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.

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

“Sexual and gender minority” (SGM) is an umbrella term that encompasses individuals whose sexual orientation, gender identity/expression, or reproductive development varies from societal, cultural, or physiological norms. This includes the lesbian, gay, bisexual, transgender, and queer communities, as well as individuals with differences of sex development (DSD), sometimes known as intersex.

It is well-established that SGM populations experience mood disorders, substance use disorders, and suicidality at rates higher than the general population (Luk et al., 2018; Reisner et al., 2016; King et al., 2008; Daniel & Butkus, 2015). The prevailing explanatory model for these mental health disparities is the minority stress model, which posits that stigma, prejudice, and discrimination place SGM individuals at higher risk of experiencing mental illness (Meyer, 2003; Hendricks and Testa, 2012). The impact of minority stress is compounded in individuals with multiple minority stressors, including SGM people of color (Balsam et al., 2011).

The COVID-19 pandemic may exacerbate existing mental health disparities affecting SGM populations due to several socio-structural factors. First, stay-at-home mandates and school closures may be particularly harmful for SGM youth who may be forced to remain in non-affirming and potentially abusive environments. One-third of SGM individuals experience parental rejection, a significant risk factor for suicidality (Rosario & Schrimshaw, 2013; Ryan et al., 2009; Katz-Wise et al., 2016). SGM youth are also more likely than the general population to experience physical and sexual abuse (Baams, 2018). Second, the financial repercussions of the pandemic are more likely to be felt by SGM individuals due to disproportionate experiences of poverty, lack of insurance, and unemployment (Crissman et al., 2017). Recent surveys have demonstrated that during the first months of the pandemic, SGM communities reported more significant reductions in work hours and endorsed greater financial strain than the general population (Human Rights Campaign, 2020). Third, shifting clinical priorities in the context of COVID-19 may lead to decreased access to gender-affirming medical and surgical procedures, which may exacerbate mental health disparities affecting transgender and gender-diverse communities (Streed & Siegel, 2020; van der Miesen et al., 2020).

SGM individuals are more likely than the general population to experience challenges accessing medical care, a historical trend that renders this population more vulnerable in the COVID-19 era. The cause of this limited healthcare access is multifactorial. As mentioned previously, SGM populations are disproportionately impacted by poverty and unemployment, and medical care may therefore be cost-prohibitive. Furthermore, some subpopulations of the SGM community are more likely to be uninsured or underinsured than the general population (Kates et al., 2018). There is also a significant body of literature documenting experiences of healthcare-related discrimination among SGM patients (Macapagal et al., 2016; Romanelli et al., 2020; Safer et al., 2016). Notably, fear of mistreatment in medical settings is associated with reduced healthcare-seeking behavior (2015 U.S. Transgender Survey). Given that SGM patients may be dissuaded from seeking care for COVID-19 symptoms, the practice of SGM-inclusive care will be essential. Resources, strategies, and recommendations for the care of SGM patients in the COVID-19 era have been developed by clinicians (Rosa et al., 2020) and community organizations (Fenway Community Health, 2020; Massachusetts Transgender Political Coalition, 2020).

Many writers have drawn parallels between HIV and SARS-CoV-2; both viruses have disproportionately impacted SGM populations, and both diseases have disrupted norms regarding abstinence, social distancing, and personal autonomy. Abstinence-only approaches to social interaction and sexual activity remain commonplace. While such policies may be crucial for controlling viral transmission, they may also exacerbate psychologically harmful sexual stigma that currently exists among SGM communities (Turban et al., 2020). There is currently no evidence that SARS-CoV-2 can be sexually transmitted, and a recent case series demonstrated that the virus is not detectable in the semen or testes of COVID-19 patients (Song et al., 2020). Some providers have therefore called for a harm reduction approach to minimize COVID-19 transmission risk while acknowledging that abstinence is not always possible (Kutscher & Greene, 2020). Recommendations for safe sexual practices in the context of COVID-19 have been developed (Turban et al., 2020).

A list of financial, legal, and mental health resources for SGM individuals has been curated by Dr. Sabra Katz-Wise at the Harvard Health Blog.

