The Mind Set
The message to people on the front lines of the healthcare system — and citizens alike — has been: “This is going to be a marathon, not a sprint.”
We have heard that phrase many times in the past weeks to help healthcare workers prepare for what’s coming next in the COVID crisis.
It sounds inspired, thinking of our healthcare colleagues as elite runners: The comparison suggests dedication, strength and stamina.
However, the COVID-19 reality is far more grim: The route to the finish line will be changing as we run. There won’t be water at all the mile markers and to the extent there is water, we won’t know when it’s coming. It’s possible the finish line will also be moved. There won’t be any fans on the sidelines cheering us on and holding homemade signs of encouragement, because they’ll be “sheltering in place.” And we’ll have to keep running. But because of who we are, we will want to keep running. It’s how we’ve been trained and who we are.
COVID-19 is a novel virus to which humans have no immunity. It is highly contagious. While the medical severity, complications and mortality are serious threats to be sure, the larger consequences to our society are due to its prevalence and the consequences that threaten to overwhelm our health care system, deplete our workforce, and disrupt our economy.
Based on currently available statistics:
- 40% of patients develop a mild illness
- 40% develop a moderate illness
- 15% develop a severe illness
- 5% develop a critical illness
- The risk of mortality increases with age:
- 15% for patients >80 yo.
- 3% for patients >60 yo.
- 1% for patients <60 yo, the risk is 1%
- With concurrent comorbid illness (e.g., hypertension, diabetes, cardiovascular disease) the mortality rate rises to about 15%
- Although the true mortality risk is likely lower, given that the rate of infection in asymptomatic patients is not known.
The guidance for containment and personal protection recommends:
- Physical or Social Distancing:
- Avoid close contact, stay 6-10 ft. away from people.
- This virus is transmitted by droplets and not airborne, so we don’t need to worry about the air we breathe unless we are in close contact
- Hand washing
- Use of disinfectant on surfaces.
- Avoid touching your face
- Wear gloves outside
- Do not travel
- Avoid crowds
- Isolate as feasible
- If exposed to someone, or symptomatic don’t go to the hospital unless severely ill, call your physician or one of the hotlines
- Testing limited: 2 forms Diagnostic and Serologic
- High risk groups include elderly, immune compromised or medically comorbid patients
- Young people may be transmitters but less prone to serious illness
The Psychological Effects
For everyone and particularly healthcare workers, living in the time of COVID-19 is complex and stressful. In many ways the uncertainty of what lies ahead causes anxiety and worry. The limited availability of testing (although this is improving), the lack of effective therapies, the process for developing new treatments and an effective vaccine, although in the works, will take time to develop and the waiting can contribute to hopelessness and despair. In addition, the prolonged isolation and interruption of normal activities adds to the dejection people are feeling.
It is important to understand these reactions, so they can be acknowledged and addressed. Rather than serve as a barrier that interferes, responding and validating these emotions can facilitate collaboration and cooperation in the communal response to the crisis. Anxiety is a normal emotion and it is to be expected during this unprecedented crisis. It increases when we experience uncertainty, are in unpredictable situations and feel unable to control our circumstances.
Mental health first aid strategies including the following can reduce and help to manage untoward emotional reactions to the crisis.
- Distract yourself or avoid focusing on the situation
- Recreational activities
- Tasks you usually don’t have time for
- If you have nothing else to do try this mindfulness exercise
- Hold an ice cube in your hand and let it melt.
- Don’t catastrophize
- Don’t watch news media 24/7
- Reach out virtually and communicate with family, friends, and health care providers as needed
- Try to reframe and take some control of your situation.
- Reframe the situation
- This will pass, it already has in China and Korea
- There are anti-retroviral treatments that are currently being tested around the world — about 200 studies currently underway. Based on the prior SARS epidemic, there has been considerable knowledge gained about coronaviruses.
- Diagnose yourself and understand your needs
- Stress indicators include disturbances in sleep, appetite, concentration, mood
- If you have a primary psychiatric condition,
- Monitor symptoms
- Adjust meds accordingly
- Increase contact with your doctor or provider as needed
- Reframe the situation
- Think about protecting yourself, then others. Start with family, then society. Like instructions for oxygen masks when on an airplane. First put mask on yourself, then your child, then others.
Differential Effects on People
People will be differentially affected, have different needs and require different treatment. Relevant subgroups include:
- The worried well – should be able to manage their stress and mental state with Mental Health First Aid as described above.
- People with mild/moderate severity mental disorders including Anxiety, Mood, Stress, Obsessive-Compulsive Disorders – will likely need increased treatment in form of adjustment in meds and/or increased contact with doctor or therapist through Telepsychiatry
- People with substance use disorders will have – temptation to use substances will increase. Increased virtual support and monitoring will be critical.
- People with serious mental disorders – meaning affective and non-affective psychotic disorders interestingly are less reactive to such crises but will need attention to their medical needs
- Medical high risk group patients need – guidance on protection from exposure, mitigate effects of isolation
- Health Care Providers are on the front lines are under the greatest pressure and stress and performing heroically at great risk to themselves.
Coming together as a community and strengthening our resilience will help. Strong bonds at the community level foster cohesion and facilitate hope.
While this may be a novel situation, we have the skills to adapt and others are here for support. Cooperation, adaptation and resourcefulness combat isolation, helplessness and hopelessness. Resilience depends on maintaining an objective assessment of the current situation coupled with an unyielding optimism that we will successfully navigate the challenges ahead.
Referring back to the marathon metaphor, we may not know the route to the finish line until we run it, there may not be water when we need it, but we have the skills we need, we just need to use them. If we do this and offer support to others along the way, together we will finish the race.
In closing, we share a quote by Albert Camus from The Plague. It’s told from a courageous doctor’s point of view who was caring for people during an epidemic:
“He knew that the tale he had to tell could not be one of final victory. It could be only the record of what had had to be done … and despite their personal afflictions, by all who, while unable to be saints but refusing to bow down to pestilences, strive their utmost to be healers.”
Stay Strong, Stay Safe.
Jeffrey A. Lieberman, M.D., is Chairman of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons, Past President of the American Psychiatric Association and the author of “Shrinks: The Untold Story of Psychiatry.”
Laurel Mayer, M.D. is Associate Professor of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons and Director, New York Presbyterian Hospital House staff Mental Health Service.