Psychiatric –Psychosocial Issues in the COVID 19 Crisis

The COVID 19 crisis has been stressful for everyone. Physicians, nurses and all healthcare professionals work both on and off the “front lines” for our patients, our communities, and society as a whole. Sometimes it feels like there we are struggling with the “Fear of Contagion” and the “Contagion of Fear.”

The Crisis of COVID-19

The Oxford dictionary defines a “crisis” as “a time of intense difficulty, trouble or danger.” It derives from the Greek word for decision, krinien, as a situation that occurs where high risk decisions have to be made. COVID 19, which has been called a pandemic by WHO (World Health Organization), has forced multiple decision points including many in matters of life and death. Crises disrupt our normal defense mechanisms, i.e. the way individuals approach and handle situations but normally our responses allow us to return to our previous “before” functioning. The COVID 19 crisis, not only strains our ability to cope, but deprives us of the usual mechanisms we use to feel whole again.

Possible vs Probable

Human beings often try to use reason as a way of creating a plan forward and as a bulwark against the emotional tsunami that crises can bring. I remind patients struggling with anxiety that all things are always possible but not probable. We must choose to live in the probable or else our anxiety would overwhelm us because we can’t plan for all things possible. For example: who would embark on a medical career unless you assumed, thank G-d correctly, that you could and would complete your training? Or when driving-- if we constantly thought about all the things that could happen our level of distraction would rise, increasing the risk for a motor vehicle accident. Therefore, under normal conditions, we assess the situation, take reasonable steps such as studying or using seat belts and proceed.

The COVID 19 crisis does not easily allow us to use this common defense mechanism. How can you readily apply logic to a situation where the information is scant and our knowledge base rapidly grows with concordant ever-shifting paradigms? How can use your medical skills to steady yourself when the normal expectations of what care is available, where it is available and who will provide that care changes almost without warning? A nurse recently shared with me that on her COVID unit, there are twice-per-shift briefings as it is likely treatment protocols in place will be altered by the shift’s end.

Mistrust in Healthcare

Healthcare systems are designed to anchor medical care but their size and complexity impedes their ability to be nimble and adjust as quickly as this evolving crisis demands. The explosion of need, the limited resources and the conflicting agendas albeit a shared goal of providing care to all those affected by COVID 19- has led to mistrust. This exacerbates healthcare workers’ feelings of insecurity. For example, are the recommendations regarding return to work for health care workers based on science or need? Who can we trust to guide us as we try to take care of our patients, our families and ourselves?

The Stability of Routines

Another element of adjustment to crisis are the routines we rely on in our work and play. We can handle the stress and strains of our days in part because of the stable foundations of our lives. It is the times when we feel most overwhelmed that we rely on everyday activities and schedules to provide an organizing structure we can “borrow”. The COVID 19 pandemic has temporarily robbed us of this element.

Our lives at home have been turned upside down as the need to ‘”shelter in place” can make it more difficult to relieve what feels like chaos in our professional lives. Schools are closed, and mothers (and fathers) are now expected to be home schoolers and camp counselors while working. This amplifies the normal stresses for working parents. How can we assess risk to the children and to our families versus the need for someone to take care of our children so we can take care of someone else’s child? Shops are closed, and even when open, they no longer function as they had. The supply chains that affect our professional lives extend to our private lives as well. Not only do we have to worry that we will not have enough masks, we also have to worry that will not have enough eggs. Our shuls are closed which makes it harder to feel the support of our most precious institutions. After all, the sin of the Golden Calf was in part related to the need for a concrete representation of G-d’s presence in spite of the miracles that abounded. Notices of births and deaths are absorbed at a distance, with limited ability to participate in the shared experience of life, its joys and tragedies. The primacy of the risk to life, supersedes the rituals, such as Shiva which most mourners find comforting. And while there has been so much gratitude expressed for doctors, nurses and the health care team, our public face as doctors is effectively the only one the community now sees. We have temporarily lost our downtime as it is COVID 19 or bust , 24/6. Our communities continue to be there for us (and we for the community) , but the lack of the physical, the routine, the concrete is felt by all and limits our ability to fully feel the fellowship of man at a time when we need it most.

The Ongoing Crisis of COVID-19

Many of us have weathered other crises, whether public or personal . What makes this different? The breadth and depth of the crisis mean that every aspect of our lives and every aspect of society has been affected directly and indirectly. Still, the full impact of which will not be known for some time to come. Thank G-d we, as humans, generally have the ability to manage, especially if we know it is temporary. Hurricane Sandy and 9/11 took place in our lifetimes but the assault was maximal immediately, which allowed for confidence that tomorrow would likely be better than today. The COVID 19 pandemic is ongoing, with the number of cases, hospitalizations and deaths continuing to rise. As physicians, the uncertainties threaten to cloud our ability to keep the hopeful news in the forefront of our minds. Part of our challenge is to know and remind ourselves that the sky has not fallen, that this will ease and that most of us will be okay.

What does all this mean for our patients, ourselves and our families? We are doing the best we can for our patients, pushing ourselves to provide direct medical care and support of our colleagues, our communities and our families.

Support for the Psychiatric Patients

For patients, all the elements that make this a crisis can make it harder for those suffering from anxiety to remain organized and to not panic. And for many, the loss of regular treatment and treatment settings, and the constant social media and news cycle can impede their ability to manage symptoms that were previously under control. For some, the shared worry and the reorientation to more primary concerns have yielded, relief, which is likely temporary. Those who have a history of depression may be affected by the isolation and the limited ability to distract, etc. but it is unclear that there is a rise in these conditions, as of yet. However, as the number of deaths increase, so too does the risk for complicated bereavement and grief. Those with PTSD, including those with medical trauma, are at increased risk for the emergence and exacerbation of symptoms past. And most worrisome are those who are internally disorganized such as schizophrenics and patients who engage in self destructive behaviors, including eating disorders.

In addition, the added stressors, the increased forced family time, the loss of normal outlets and observers raises the risk of domestic abuse. As a physician do what you always do: ask your patients about their environments and symptoms. We are all working as hard as we can so please use referral sources liberally, even if you would typically treat uncomplicated anxiety or depression.

Support for Physicians and Healthcare Workers

JOWMA has provided a support network for us as physician, community members and just as people. The JOWMA initiatives, its public letters, its relentless sharing of information and its open forums have made the public more aware of the risks and how to respond. In addition campaigns, such as Dr Miri Lieberman’s fundraiser to purchase PPE to distribute to healthcare professionals, and the creation of a centralized contact database at a time when we are all oversubscribed, are unbelievable. Thank you to all for this all.

From a psychiatric perspective we need to be mindful of the airplane mask analogy. Flight attendants always remind passengers: “you have to put your own mask on first before you can put it on others.” This recommendation hold true for us as well . Take stock of the good things in your life: of your safety, your health and the people close to you. Take care of yourself, get enough sleep, let go of those things that are not critical, simplify life as is possible (ordering food in is a win-win in my book, because you get what you need and you support the community at the same time), and breathe. Take reassurance in your ability to rise to complex problems and prevail. And if you are having difficulty functioning, if you can’t think straight due to anxiety or obsessions, you can’t ‘level set,’ if you are panicked, if you are unable to sleep or eat, if you find yourself irritable, or if feel like you are experiencing life through gray gauze-- please speak to a someone. Even if your symptoms are triggered by the current crisis, professional help can truly be of help.

With G-d’s help this crisis will end soon so that we can go back to our “normal crazy” and begin the healing process.

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