2021 Namey/Burnett Preventive Medicine Writing Award Submission
By Tiffany Zai, OMS-II, Touro University College of Osteopathic Medicine-California
Introduction: Mental Health in COVID-19
Large disruptions, especially from natural disasters, have impacted the psychological health of affected populations, and the COVID-19 pandemic is no exception.1 The immense change affects every individual—not only through their health but also through healthcare and the economy. As quarantines and lockdowns stay in effect, self-isolation may increase feelings of stress, anxiety, depression and unhealthy behaviors, such as excessive substance use.2 Studies report increased mental health problems in previously healthy people and exacerbation of symptoms in people with preexisting mental health disorders since the beginning of the pandemic.3 This global crisis has highlighted the limited access, inadequate quality and high cost of mental health resources, putting more responsibility onto the individual to evaluate their own mental health.
Routine Mental Health Self-Screening
The frequency of routine mental health screening is highly debated, and more recent findings suggest that routine screenings in primary care settings may be not as accurate or cost-effective as projected.4 Despite new suggestions to limit these screenings in primary care, the increasing risk of psychological stress during COVID-19 shows that mental health screenings might become more necessary. Fewer people are seeking out regular, non-essential care, such as physical checkups.5 With fewer opportunities for healthcare providers to catch early signs of mental health disorders, individuals may have to be more proactive in recognizing these signs themselves.
Encouraging self-reported screenings can help people better evaluate their mental health. Web-based systems that allow self-screening have been well received and useful in connecting people with professional help.6 People who use accessible screening tools, such as phone app, tend to follow up with a healthcare provider about their results.7
Brief screening tests that have been validated by many studies include the Generalized Anxiety Disorder (GAD-7) for generalized anxiety and Patient Health Questionnaire-9 (PHQ-9) for major depression. Both screening tests are easy to complete and take only a few minutes, making them accessible in an internet or app-based format.8,9 Because anxiety and depression are often related, both screening tools are recommended.10
It is important to note that the GAD-7 and PHQ-9 assessments are more effective in screening people who do not have preexisting mental health disorders.8,9 Recently, a new tool titled the Coronavirus Anxiety Scale was developed to be a better measure of anxiety during this specific pandemic period.11 Overall, there is growing potential for future application of self-assessment online resources that can also easily connect patients to mental health services.
Connecting to Mental Health Resources
The failure to meet mental healthcare needs drives innovation to improve the system, especially in primary care. Because patients often contact their primary care provider first regarding mental health concerns, more primary care settings have been strengthening their collaboration with mental health services.12 Integrated primary care and behavioral health systems with emphasis on interprofessional communication have shown improved outcomes in patients with anxiety and depression.13 Using telehealth and digital mental health services can hasten integration between primary care and behavioral health.14
Although digital healthcare is becoming increasingly popular, COVID-19 creates a greater force to improve mental health care delivery through telehealth services; these include—but are not limited to—videoconferences, telephone and email.15 Online resources can also expand the scope of service beyond seeing a provider.14 For example, psychological self-help intervention systems, such as online cognitive behavioral therapy for depression and anxiety, are available through smartphone apps.16 Artificial intelligence platforms are even being researched and developed to help people recognize when to refer to professional help.15 Although these self-help interventions cannot substitute seeing a healthcare professional, the accessibility of online care has changed the way people interact with mental health resources.
In the age of the internet, many people rely on social media as their primary source of COVID-19 information and are making decisions about their health through media sources.17 Using internet platforms is an essential way to inform individuals about how to maintain their mental health.
Exposure to COVID-19 and pandemic related news, an increase in social media use and conflicting information on these sources has led to increased stress and anxiety.17 Therefore, messaging about caring for one’s mental health and recognizing when they need additional support needs to be clear and non-contradictory.18
Strategies to maintain mental health on a daily basis, such as reaching out to support networks and establishing a routine, should be shared frequently to remind people the importance of implementing them.19 Communication about available mental health services and hotline numbers can encourage more proactive utilization.20 Improving awareness for one’s health is crucial during times of crisis, and effective communication strategies are necessary to increase individual health literacy.21
Populations at Risk for Mental Health Disorders During COVID-19
Although everyone can develop mental health disorders, some populations are more at-risk for experiencing psychological symptoms. Many of these high-risk individuals may require more specific screening tests and interventions. For example, people who were infected with COVID-19 may experience long-term physical and psychological effects and need additional support beyond the pandemic.22 Those who have experienced loss of someone to COVID-19 may also need specific support for their grief.23 Discontinuation of in-person mental healthcare services can worsen symptoms in those who have a preexisting mental health disorder; thus, in-person care needs to be prioritized in the safest way possible.22
Especially vulnerable populations include front-line healthcare workers, who report greater rates of depression, anxiety and distress, and people of marginalized communities, due to race, ethnicity, gender, immigration status and many other socioeconomic factors. Strategies for safety and resources available in the workplace may need to be heavily considered,24 and interventions outside of the mental healthcare system are also needed to mitigate health disparities.25
COVID-19 has drastically challenged the way mental healthcare is being delivered. Many of the psychological impacts of this time will remain, even after the pandemic is over, and the system needs to be ready for long-term needs. As quarantine and self-isolation continues to increase risk for psychological stress, it has become more crucial to educate individuals regarding their mental health. More research on strategies, especially self-help online resources, to help individuals assess and evaluate their mental health is needed. Maintaining good mental health is an everyday process, and now, more than ever, people are empowered to do so.
