Special Considerations for At-Risk Populations

As society reels from the disruptions and losses resulting from the pandemic, some communities and populations may be particularly vulnerable. This added distress may increase mental health concerns in these populations. Below, we highlight several of these populations, keeping in mind that this is not an exhaustive list, and these principles may be applied to other at-risk populations.

Healthcare Workers and Frontline Providers

Healthcare workers represent a particularly vulnerable population in the pandemic. Early studies from the COVID-19 pandemic have documented adverse mental health effects of COVID-19 among frontline caregivers. Experiences from China suggest high rates of depression (50.4%), anxiety (44.6%), insomnia (34.0%), and emotional distress (71.5%) (Lai et al., JAMA 2020). These effects were more pronounced in frontline healthcare workers directly engaged in the triage, diagnosis, and treatment of COVID-19 patients. Even prior to the COVID-19 pandemic, anyone involved in patient care (CNAs, interpreters, nurses, physicians, trainees, transport staff) was susceptible to secondary traumatization—a potential consequence of caring for patients in extreme suffering (Guitar & Molinaro, AWOMJ 2017). The broadened suffering during a pandemic can intensify the existing burden of secondary traumatization, perpetuating a serious acute-on-chronic condition for many healthcare workers (CDC 2020). For example, PPEs shortages have caused healthcare workers to feel abandoned by their institutions and insufficiently protected at work. In addition to frontline caregiving roles, many healthcare workers also care for loved ones at home. The demands from increased clinical duties amidst a pandemic may complicate these caregiving roles and further exacerbate healthcare worker distress. Beyond this, there is the added stress of worrying about bringing the virus home and infecting one's loved ones.

We realize many of our readers fall into this category and are at risk for the concerns enumerated above. For strategies to maintain well-being both at work in clinical roles, as well as in caregiving roles at home with loved ones, please reference Module 6: Care for Self and Others During Crisis. This module reviews trauma reactions of caregivers including medical trainees and physicians, details practical strategies for staying well, and highlights institutional strategies to support provider wellbeing.

Elderly Patients

Risk-mitigating measures, such as physical distancing, are geared to protect everyone, but especially the populations at-risk for much more serious presentations of COVID-19. One such population is the elderly (over 60 years in age), a group that also has a higher prevalence of comorbid chronic conditions (see Module 1). At baseline, it is estimated that 20% of adults older than 60 years old suffer from a neurologic or mental disorder (WHO 2017). Given that an estimated 43% of elderly people report feeling socially isolated with few relationships and infrequent social contact, many lack a vital social safety net to cope with stress (NAP 2020).

The COVID-19 pandemic further amplifies underlying psychosocial stressors for elderly patients, including limited mobility, unease with technology, smaller social circles, and managing the burden of comorbid conditions. These issues frequently impact the ability of elderly people to care for their daily needs and feel connected to family and friends. As a result, reports suggest that many older people are foregoing physical distancing to maintain any degree of normalcy and social connectedness (CNN 2020).

Therefore, as we advocate for risk-mitigation strategies like physical distancing to limit viral transmission, we must also account for the toll that pandemic-associated social isolation and psychosocial stressors have on the mental and emotional health of elderly patients (ScienceNews 2020). One strategy to respond to these challenges is by establishing virtual communities using telecommunication services. Such efforts to improve the accessibility of such technologies already exist, including: clear and illustrative instructions for setting up devices, and accessible applications that have functionality for patients with visual or auditory limitations. With adequate technological support, telecommunication services can help elderly individuals—or anybody, for that matter—-adhere to necessary physical distancing while maintaining social connectedness.

Pregnant and Postpartum Patients

Pregnant and postpartum patients are, even in times of relative normalcy, a psychiatrically vulnerable population. This is generally due to increased risk of psychotic, mood, and anxiety disorders during and after pregnancy as well as risk for psychiatric trauma during childbirth (Carter & Kostarasm, BCMJ 2005). These disorders might include postpartum psychosis, postpartum depression and mania, and postpartum-OCD, to name a few. However, the current responses, including physical distancing guidelines during the COVID-19 pandemic, may further increase psychiatric risk in this already vulnerable population in two very prominent ways.

