For the past few weeks, the attention of our government, medical community and public health systems has appropriately been focused on "flattening the curve" of a coronavirus epidemic that would otherwise result in a massive loss of life. I wouldn't want to be working in an intensive care unit or emergency room for the next 4-6 weeks. My medical colleagues who do so are true heroes. I'm fortunate as a child psychiatrist to have only experienced mild inconvenienced over the last week or two. The lack of disruption in my routine has given me time to ponder a second rapidly approaching "curve" that threatens to overwhelm our service delivery system, resulting in significant loss of life and great suffering.
How might COVID-19 impact our society's pre-existing epidemic of mental illness? Our medical system has experienced a similar pandemic in 1918-19 resulting from the "Spanish Flu." The mental health epidemic likely to result in large part from measures taken to contain the spread of the coronavirus will be unprecedented.
My curiosity recently led me to check out the National Library of Medicine to explore the mental health effects of quarantines and "social distancing." There's not much research on the topic, but the available data doesn't look pretty.
This study by Hawryluck and associates examined the effects of quarantine among adults in Toronto in response to the SARS epidemic in 2003. In a sample of 129 adults (68% of whom were healthcare workers) quarantined for an average of ten days. Symptoms of PTSD and depression were observed in 28.9% and 31.2% of respondents, respectively. PTSD symptoms were highly correlated with the onset of depressive symptoms.
The best paper I found was a review on the psychological effects of quarantine published three weeks ago by Brooks and colleagues. Here are some key findings from their review...
A study comparing PTSD symptoms in parents and children quarantined with those not found that mean PTSD stress scores were four times higher in children who had been quarantined. 28% (27 of 98) of parents reported sufficient symptoms to warrant a diagnosis of a trauma-related mental health disorder, compared with 6% (17 of 299) of parents not quarantined.
Another study examining long-term impacts of quarantine among hospital staff following the SARS epidemic found that workers who were quarantined were 4.9 times more likely than peers who hadn't to experience depressive symptoms three years later after controlling for age, gender, marital status, family income, and prior exposure to other traumatic events.
The authors summarized the research literature as follows...
Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma.
We have a couple of brief reports from China looking at psychological impacts of COVID-19.
A paper published by Xiang and associates last month in the Lancet called for urgent development of timely mental health support for patients and healthcare workers.
This clinical report from Liu and associates includes the results of a multi center survey of 1563 medical staff actively involved with caring for patients infected by COVID-19. Based upon responses to four standardized measures, the prevalence of depression was estimated to be 50·7%, anxiety 44·7%, insomnia 36·1% and stress-related symptoms (defined as a total score of ≥9 in the Impact of Events Scale-Revised) as 73·4%
Another way of considering the situation is to contemplate the association of new COVID-19 related stressors with increased risk for mental illness. We know that life change events are associated with increased prevalence of depression, anxiety and schizophrenia. One of the most commonly used instruments to measure the impact of these events is the Social Readjustment Rating Scale (SRRS).
The SRRS score is based upon stressful life events that occurred in the last twelve months. Scores of 150 or below suggest a low probability of developing a stress-related disorder. Scores of 150 to 299 suggest a moderate level of stress, and chances of developing a stress-related disorder of approximately 50%. The likelihood of stress-related disorders is around 80% for scores of 300 or above. Here are some stressful events associated with the response to COVID-19 and the associated point value on the SRRS scale:
Change in health of family member (44)
Business readjustment (39)
Change in financial state (38)
Change in responsibilities at work (29)
Change in living conditions (25)
Revision of personal habits (24)
Change in work hours or conditions (20)
Change in school/college (20)
Change in recreation (19)
Change in church activities (19)
Change in social activities (18)
Change in number of family get-togethers (15)
When I think about this as a child psychiatrist, I'm interested in potential impacts on the kids and families I see in my practice...
Consider that the studies involving quarantine typically involved periods of 10-21 days. What happens when kids and adults are isolated for far longer periods of time?
How will my kids do if they're stuck in homes where domestic violence or sexual abuse have already taken place?
How will my kids cope when their parents lose their jobs or their businesses?
How will the needs of my kids requiring special education services be met?
How will my kids with parents on the frontline of the COVID-19 epidemic (physicians, nurses, first responders) cope with the medical and mental health consequences their parents are likely to experience in the coming weeks?
How will my kids with anxiety cope with separation from their older relatives - aunts, uncles, grandparents and great-grandparents?
