Before the pandemic, mental health wasn't a huge priority for most Americans as compared to physical health. But the ongoing pandemic has changed this. In fact, 82% of people now believe mental health to be just as important as physical health—up from 68% just three years ago.
Posted in Physician Connection on Monday, February 7, 2022
A 2021 survey of 2,000 people, sponsored by the Cleveland Clinic and Parade, leads us to believe that COVID-19 has helped to destigmatize mental health. It’s lauded as a win, yet the survey revealed a darker side that is likely not surprising to physicians—people with chronic health conditions fared worse.
- Patients with cardiovascular disease reported dips in mental health, and half of diabetic patients developed unhealthy habits during the pandemic.
- People with skin conditions report being worse off mentally and emotionally, as well.
A survey in 2021 conducted by The Harris Poll on behalf of the American Psychological Association found despite pandemic-related struggles, many US adults are keeping a positive outlook. However, this optimism focuses more on the future than it does on today. Daily tasks and the ability to make decisions have become harder for young adults and parents.[1] Behind this professed optimism about the future, day-to-day struggles are overwhelming many. Prolonged effects of stress and unhealthy behavior changes are common.
As providers themselves deal with burnout and stress, it’s important to consider how the health of our collective population is being impacted—and how it might impact how you treat your patients.
“As each day can bring a new set of decisions about safety, security, growth, travel, work, and other life requirements, people in the United States seem to be increasingly wracked with uncertainty.”—Stress in AmericaTM 2021
Collective Mental Health Matters
Mental health is typically thought of as an issue of the individual, yet the pandemic is teaching us how mental health is important for groups and organizations, as well.
Geoff Mulgan is a professor of collective intelligence, public policy and social innovation at University College London. He acknowledges how the pandemic has negatively impacted children and the elderly and points to health care workers as a large group of people currently experiencing diminished mental health. Mulgan cites a study of UK intensive care unit workers where nearly half of those report severe anxiety, depression, post-traumatic stress disorder or harmful use of alcohol.[2]
He also believes that a legacy of COVID-19 may be a difference in how we measure mental health. Most mental health assessments come from the individual standpoint, such as using the Diagnostic and Statistical Manual of Mental Disorders or DSM. He cautions that this singular approach has limitations, especially given what we know about toxic cultures and dysfunctional organizations. “There can be a pervasive culture where employees are depressed, deluded or prone to compulsive behaviors,” and suggests we engage with and explore pandemic data to find ways to better measure and understand collective mental health.
Mulgan supports looking at mental health categories as “maps” to collective mental health, citing depression, delusion, compulsive behavior and PTSD as relevant, both in terms of understanding differences and averages. The goal? Better, more proactive treatment.[3]
Pandemic: Widespread Trauma?
The verdict is still out as to whether the pandemic can be considered a “traumatic” event. While it doesn’t fit into the diagnostic criteria for post-traumatic stress disorder, research is coming out indicating COVID-19 could lead to symptoms of PTSD.
Researchers looked at a sample of 1,040 people from five western countries, asking what COVID-19 events they’d been directly and indirectly exposed to and what events they anticipated being exposed to in the future. The participants also completed a PTSD checklist and documented their general emotional reactions, such as sadness, anger, anxiousness and psychosocial functioning. They found participants had PTSD-like symptoms for direct and indirect exposure, going as far as to say 13.2% were likely to have PTSD, despite not fitting DSM-5 criteria. The researchers believe COVID-19, “can be understood as a traumatic stressor event capable of eliciting PTSD-like responses and exacerbating other related mental health problems (e.g., anxiety, depression, psychosocial functioning, etc.).”[4]
The researchers cautioned that such traumatic responses may get worse over time, as generally speaking, people tend to go into “crisis mode” in the middle of traumatic events. Given the long-term nature of the pandemic, the number of people struggling with mental health may increase.
Sara Gorman, Ph.D., MPH, and Jack M. Gorman, MD, caution that more studies need to be done before labeling COVID-19 as a traumatic event. Yet, they do remind us that traumatic events can be “slow to unfold, collectively experienced,” and even somewhat indirect.”[5]
“It is essential that we be mindful of the fact that even though the pandemic does not neatly fit into our usual notions of trauma, we should be sensitive to the fact that some people might still be experiencing symptoms of post-traumatic stress. This will make it easier to guide more of the many people who are suffering right now to the appropriate form of help.” —Sara Gorman, Ph.D., MPH, and Jack M. Gorman, MD, for Psychology Today
How Trauma Impacts the Body
During times of stress (COVID), the body’s sympathetic nervous system activates a fight or flight response. It happens quickly so that the body is almost instantly ready to run or defend itself. In contrast, the parasympathetic nervous system’s job is to relax the body and use hormones to slow down those frantic responses once the threat is gone.
Fight, flight, freeze or fawn are responses of the sympathetic nervous system that prepare the human body for survival mode. During a traumatic experience, the brain shuts down nonessential systems, allowing the human to survive the threat. When the threat passes, the parasympathetic (or, “rest and digest” aspect of the nervous system) is again activated. Yet for some, this switch does not occur. PTSD is characterized by the brain remaining in survival mode.