First, there has been much media coverage about hospital systems limiting or even banning partners and visitors from delivery rooms at different points during the pandemic response. While these policies were viewed as necessary responses to the current situation, they may put patients at increased risk of trauma during childbirth. There is increasing evidence that a subjectively negative experience of childbirth is associated with posttraumatic stress symptoms (Garthus-Niegel et al., BIIPC 2014). It will be important for both obstetricians and mental health providers to increase monitoring of patients delivering during this time and ensure those experiencing birth trauma are connected with appropriate mental health care following up.

Second, patients in the postpartum period, even those without psychiatric histories, are finding their planned postpartum support systems collapsing during this time of physical distancing. Decreased access to family or nursing support, group supports, and even medical provider support may overwhelm what is already a notoriously difficult time for new parents. Given that recent literature has estimated postpartum depression rates to be as high as 12.9%, the burden of these additional stressors may result in increased mental health concerns for this vulnerable population (Stewart & Vigod, NEJM 2016).

Patients with Housing Insecurities

The COVID pandemic poses a large burden both on patients experiencing homelessness as well as on the institutions that serve them. Patients experiencing housing insecurity/homelessness often report higher levels of stress, which negatively impacts their physical and mental health (Stahre et al., CDC 2015). There is a two-way relationship between homelessness and mental illness (Patten, Can J Psychiatry 2017). A patient’s pre-existing mental illness might make it difficult to maintain stable housing or get a job; in turn, a patient suffering from homelessness is at risk for developing a mental health illness. This cycle also highlights how housing serves as more than a protective physical barrier providing an intimate environment for personal growth, relationships, and security (Robinson & Adams, AFRC 2008). Therefore, people experiencing homelessness are at risk for mental health diseases including affective disorders, such as major depressive, bipolar disorder, schizophrenia, and substance use disorder.

In addition to its effect on individuals, there are institutional ramifications from the pandemic. Patients experiencing homeless often have limited access to healthcare due to various socio-economic factors including finances, institutional policies, lack of insurance, and more (Robertson & Cousineau, AJPH 1986). The COVID-19 pandemic will, unfortunately, exacerbate the health disparities caused by these determinants. Baggett et al. (2010) demonstrate that mental health services remain a major area of need for patients suffering from homelessness (refer to the figure below). Emergency departments provide a bulk of primary care for homeless patients but are currently running at the limit of personnel and therapeutic limits (Feldman et al., WestJEM 2017). Therefore, it is crucial to expand on our current health infrastructure to accommodate homeless patients.

Beyond the healthcare system, patients experiencing homelessness may have limited options in seeking safe, clean shelters and housing options. However, they might be at risk for contracting COVID-19 if they lack access to uncrowded, sanitary housing or personal sanitary products (Tsai & Wilson, Lancet 2020). There have been several measures to combat these issues including renting hotel rooms, but these traditional resources including meals, and housing are rapidly becoming unavailable. As such, it is imperative to address these issues with holistic solutions; various organizations such as Boston Healthcare for the Homeless provide health resources targeted at the homeless population and provide a model for reaching out to this disadvantaged population. For more information on the ethical considerations surrounding this population, check out Module 7.

Individuals Suffering from Domestic Violence

Another vulnerable group of patients are individuals suffering from domestic and intimate partner violence (IPV). According to the WHO, one out of three women will experience physical or sexual violence in her lifetime (WHO 2018). In the United States, according to data collected by the Williams Institute, 32.9% of females and 28.1% of males have been exposed to intimate partner violence in their lifetimes, with higher rates of violence for sexual and gender minorities (Brown & Herman, The Williams Institute 2015). Survivors of domestic violence, regardless of gender identity, are at increased risk of depression, anxiety, and PTSD (Warshaw et al., NCDVTMH 2009).

For vulnerable individuals, stay-at-home orders and quarantine may place them at greater risk, as it effectively traps them in a home with their abusive partner. As the United Nations Secretary-General Antonio Guterres stated on April 6th, “For many [individuals], the threat looms largest where they should be safest — in their own homes...We know lockdowns and quarantines are essential to suppressing COVID-19, but they can trap [individuals] with abusive partners. Over the past weeks, as the economic and social pressures and fear have grown, we have seen a horrifying surge in domestic violence.”

