Module 4: Mental Health in the Time of COVID-19

Assess how the COVID-19 pandemic affects the mental health of patients and identify basic tools for responding to these changes in the clinical setting.

Authors: Anthony Almazan; Okechi Boms; Maggie Beazer; Taylor Brown; Andrew Chun, Sun Fletcher; Colby Hyland; Katie Kester; Danny Linggonegoro; Catherine Mankiw; Katherine McDaniel, MSc; Larisa Shagababayeva; Miriam Zawadzki

Editor: Catherine Mankiw

Reviewers: Jennifer Potter, MD; Fernando Rodriguez-Villa, MD; Nhi-Ha Trinh, MD, MPH; Aliya Feroe; King Fok, MSc; Sabra Katz-Wise, PhD

Update Disclaimer: Thank you for visiting Module 4! Due to the wide availability of high-quality resources at the medical student level, we are no longer updating this module regularly. This module last underwent major updates in December 2020. We hope that the material, including our learning objectives, cases, and thought questions can still be useful as an educational resource. If you find that material is incorrect or that a link is broken, please do let us know by emailing [e-mail].

Introduction

The COVID-19 pandemic has already caused a significant psychological impact across the globe, and patients are now experiencing many new stressors that may negatively affect their overall mental health status.(Galea et al., JAMA 2020). The World Health Organization, National Alliance on Mental Illness, Centers for Disease Control and Prevention (CDC), and Substance Abuse and Mental Health Service Administration (SAMHSA) have all released guidelines for individuals to address the mental health consequences of the pandemic.

Multiple surveys and epidemiologic studies have attempted to capture the effect of the pandemic on mental health. When compared to April 2018, an increased number of US adults reported symptoms of serious psychological distress in April 2020 (13.6% versus 3.9%) (McGinty et al. JAMA 2020). Perhaps most concerningly, one nationwide study in June 2020 found that approximately 10% of respondents reported serious consideration of suicide in that past 30 days (up from 4.3% in the previous 12 months) (Czeisler et al. MMWR 2020). These psychiatric sequelae fall disproportionately on specific patient populations, including black and Hispanic patients, essential workers, unpaid caregivers, patients with less than $5,000 in savings, and those with pre-existing mental healthcare conditions (Ettman et al. JAMA Netw Open 2020, Czeisler et al. MMWR 2020). Unfortunately, these mental health consequences may be increasing over time: in a tracking poll conducted by the Kaiser Family Foundation (KFF) in July 2020, 53% of adults reported that their mental status had been negatively impacted as a result of the pandemic, up from 32% during a similar survey in March 2020.

How we as medical providers can respond to these increased mental healthcare needs during this time of crisis is an open question (Pfefferbaum & North, NEJM 2020). As medical students, we too can have an important role in the mental health response.

Module 4 of the curriculum will teach students about the mental health ramifications of the COVID-19 pandemic. We will first utilize two cases to demonstrate how the biopsychosocial framework can illuminate the many stressors COVID-19 is currently inflicting on our patients. Second, we will address populations that may be particularly vulnerable to mental health sequelae and special considerations we must take when working with these patients. These include healthcare workers, elderly patients, pregnant women, patients with pre-existing mental health conditions, patients experiencing homelessness, individuals experiencing intimate partner violence, and several minority communities. And finally, we will outline the ways we can expect clinical care and mental healthcare delivery to change as a result of COVID-19. This section introduces a framework to help us evaluate the mental health resources available for our patients, an update on the use of telehealth during the crisis, and a set of trauma-informed precautions that should guide our patient encounters in the months ahead.

Learning Objectives

At the end of this module, medical students should be able to:

• Describe the multidimensional factors that impact mental health during the COVID-19 pandemic.

• Identify vulnerable patient populations, and critically evaluate and describe how to respond to the unique needs of each one.

• Identify both health systems and community resources for individuals requiring mental health support.

• Evaluate the current state of telehealth in the context of mental health delivery and describe barriers to its dissemination.

• Practice trauma-informed care with patients as a universal precaution.

Note: This module is primarily aimed to help us as medical providers and future physicians understand the impact of the COVID-19 pandemic on the mental health of our patients. Our goal is to help you identify the complex ways that the crisis contributes to our population’s mental health and how your role in clinical settings may evolve to respond to these new mental health challenges. But before we can take care of our patients, it is important that we first take care of ourselves. Your own mental health and well-being as a trainee and medical provider are incredibly important in this time. For information on care of self and others, and tools to protect your own mental health in the setting of this traumatic exposure, please refer to Module 6.