- Cosic K, Popovic S, Laboratory for Interactive Simulation Systems, Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia, et al. IMPACT OF HUMAN DISASTERS AND COVID-19 PANDEMIC ON MENTAL HEALTH: POTENTIAL OF DIGITAL PSYCHIATRY. Psychiatr Danub. 2020;32(1):25-31. doi:10.24869/psyd.2020.25
- Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet. 2020;395(10227):912-920. doi:10.1016/S0140-6736(20)30460-8
- Thombs BD, Bonardi O, Rice DB, et al. Curating evidence on mental health during COVID-19: A living systematic review. J Psychosom Res. 2020;133:110113. doi:10.1016/j.jpsychores.2020.110113
- Thombs BD, Coyne JC, Cuijpers P, et al. Rethinking recommendations for screening for depression in primary care. CMAJ. 2012;184(4):413-418. doi:10.1503/cmaj.111035
- Alexander GC, Tajanlangit M, Heyward J, Mansour O, Qato DM, Stafford RS. Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US. JAMA Netw Open. 2020;3(10):e2021476-e2021476. doi:10.1001/jamanetworkopen.2020.21476
- Kim E, Coumar A, Lober WB, Kim Y. Addressing Mental Health Epidemic Among University Students via Web-based, Self-Screening, and Referral System: A Preliminary Study. IEEE Trans Inf Technol Biomed. 2011;15(2):301-307. doi:10.1109/TITB.2011.2107561
- BinDhim NF, Alanazi EM, Aljadhey H, et al. Does a Mobile Phone Depression-Screening App Motivate Mobile Phone Users With High Depressive Symptoms to Seek a Health Care Professional’s Help? J Med Internet Res. 2016;18(6):e156. doi:10.2196/jmir.5726
- Spitzer RL, Kroenke K, Williams JBW, Löwe B. A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092
- Kroenke K, Spitzer RL, Williams JBW. The PHQ-9. J Gen Intern Med. 2001;16(9):606-613. doi:https://doi.org/10.1046/j.1525-1497.2001.016009606.x
- Moffitt TE, Harrington H, Caspi A, et al. Depression and Generalized Anxiety Disorder: Cumulative and Sequential Comorbidity in a Birth Cohort Followed Prospectively to Age 32 Years. Arch Gen Psychiatry. 2007;64(6):651-660. doi:10.1001/archpsyc.64.6.651
- Lee SA. Coronavirus Anxiety Scale: A brief mental health screener for COVID-19 related anxiety. Death Stud. 2020;44(7):393-401. doi:10.1080/07481187.2020.1748481
- Luoma JB, Martin CE, Pearson JL. Contact With Mental Health and Primary Care Providers Before Suicide: A Review of the Evidence. Am J Psychiatry. 2002;159(6):909-916. doi:10.1176/appi.ajp.159.6.909
- Rajesh R, Tampi R, Balachandran S. BEHAVIORAL HEALTH CONSULT. J Fam Pract. 2019;68(5):7.
- Balcombe L, Leo DD. An Integrated Blueprint for Digital Mental Health Services Amidst COVID-19. JMIR Ment Health. 2020;7(7):e21718. doi:10.2196/21718
- Taylor CB, Fitzsimmons‐Craft EE, Graham AK. Digital technology can revolutionize mental health services delivery: The COVID-19 crisis as a catalyst for change. Int J Eat Disord. 2020;53(7):1155-1157. doi:https://doi.org/10.1002/eat.23300
- Liu S, Yang L, Zhang C, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7(4):e17-e18. doi:10.1016/S2215-0366(20)30077-8
- Holman EA, Thompson RR, Garfin DR, Silver RC. The unfolding COVID-19 pandemic: A probability-based, nationally representative study of mental health in the United States. Sci Adv. 2020;6(42). doi:10.1126/sciadv.abd5390
- Amsalem D, Dixon LB, Neria Y. The Coronavirus Disease 2019 (COVID-19) Outbreak and Mental Health: Current Risks and Recommended Actions. JAMA Psychiatry. Published online June 24, 2020. doi:10.1001/jamapsychiatry.2020.1730
- Galea S, Merchant RM, Lurie N. The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention. JAMA Intern Med. 2020;180(6):817-818. doi:10.1001/jamainternmed.2020.1562
- Arendt F, Markiewitz A, Mestas M, Scherr S. COVID-19 pandemic, government responses, and public mental health: Investigating consequences through crisis hotline calls in two countries. Soc Sci Med. 2020;265:113532. doi:10.1016/j.socscimed.2020.113532
- G L, M A, R G, B R, S D. Implementing Health Literacy Intelligence during COVI-19 outbreak. Eur J Public Health. 2020;30(Suppl 5). Accessed December 15, 2020. https://europepmc.org/article/pmc/pmc7543568
- Moreno C, Wykes T, Galderisi S, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry. 2020;7(9):813-824. doi:10.1016/S2215-0366(20)30307-2
- Wallace CL, Wladkowski SP, Gibson A, White P. Grief During the COVID-19 Pandemic: Considerations for Palliative Care Providers. J Pain Symptom Manage. 2020;60(1):e70-e76. doi:10.1016/j.jpainsymman.2020.04.012
- Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ. 2020;368:m1211. doi:10.1136/bmj.m1211
- Progovac AM, Cortés DE, Chambers V, et al. Addressing Major Health Disparities Related to Coronavirus for People With Behavioral Health Conditions Requires Strength-Based Capacity Building and Intentional Community Partnership. World Med Health Policy. 2020;12(3):242-255. doi:https://doi.org/10.1002/wmh3.364