Some countries have already seen an increase in domestic violence cases and need for services. According to an April 6th NYT article, Spain has seen an 18% increase of domestic violence calls during the first two weeks of lockdown. Beijing-based NGO Equality reports it has seen a surge of hotline calls since early February.

Medical care for these patients will have to change in order to accommodate the new challenges they face. Many mental health and primary care visits are now conducted via telehealth. Privacy in these settings cannot be guaranteed, so providers will need to take extra precautions when performing IPV screening. In addition, individuals may now be unable to carry out existing safety plans. For example, a patient who spends select nights with family or friends to protect themselves from abuse may feel unable to do so, due to fear of infecting loved ones with COVID-19, limited public transportation, and quarentines. We may need to reassess safety plans for feasibility and adjust them as necessary. Here is a resource to assist us in developing safety plans for our patients.

Further resources for individuals experiencing domestic abuse during the COVID-19 pandemic can be found at the National Domestic Violence Hotline.

Thought Questions:

  • If you were a PCP at this time conducting telehealth visits, how might you bring up IPV with your patients?

  • Assume you have a patient who you know is currently experiencing IPV, how might you structure a new safety plan for them?

Sexual and Gender Minority (SGM) Populations

The COVID-19 pandemic poses several challenges for the SGM (Sexual and Gender Minority) community, which includes, but is not limited to, the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, as well as individuals with non-binary gender identities or expressions, sexual orientations, or reproductive sex. Both cisgender (i.e., non-transgender) and transgender LGB individuals experience minority stress (Meyer, 2003, Hendricks and Testa, 2012) and are subsequently at increased risk for depression and anxiety disorders, suicide, and alcohol and substance use (King et al., 2008, Daniel and Butkus, 2015), all of which may be exacerbated by the social and economic impacts of COVID-19. These negative impacts also may be compounded in individuals with multiple minority stressors, such as SGM people of color (Balsam et al., 2011). Adequate access to mental health and substance use services will therefore be increasingly important, especially given higher rates of maladaptive coping strategies in response to stress (e.g. alcohol, tobacco, and drug use) in this population (Parent et al., 2018). In addition, school closures and stay-at-home orders may lead to greater exposure to negative environments. This is particularly concerning for SGM youth, who may experience negative reactions from family regarding their sexual orientation (D’Augelli et al., 2008, Katz-Wise et al., 2016) and/or gender identity (Spivey et al., 2018) and who are at increased risk for physical, psychological, and sexual abuse at home (Roberts et al., 2012) and homelessness (Morton et al., 2018).

SGM individuals also face unique challenges regarding access to healthcare services. Transgender patients have noted discrimination and lack of cultural responsiveness from healthcare providers (Romanelli et al., 2020; Safer et al., 2016), and 23% of transgender respondents in a 2015 survey noted fear of mistreatment as a reason for not seeking healthcare. Cisgender patients have also noted negative experiences related to their sexual identity in healthcare (Macapagal et al., 2016). SGM patients therefore may be dissuaded from seeking care for COVID-19 symptoms. Educating providers and practicing SGM-inclusive care is essential, and recommendations for providing SGM-inclusive palliative care during COVID-19 have been provided (Rosa et al., 2020). Furthermore, SGM patients may encounter decreased access to life-saving gender-affirming procedures like surgery and hormone therapy due to prioritization of COVID-19 related services in many hospitals. However, clinics like Fenway Health have developed creative strategies, resources, and specific support groups related to these specific challenges during the pandemic.

Additionally, many SGM patients are at an increased risk of sexually-transmitted infections (STI’s) like HIV (Blondeel et al., 2016). Given reduced clinic operations due to COVID-19, screening SGM patients for STI’s, connecting patients with effective preventative measures like PrEP (pre-exposure prophylaxis), and monitoring existing medication regimens may be increasingly difficult. Clinics in Seattle, WA (Beima-Sofie et al., 2020) and Providence, RI (Rogers et al., 2020) have provided useful recommendations for care strategies in this population due to COVID-19, such as telemedicine interventions. In addition, there is lack of data regarding sexual transmission of SARS-CoV-2 at present, which may lead to psychologically damaging abstinence-only recommendations for SGM populations (Turban et al., 2020). As a result, affirming counseling and risk-reduction strategies will be especially important for SGM patients. While studies documenting the mental and physical health impacts of COVID-19 on the SGM community have not yet been conducted, many distinct challenges are evident.