Trauma impacts the brain in a variety of ways:
- The amygdala activates the fight-or-flight response. It doesn’t recognize the difference in time, i.e., if you’re reminded of the past event, you’ll experience the rush of stress hormones. This can keep people at high levels of stress and anxiety.
- The hippocampus is the brain’s learning center. People with trauma have been shown to have a smaller, less active hippocampus, which impacts memory and problem-solving.
- The prefrontal cortex helps with decision-making. It’s less active in people living with trauma, which can make it harder to override trauma responses because it can’t take in new information that can help control the fear.
According to the American Psychiatric Association (APA), people with PTSD may experience rage, anxiety, irritability, flashbacks, nightmares, panic attacks, memory issues, trouble making decisions, difficulties in thinking, concentrating, or learning, lack of motivation, general depletion of energy and/or communication challenges.
Healing from Trauma
Traditional ways to help people heal from trauma typically center around forms of psychotherapy, including cognitive-behavioral therapy, cognitive processing therapy, prolonged exposure therapy and eye movement desensitization and reprocessing (EMDR). Selective serotonin reuptake inhibitors (SSRIs) can also assist in treating PTSD.
Additionally, there’s growing evidence that somatic healing therapy can help. This type of therapy focuses on a person's physical body and mental connection. It can help people, “build awareness, coherence and self-regulation. The result is a deeper understanding of the body/mind connection with an improved ability to release and regulate emotions. It also helps manage stress, resolve issues related to trauma, heal from and navigate life transitions and relationships and build resilience. It’s also recommended that patients experiencing trauma follow proper self-care, taking into consideration good sleep hygiene, nutrition, exercise and mindfulness and meditation practices.
Disorder or Natural Response to Traumatic Events
Steven C. Hayes is a professor of psychology at the University of Nevada. He believes there’s a worldwide need to address the traumatized workforce. He also cautions everyone to remember that our response to pandemic stress is normal. He’s quoted as saying, “In the modern world, you have a constant invitation to take these normative concepts of anxiety disorders, depressive disorders, burnout syndrome and climb inside that category. Very often people are asked to rely more and more on medications to view themselves as having a disorder rather than responding in a natural way to what is a very stressful and difficult situation.”[6]
“If anybody has gotten through this year of COVID-19 without realizing that it’s hard to be human, [they should know that it is] just like working on our skills at the gym, that we want to work on our strength and our flexibility. We need to be doing that not just when we’re suffering but before the time when those skills are needed.”—Steven C. Hayes, professor of psychology, University of Nevada[7]
The effects of the COVID-19 pandemic can be seen now and will continue to rise for the foreseeable future. Improving collective health will require systemic efforts of care for providers and patients alike. It will invite us all to change the dialogue around mental and physical health.
Medical Professional Liability Concerns
Physical Illness Presenting as Psychiatric Disease
A 1978 study titled Physical Illness Presenting as Psychiatric Disease[8] (Hall, et all) found that medical illness often presents with psychiatric symptoms. Basing diagnosis on psychiatric symptoms alone does not allow for distinguishing physical disorders from functional psychiatric disorders alone. Patients are often unaware of medical illnesses causing psychiatric symptoms.
The most common medical causes for psychiatric symptoms include cardiovascular, endocrine, infectious and pulmonary disorders. Initially, patients can be misdiagnosed with psychosis when in fact it’s a medically-induced symptom. Medical evaluation is indicated in patients presenting with visual hallucinations, distortions or illusions.
The Differential Diagnosis
A common malpractice claim is a misdiagnosis or failure to diagnose a condition, resulting from a physician failing to follow the process of the differential diagnosis. For all patients, it’s important to examine all possible explanations for a patient’s symptoms and eliminate them as the collected data allows.
The Process
- Data gathering, including symptoms, medical history, risk factors, and anything else related to illness or injury.
- Lists of all possible causes of symptoms.
- Rule in and rule out. Each potential diagnosis needs to be examined and tested, ruling in or ruling out a diagnosis based on data.
This process helps keep the patient safe and documentation of the process is essential, should an adverse event occur and allegations of substandard care arise.
[1] https://www.apa.org/news/press/releases/stress/2021/october-decision-making
[2] https://www.ucl.ac.uk/steapp/news/2021/jan/mental-health-intensive-care-staff-should-be-immediate-priority
[3] https://www.weforum.org/agenda/2021/04/your-mental-health-depends-on-collective-wellbeing/
[4] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240146
[5]https://www.psychologytoday.com/us/blog/denying-the-grave/202110/is-the-covid-19-pandemic-traumatic-event
[6] https://www.healthline.com/health-news/the-shadow-pandemic-covid-19s-impact-on-healthcare-workers-mental-health#The-cost-of-a-run-down-workforce
[7]https://www.healthline.com/health-news/the-shadow-pandemic-covid-19s-impact-on-healthcare-workers-mental-health#The-effects-will-be-seen-for-years-to-come
[8] https://jeffreydachmd.com/wp-content/uploads/2014/04/Physical_Illness_Presenting_Psychiatric_Disease_Richard_Hall_Arch_Gen_Psych_1978.pdf [PDF]