Supporting patient and clinician mental health during COVID-19

Challenge 1: balancing patient mental health with COVID-19 best practices.

In the face of a deadly pandemic, it would be easy to think that patient mental health and psychosocial concerns “take a back seat” for the time being. This idea might arise from acute concerns in patients and clinicians regarding COVID-19 contagion and morbidity, or from feelings that mental health concerns are less important in the face of catastrophic illness. We caution against this approach and, instead, encourage clinicians to continue assessment for the documented positive feedback loop linking presentations that might otherwise be simplified into either psychosocial or medical domains.^5,6 This feedback loop is certainly evident in the case of trauma, where psychiatric symptoms can interact with and exacerbate medical illness.⁷ Furthermore, emotional distress might limit an individual’s capacity to learn new information and follow instructions, which could be extended to pandemic public health measures, including hand-washing, not touching one’s face, and physical distancing.

In following the central tenets of trauma-informed health care, clinicians will consider the role of adversity (in particular, life-threatening events) in the development of human suffering, and respond compassionately with universal and targeted practices to optimize care and outcomes.^8,9 The theme of a patient’s subjective feelings of safety is paramount to avoid interventions that might exacerbate psychological symptoms and reduce service-seeking behaviour. Thus, given the ubiquity of COVID-19, our recommendation is the trauma-informed universal practice of approaching each encounter open to the possibility that mental health problems and feelings of safety have become an increasing concern for patients. This stance will create a compassionate ethos for patient-provider alliance, thereby facilitating the raising of concerns such as health-related anxiety, loss, and compounding hardship, which likely interact with the primary presenting concerns.

Challenge 2: allocating a realistic amount of time to discuss psychosocial concerns.

When health care providers first begin trauma-informed practice, a paradox emerges: we are asking them to do more, it seems, when they have less (time, resources, and energy). However, trauma-informed care does not necessarily mean longer appointments. Brief strategies can be effective in the facilitation of trauma-informed communication surrounding mental health in primary care.¹⁰ Indeed, clinicians might begin encounters in an open-ended way, following up with questions regarding emotional well-being (now, specifically in relation to the pandemic) and providing brief psychoeducation or motivational interviewing around the role of stress in health. Follow-up questions can include querying around mood, anxiety, unhealthy coping strategies (eg, substances), and family conflict, while considering the potential of routine physical examinations acquiring additional emotional valence (ie, being “triggering”). In encounters with pediatric patients, clinicians can apply the familiar strategy of using developmentally appropriate language around “germs” and take the opportunity to punctuate parent-child attachment by emphasizing what caregivers are doing to promote safety (eg, “Your mommy and daddy are making sure everyone stays at home so that children are safe and don’t get sick, because they are loved very much”).¹¹

Thus, by inserting a brief and targeted conversation around emotional well-being early during patient encounters, providers can help cultivate a warm, secure, and (where applicable, developmentally appropriate) patient-provider alliance, without derailing the usual flow of care and while still addressing presenting concerns. In extreme situations (where mental health problems merit ongoing treatment, eg, grief counseling), providers can remind patients about the importance of their concern, which is why they are making a high-quality referral (see challenge 3), as well as providing their own follow-up at the next encounter. Engaging patients in shared decision making as much as possible in this process further enhances the therapeutic alliance and the outcomes of clinical encounters.

Challenge 3: access to high-quality referrals in a disrupted health care system.

Clinicians might have found their referral networks have ground to a halt. In some instances, these referrals might simply be delayed without great consequence. In other instances, crucial medical care (eg, cancer treatment and surgery) might be deferred due to the crisis, or acute mental health concerns might warrant nonemergency treatment. In all instances, psychological services might be beneficial to address pre-existing or newly arising mental health concerns.¹² However, most outpatient mental health services have closed their doors to prevent the spread of the virus. As such, we recommend that providers become aware of local mental health professionals providing disaster response services using telehealth.¹³ It is important that physicians refer patients to telehealth providers with operations in the jurisdiction in which patients are eligible. Finding them might require a Google search of the provincial or state professional psychology association for a list of providers. Many jurisdictions are rapidly onboarding licensed providers to expand coverage, and introducing new billing codes for the provision of telehealth, as in the case of the Ontario Health Insurance Program (the authors’ jurisdiction) or Medicaid and Medicare in the United States (Table 1).

Challenge 4: balancing self-care with increasing service demands.

Heightened levels of clinician distress, fatigue, burnout, and mental health challenges are understandable and expected consequences of this pandemic.¹⁴ Research has shown that burnout can spill over into the clinician’s own family life, creating interpersonal difficulties with family members and exacerbating an already difficult situation.¹⁵

Clinical wisdom tells us that those who enter helping professions often struggle to shift to “being the patient” themselves. If there was ever a time for front-line practitioners to consider their own use of supportive mental health care, it is now. Counseling for physicians with symptoms of burnout statistically significantly reduces distress and need for extended sick leave.¹⁶ Physicians who take up this suggestion should do so free of guilt about “overcrowding” a struggling system. Instead, they can take to heart the World Health Organization’s declaration that an effective pandemic response demands medical and affiliated health care providers who are emotionally, physically, cognitively, and spiritually well.¹⁷

Thus, our final recommendation is to consider specialized telehealth psychotherapy or counseling for front-line providers during the disaster response, especially for those responding to elevated levels of acute illness, emergency care, resource scarcity, and death. If this is not something being discussed in your clinic, agency, service, ward, unit, or care setting, we encourage you, junior clinicians and senior administrators alike, to facilitate these conversations. Many professional psychological associations are now providing these resources to front-line clinicians at no cost (Table 1).