A list of mental health, economic, and legal resources for SGM individuals can be found here.

Individuals with Pre-existing Mental Health Conditions

Individuals with pre-existing mental healthcare conditions are also vulnerable to exacerbations during this stressful time. A study of mental health outcomes following Hurricane Katrina suggested that the odds of screening positive for a new mental illness were 6.8 times greater in individuals with prior psychiatric diagnoses than those without (Greer et al., J Nerv Ment Dis 2013). These risks were particularly pronounced among individuals with prior PTSD diagnoses, for whom the odds of screening positive for a new secondary mental health condition were 11.9 times greater than the general population.

It is unclear whether this pandemic will result in similar outcomes, but there are many explanations for why our patients with mental health conditions are at risk for acute exacerbations at this time. For one, uncertainty about the future and worry about becoming ill may worsen underlying anxiety symptoms. Second, barriers to accessing usual support tools, such peer groups, may interrupt established psychiatric care plans. Third, patients may face increased barriers to obtaining and undergoing appropriate monitoring. For example, we know that patients taking some antipsychotics, such as clozapine, require regular blood tests for screening. The FDA is advising providers to reassess individual risk/benefit for their patients when thinking about prescribing these drugs at this time. Finally, individuals may be apprehensive to seek needed mental healthcare in hospital systems due to perceived risk of infection, particularly Psychiatric Emergency Care.

In addition, prior research has suggested individuals with psychiatric disorders are at increased risk for pneumonia (Seminog & Goldacre, BMJ 2012). There are several hypotheses for why this is true, including engaging in high-risk activities such as smoking and alcohol consumption (which tend to be more prevalent among patients with psychiatric comorbidities), having lack of health literacy and understanding of healthcare risks, and presenting with atypical pain-related symptoms. Some have already begun hypothesizing whether this increased risk will carry over to COVID-19 (Yao et al., Lancet Psychiatry 2020). If true, individuals with mental illness may not only be at risk for mental but also medical exacerbations at this time.

Patients with specific mental health conditions may face additional challenges:

Substance and Alcohol Use Disorders

The shockwaves of the pandemic are hitting everyone with active substance use disorders as well as those in recovery. Alcoholics Anonymous and other peer support meetings have been converted to virtual platforms. Methadone clinics are closing, and individuals are being taught how to administer the medications at home. Social support is critical for individuals recovering from substance use disorder, and social isolation is a known risk factor for relapse (Volkow, ACP 2020). Physical distancing is a key part of the containing the rapid spread of COVID19; however, for individuals in recovery, these measures may limit access to peer-support meetings and other sources of social support. Many who feel isolated and overwhelmed -- as much of the population is during this pandemic -- will turn to substances to alleviate their negative thoughts and emotions.Those in recovery may face increased urges to use and may be at increased risk for relapse. However, there are still resources available.

Resources for Individuals with Substance Use Disorders: Online Resources to Support Substance Use Disorder Recovery

Anxiety Disorders

Individuals with anxiety disorders, such as obsessive compulsive disorder (OCD) and social anxiety disorders, also require special consideration given the complex relationship between pre-existing psychiatric symptoms and current physical distancing/protective measures. OCD is particularly relevant in this context. A recent NYT article describes the experience of several patients with OCD, specifically the blurred boundary between observing appropriate safety measures such as adequate handwashing and fears of contamination leading to excessive hand washing. A careful altering or restructuring of any current exposure therapy may be necessary to maintain safety during physical distancing, and may hinder an individual’s clinical progress for the time being.

Resources for Individuals with OCD: International OCD Foundation

For more information on Specific Mental Health Condition and COVID-19, please refer to the Massachusetts General Hospital Guide to COVID-19 Mental Health Resources.