How will my kids with ADHD cope with the distractions of trying to learn at home?
How will my kids who develop much of their self-confidence and well-being from their extracurricular activities (sports, theater, music, dance, martial arts, scouts, youth groups) cope when denied access to those activities for an extended time?
How will my kids with autism adjust to the dramatic change in their routines?
How will my kids with anxiety or OCD cope with their intrusive and distressing thoughts without the distractions of their school day and outside activities?
How will my kids who are planning to attend college in the next year or two cope with not being able to take their entrance exams (ACT and SAT) or visit schools of interest? How will they and their families cope as their 529 plans or other college savings are decimated by the downturn in the stock market?
How will my kids who have come to enjoy their freedom at college adjust to moving back in with their parents and being separated from friends?
How will my seniors cope with losing their last season with teammates, last chance to star in the musical, last opportunity to go to prom and last opportunity to receive a diploma in front of friends and family?
That's what I think about. What will all of us need to think about after the crush on our emergency rooms and ICUs from COVID-19 begins to resolve?
Dr. Xiang described a series of public mental health interventions in his paper - establishment of multidisciplinary mental health teams including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers to support patients and healthcare workers, clear communication with regular and accurate updates about the COVID-19 to address uncertainty and fear, provision of psychological counseling using electronic devices and apps and technology to improve communication between patients and families, and regular mental health screenings of patients and healthcare workers for depression, anxiety, and suicidal thinking followed by timely access to psychiatric treatment for those with more severe conditions.
Little of what he suggests is realistic. Relatively few mental health services are currently available through our hospitals and clinics. The available professionals will be dealing with more acute need among established patients or clients. Mental health professionals will be getting sick or staying home to watch children or care for family members. Recent steps taken by the government to facilitate telepsychiatry services are enormously helpful, but won't stop the mental health system from collapsing under a tidal wave of need.
More importantly, what can we do now to mitigate the mental health impact of actions being taken to control spread of the virus? How might a "mental health-friendly" church step up to meet needs of members, attendees and the surrounding community in such a time as this?
We can be as intentional in promoting social connectedness for the mental health benefits as we are in promoting social distancing for slowing the spread of COVID-19. No one should be alone. Every church member needs someone to talk with, pray with or serve alongside during this time. Churches need to be intentional in reaching out to every member and attendee.
We need to reach out to neighbors and coworkers who aren't part of the church and demonstrate to them that they're cared for and valued. This ministry doesn't require three years of seminary education.
Check out the list of life stressors related to COVID-19 posted above. What can we do to provide tangible support to those around us experiencing acute stressors? Deliver food and household supplies for friends and neighbors who are quarantined? Offer child care for the healthcare or mental health professional who needs to work? Money or gift cards for neighbors or co-workers who lost their jobs in restaurants or entertainment venues? A spare computer or wireless access for the family next door with three kids doing school online at the same time?
It was wonderful to see so many friends inviting one another to join in online services this morning, but online church is just a start! We need to put the social infrastructure of our churches on the web this week. Christian education. Bible studies. Small groups. All of it. The research on the mental health benefits of church suggest the social connections and relationships that develop through church are critical. This coming Wednesday we're offering an opportunity for churches interested in doing so. See the end of this post for information.
The availability of peer support will be extraordinarily important. There's never been a better time to start a mental health support group online. Our friends at Fresh Hope or the Grace Alliance would be happy to help.
One more thought for now...hundreds of churches around the U.S. and around the world got together last month to host a Night to Shine for teens and young adults with developmental or intellectual disabilities. We do proms well! A great way to share the love of Christ with the teens and young adults of our communities would be through hosting proms this summer for seniors who won't be able to go to prom if schools are closed during April and May.
At church this morning, my pastor spoke of the witness presented by the early church through caring for the sick during the plagues that impacted the Roman Empire. The sick during the plague before us are found in our hospitals hooked to ventilators but will soon turn up in emergency rooms following overdoses.
How might we respond in such a time as this?
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This coming Wednesday (March 25th) at noon our Key Ministry team will be sponsoring a special event featuring Nils Smith, one of the world's leading experts in online ministry. Our team will be engaging Nils in a discussion on Using Technology in Ministry With Vulnerable People. Interested in developing alternate ways of connecting together as the church during a time when social isolation is required? This is the roundtable for you? The event is free, but early registration is encouraged! Click here if you'd like to join us this Wednesday.