Individuals with Pre-existing Mental Health Conditions

Individuals with pre-existing mental health conditions may be particularly vulnerable to the physical health impacts of COVID-19. It is well-established that this population has lower life expectancy than the general population. Most of this excess mortality is attributable to higher rates of low socioeconomic status, lack of health insurance, and poor physical health (Druss et al., 2011). These factors likely contribute to higher risk of pneumococcal pneumonia in people with severe mental illness (Seminog & Goldacre, 2012). Given this predisposition to respiratory infection, people with mental illness may also be more susceptible to SARS-CoV-2. Higher rates of homelessness in people with mental illness may predispose this population to developing COVID-19 and experiencing barriers to treatment (Tsai & Wilson, 2020). Furthermore, people with mental illness are more likely than the general population to smoke tobacco (Lasser et al., 2000), a practice that may be associated with worse outcomes from COVID-19 (Vardavas & Nikitara, 2020). Notably, at least one outbreak of nosocomial COVID-19 has been reported in a psychiatric hospital, likely due to a combination of overcrowding and the inability of some psychiatric patients to comply with physical distancing measures (Zhu et al., 2020).

There is evidence that disaster events disproportionately impact the mental health of individuals already living with mental illness. Following Hurricane Katrina, subjects with prior psychiatric diagnoses were 6.8 times more likely than the general population to screen positive for a new mental illness (Greer et al., 2013). Similarly, in the aftermath of 9/11, pre-event psychopathology was a risk factor for the development of PTSD (Cohen et al., 2005). These findings suggest that individuals with mental illness predating COVID-19 may be at risk for the most significant mental health consequences of the pandemic.

In the COVID-19 era, individuals with pre-existing mental illness may experience relapses or worsening of mental health conditions due to higher baseline psychosocial vulnerability (Yao et al., 2020). COVID-19 has given rise to many new stressors: threat of infection, financial strain, social isolation, and loss of in-person psychiatric supports. The pandemic may also disrupt the pharmacologic management of mental illness. Physical distancing measures may preclude the regular blood testing required for psychotropic agents such as clozapine. Consequently, the FDA has advised prescribers to reassess the individual risks/benefits of prescribing such agents.

Mental health conditions encompass a broad range of disorders, and COVID-19 has impacted the management of these conditions in distinct ways. We provide an overview of the impact of COVID-19 on patients with two types of psychiatric disorders that have gained increasing attention: substance use disorders and anxiety disorders.

Substance Use Disorders

Physical distancing measures have produced conditions that increase the risk of new or worsening substance use disorders. Social isolation, loss of psychosocial support, and loss of structure are significant risk factors for high-risk substance use (Volkow, 2020). A survey of addictive behaviors in a Chinese population at the onset of the COVID-19 pandemic demonstrated increases in relapses to alcohol and tobacco use, as well as increases in problematic internet consumption (Sun et al., 2020). Furthermore, a Canadian study of adolescent substance use behaviors during the pandemic demonstrated increases in their frequency of alcohol and cannabis use (Dumas et al., 2020)

As the burden of substance use disorders has increased, physical distancing measures have concurrently disrupted existing treatment approaches. Group counseling is a cornerstone of therapy for many relapse prevention programs, but support structures such as Alcoholics Anonymous are no longer available in-person. Patients with lower socioeconomic status who lack the means to attend digital support groups will be disproportionately impacted (Da & Im, 2020). Pharmacologic management of substance use disorder is also complicated by COVID-19. Methadone maintenance therapy for opioid use disorder is tightly regulated, with most patients receiving one directly observed daily dose at a time. However, physical distancing measures have necessitated new treatment strategies (Alexander et al., 2020). Guidelines from the Substance Abuse and Mental Health Services Administration and the Drug Enforcement Agency have been released to promote take-home maintenance therapy and more flexible prescribing of controlled substances.

Online resources to support individuals with substance use disorders are available here.

Anxiety Disorders

The new psychosocial stressors generated by the COVID-19 pandemic may exacerbate existing anxiety symptoms in people with mental illness (Druss, 2020). In one survey of U.S. and Canadian respondents, individuals with pre-existing anxiety disorders exhibited more COVID-related distress, were more likely to self-isolate, and were more likely to experience isolation-related stressors than those without a mental health disorder (Asmundson et al., 2020)

Individuals with obsessive-compulsive disorder (OCD) are particularly prone to exacerbations of their symptoms in the COVID-19 era. Health-related dangers such as HIV/AIDS are a known precipitant of new or worsening OCD symptoms (Fisman & Walsh, 1993). COVID-19 may pose similar challenges. Individuals with pre-existing OCD characterized by contamination obsessions may be particularly high-risk. The extant literature now has several case reports of acute exacerbations of previously well-controlled OCD symptoms following exposure to media about COVID-19 (French & Lyne, 2020; Kumar & Somani, 2020). The experiences of individuals with OCD have also been highlighted in the lay press (Rosman, 2020). Clinicians should be prepared to offer counseling that supports observation of CDC sanitation recommendations while also managing contamination fears. Effective language for counseling patients with contamination OCD regarding COVID-related hygiene has been developed (Shafran & Whittal, 2020).

