers regarding the toll that COVID-19 is taking on you:

    • Acknowledge that stress can impact anyone 
    • Learn the symptoms (fatigue, illness, fear, withdrawal, guilt).
    • Allow time for you and your family to recover from responding to the pandemic.
    • Do personal self-care activities that you enjoy.
    • Take a break from media coverage.
  • Ask for help 

Remember, the care you provide will only be as good as the care you present yourself during crisis times. If you are experiencing PTSD or secondary traumatic stress and not seeking a way to care for yourself, you are doing a disservice to yourself and your patients. On planes, we are told to put on our oxygen mask before helping others; the same is valid for mental health service providers and addiction treatment providers. Put on your mask first, then help your patients do the same.

Leadership in addiction centers and behavioral health centers also need to foster an environment that supports their staff as they navigate this time. For example, creating an atmosphere where staff members know it is okay to address their concerns regarding COVID-19, patient and staff safety and health, and burnout. It’s critical that as a leader, you create forums in which your staff can address their concerns and that you take the time to listen and evaluate them honestly. We suggest implementing an employee feedback chain, whether it be via an anonymous form, a survey, a suggestion box in a communal area like a break room, or a seminar-style staff meeting. Creating an environment that puts our teams first will allow them to focus on what matters most, our patients.

Every crisis comes with its own set of challenges and obstacles.  Whether it is war, plague, earthquakes, hurricanes, or tsunamis, each generation faces its disaster.

The global pandemic of COVID-19 is taking us through uncharted waters, so we better use the information and guidance from the outbreaks and disasters that came before. These experiences will provide us with the insights we need to provide better mental health and addiction treatment services.

History cannot be unlived, but it can be understood to prevent being repeated. 

Kim Hazel
  1. Tucci, V., Moukaddam, N., Meadows, J., Shah, S., Galwankar, S. C., & Kapur, G. B. (2017). The Forgotten Plague: Psychiatric Manifestations of Ebola, Zika, and Emerging Infectious Diseases. Journal of Global Infectious Diseases, 9(4), 151–156. [] [] [] [] []
  2. Lima, C. K. T., Carvalho, P. M. de M., Lima, I. de A. A. S., Nunes, J. V. A. de O., Saraiva, J. S., de Souza, R. I., da Silva, C. G. L., & Neto, M. L. R. (2020). The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psychiatry Research, 287, N.PAG. []
  3. Page, L. A., Seetharaman, S., Suhail, I., Wessely, S., Pereira, J., & Rubin, G. J. (2011). Using electronic patient records to assess the impact of swine flu (influenza H1N1) on mental health patients. Journal of Mental Health, 20(1), 60–69. []
  4. Page, L. A., Seetharaman, S., Suhail, I., Wessely, S., Pereira, J., & Rubin, G. J. (2011). Using electronic patient records to assess the impact of swine flu (influenza H1N1) on mental health patients. Journal of Mental Health, 20(1), 60–69. []
  5. YADAV, S., & RAWAL, G. (2015). The Current Mental Health Status of Ebola Survivors in Western Africa. Journal of Clinical & Diagnostic Research, 9(10), 1–2. []

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