People Living with Disabilities

With the advent of strict COVID-19 prevention policies, many people living with disabilities (PLWD) face additional challenges. Some of the practices and policies currently in place have often been abruptly instituted and can lead to disruptions in daily life and access to regular care for those living with disabilities.

For example, with new physical distancing measures, PLWD experience limited access to support, care and therapy (speech, physical, occupational, etc) that they may regularly use. While some clinical practices are transitioning to telehealth, specific services such as physical therapy and audiology testing may be more difficult to translate virtually. Physical distancing has also caused widespread closure of day rehabilitation programs that PLWD utilize to thrive. These closures have caused severe disruption to the structure of these individuals’ lives which can result in increased psychological distress for those living with developmental disabilities, such as individuals on the autism spectrum, as well as their caregivers.

In addition, for PLWD, medical resource allocation may also be a particular concern and source of anxiety. States such as Kansas and Tennessee have issued emergency guidelines suggesting that people with “advanced neuromuscular disease” might be excluded from receiving critical care. Until recently, Alabama had a proposed emergency plan that deemed people living with intellectual disabilities among those who “may be poor candidates” for lifesaving therapy. These guidelines and others have caused concern for disability rights advocacy groups since they legitimize the ability of doctors to withhold care or to deliver lesser priority treatment. Individuals, such as Rabbi Elliot Kukla who lives with a disability, have written Op-Ed pieces to describe their fears of being dismissed during this pandemic; Kukla describes worry over physicians and policymakers regarding his body as “simply worth less than others’ bodies.” For a longer discussion on the ethical considerations in this debate, check out Module 7’s section on vulnerable populations.

Thought Questions:

  • Imagine you are a pediatrician caring for a 13-year-old boy with autism spectrum disorder. How would you explain the current situation to your patient?

  • His parents have heard about the recent rationing measures in other states and are worried their son won’t receive the care he needs, were he to get sick. How would you address and alleviate their anxieties?

Racial and Ethnic Minority Communities

If we revisit the socioecological model of trauma presented in the previous section, we quickly realize that racial and ethnic minorities are at increased risk of trauma at historical and societal, interpersonal, and individual levels. Populations that have been marginalized and discriminated against in a systemic, institutionalized fashion are more vulnerable to the effects of the pandemic and undermines their ability to respond safely. Data from around the United States points to health disparities in the incidence and case fatality of COVID-19 based on race (CDC MMWR, 17 April 2020). A more complete discussion of these health disparities and inequities can be found in Module 3 and also discussion of xenophobia and ethics can be found in Module 7.

The increased disease burden and death among minority communities will likely have significant mental health effects. A poll collected by the Kaiser Family Foundation shows a greater proportion of Black and Hispanic participants self-reporting the coronavirus pandemic having a “major impact” on their mental health compared to their White counterparts (Kirzinger et al., KFF April 2020).

In addition to structural-level trauma, certain communities including Asian American and Pacific Islander (AAPI) communities have seen an increase in interpersonal trauma and interpersonal racism (A3PCON press release). The Crisis Text Line, a global not-for-profit organization, found that the percentage of AAPI seeking counselors made up 16% of texters, despite being only 5.3% of the U.S. population, with the majority reporting bullying, harassment, and depression related to the virus (Filbin, Crisis Text Line 2020). These findings support those from San Francisco State University, which found a 50% rise in news pieces on COVID-19 and anti-Asian discrimination between February 9th and March 7th, 2020 and their analysis of the 673 reports of coronvirus discrimination against AAPIs from March 19-25, 2020.

Although to date, little published data exists on the mental health impact on Asian Americans, many physicians have begun speaking out about the negative mental health impacts on Asian Americans and Asian individuals residing in the U.S. (Zhai & Du, Lancet Psychiatry 2020; Zheng & Goh, Anatolia 2020). It has been established that perceived racial discrimination is positively correlated with a mental illness diagnosis, and recent analyses support inferences of the impact of discrimination through the media on Asian Americans mental health during the coronavirus pandemic (Rodriguez-Seijas et al., JAMA 2015; Wen et al., Anatolia 2020).