Resources for individuals living with OCD in the COVID-19 era are available from the International OCD Foundation.

Additional resources for people with other mental health conditions are available at the Massachusetts General Hospital’s 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

The disproportionate impact of COVID-19 on racial/ethnic minority communities remains a key shortcoming of the pandemic response. The CDC’s surveillance efforts have demonstrated higher rates of COVID-19 in racial/ethnic minority individuals compared to their White counterparts (Moore et al., 2020). Furthermore, mortality rates from COVID-19 are demonstrably higher in regions with higher proportions of racial/ethnic minorities (Wadhera et al., 2020). The social-ecological model presented in Module 3 offers a framework for understanding inequities in the distribution of COVID-19. These populations have historically experienced discrimination at individual, interpersonal, institutional, community, and public policy levels, and those experiences conspire to produce enduring health disparities.

The same forces that give rise to general health inequities also contribute to well-established racial/ethnic disparities in mental health. While most racial/ethnic minority subgroups have a lower lifetime risk of psychiatric disorders than White individuals, there is evidence that racial/ethnic minorities tend to have more persistent and debilitating mental illness (McGuire & Miranda, 2014). The cause of these disparities is likely multifactorial. Notably, racial discrimination is associated with psychological distress and psychiatric disorders (Todd et al., 2012; Rodriguez-Seijas et al., 2015). Furthermore, racial/ethnic minority patients are much less likely than their White counterparts to utilize mental health services (Smith & Trimble, 2016).

The increasing burden of mental illness attributable to COVID-19 has disproportionately affected racial/ethnic minority communities. One survey examining mental health at the height of the pandemic demonstrated that Black and Hispanic participants reported a “major impact” on their mental health at rates higher than their White counterparts (Kirzinger et al., 2020). Unfortunately, the resources to engage in mental health care are not equitably distributed. Black and Hispanic individuals have experienced pandemic-related unemployment and financial strain at rates that are much higher than White individuals (Fairlie et al., 2020). Furthermore, as the shift to teletherapy and telepsychiatry continues, new care delivery structures may exacerbate existing racial/ethnic disparities, as Black and Hispanic patients are less likely than their White counterparts to own computers, use smartphones, or have home internet access (Perrin & Turner, 2019).

Although research on racial/ethnic disparities in COVID-19 distribution is still developing, the mainstream discourse concerning the disease has been racialized since the onset of the pandemic. The initial spread of COVID-19 beyond the borders of Wuhan, China led to a surge of anti-Asian discrimination. In March 2020, the U.S. FBI and Department of Homeland Security issued alerts regarding the potential for a rise in hate crimes and terrorist events targeting Asian-American and Pacific Islander (AAPI) communities (Mallin & Margolin, 2020). A surveillance study of anti-Asian discrimination related to COVID-19 yielded 1,843 incident reports from March to May 2020 (STOP AAPI Hate Report, 2020). It is broadly understood that this escalation of interpersonal racism has placed AAPI individuals at increased risk of adverse mental health experiences (Zhai & Du, 2020; Zheng & Goh, 2020). Early studies have demonstrated a disproportionate impact of COVID-19 on AAPI mental health. Crisis Text Line, a crisis intervention service, released data demonstrating that AAPI individuals made up 16% of users seeking support for COVID-related mental distress, despite making up only 5% of the U.S. population (Filbin, 2020). Mental Health America, an online mental health screening service, examined screening data following the first month of the U.S. COVID-19 surge; the data revealed that AAPI individuals exhibited the sharpest increase in severe anxiety (measured by the GAD-7 screen) of any racial/ethnic subgroup (Gionfriddo et al., 2020). Given the psychological impact of COVID-related racial discrimination, evidence-based stigma reduction initiatives and policy responses to combat anti-Asian racism have been suggested (Misra et al., 2020).

Additional resources for racial/ethnic minority communities are available at the Massachusetts General Hospital’s guide to Mental Health Resources for BIPOC.