The Biopsychosocial Framework

A Tool To Understand the Mental Health Impact of COVID-19

To better understand how the pandemic may be causing this spike in mental health concerns, we are going to consider the cases of Brian and Diane through the lens of the biopsychosocial (BPS) framework as well as the physiology of the trauma response. You’ve likely learned the BPS model in your past medical training, but if you want a refresher on the topic, you can review it here.

These cases capture some of the ways the pandemic may impact the mental health of our patients; we appreciate that there may be numerous factors that affect their health. Our goal is to demonstrate some of the prevalent stressors that we are seeing in our patients right now and provide examples of how to pull together the many interwoven life events that contribute to our patients' mental health.

Brian’s Case

Let’s start with Brian. As you might recall, Brian is a healthy, 22 year-old college senior in Boston who just graduated from college. He was planning on living with his grandmother, Diane, until he had enough money to pay rent. Now he’s been told that he cannot move in with her because of the dangers that might pose to her health. On top of that, he has no earnings, $20k student debt, and a post-graduate job that is on indefinite hold.

If this were a psychiatric interview, you would definitely want some more information. So let’s add a bit more to his story:

Brian grew up outside of Seattle with his parents and older brother. He reports that he had a “happy childhood”, but that his high school years were challenging due to a tense relationship with his father. This relationship further deteriorated over the course of college because his father was constantly upset with Brian for spending his free time at parties with his friends from the soccer team, rather than focusing on his studies. Hanging out with his teammates both in practice and on the weekends was Brian’s favorite part of college. After graduation, Brian planned to live with his grandma Diane, with whom he has always been close. He worried that moving back in with his father would result in more nagging and fighting. Now, he has no other choice but to move back home to his childhood room.

His parents are worried that Brian may have been exposed to COVID-19 on his recent social outings, so he feels they are forcing him to self-quarantine for the next 14 days in his bedroom. He reports that he passes the day watching Netflix, playing Animal Crossing, and scrolling through social media. He originally tried looking for a temporary job but gave up after the first few companies he called said they weren’t hiring. On social media, he notices that a few distant friends have commented on his Instagram-story from a recent dinner with his friends, reprimanding him for being irresponsible and not “socially distancing.” Brian feels like they are acting holier-than-thou and is frustrated that they don’t understand everything he is going through right now. He ultimately decided to reach out for care via a telehealth provider because he found that his friends were getting annoyed with him for “being such a downer,” and he felt that no one could really understand all of the stress he is under right now.

Brian does not have any past psychiatric history. His family mental health history is notable for depression in his maternal grandmother as well as anxiety and panic disorder in his mother. He reports that in college, he used to drink 8-9 beers on weekend nights because that’s what all his friends were doing. Now, amidst his self-quarantine, he reports drinking 4-5 beers per day. Without prompting, he justifies his behavior by saying that “it’s not like [I’m] drinking alone” since he’s “always talking to friends online” and that he “doesn’t have anywhere to be anyway.” He denies tobacco or drug use.

Thought Question:

  • What additional information have we missed here that you might want to help evaluate Brian’s current presentation?

Brian’s Biopsychosocial Formulation

What biological factors are contributing to Brian’s current presentation? In addition to his family history, Brian’s alcohol misuse is likely playing a role. We know that stress is a risk factor for onset and maintenance of an alcohol use disorder (Koob et al., Am J Psychiatry 2007). Given the increased stress faced by many who are socially distancing or caring for sick loved ones, our patients may be at increased risk for slipping into alcohol misuse. In fact, we have already seen an increase in alcohol sales in the United States since physical distancing efforts have begun (Nielsen 2020). These findings are particularly concerning given evidence that excessive alcohol use may weaken the immune system (Molina et al., ARCR 2010). Some have even postulated it may put individuals at increased risk for poorer outcomes if they contract COVID-19, although this is certainly controversial and an area of open investigation. The WHO provides a helpful handout with important facts on alcohol use and COVID-19.

Of note, individuals with pre-existing substance use disorders may face additional burdens during this crisis. We will outline specific challenges that these individuals face in our at-risk populations sections here.

Now, what psychological factors are contributing to Brian’s current presentation? There are many psychological factors and underlying personality vulnerabilities that could contribute to Brian’s current mental health status. One that is particularly relevant to the COVID-19 pandemic may be barriers to using previously formed coping mechanisms. Some of Brian’s existing coping mechanisms, such as playing soccer or spending time with friends, are now no longer available to him. Like Brian, many of our patients must now identify new coping mechanisms to help them deal with their day-to-day-stressors.

Thought Question:

  • How would you coach Brian to consider additional coping mechanisms during the pandemic? If you want to learn more about a framework for thinking about coping mechanisms and stress during the pandemic, here is a recently-published perspective piece that delves further into the issue.

In addition, Brian is now facing the psychological effects of quarantine, which are likely further exacerbating his presentation. A recent review of the mental health impact of quarantine during prior infectious disease outbreaks—including the 2003 SARS, 2010 H1N1, and 2014 Ebola outbreaks—suggested that individuals undergoing quarantine reported increased post-traumatic stress symptoms, confusion, and anger. Some of these effects may even be long lasting (Brooks et al., Lancet 2020). For example, a study of health-care workers suggested that quarantining was positively associated with increased alcohol use disorder or alcohol dependency three years after the SARS outbreak (Wu et al., Alcohol Alcohol 2008). There were also social effects of quarantine. Quarantined healthcare workers continued to engage in avoidance behaviors following quarantine, including minimizing contact with patients (Marjanovic et al., IJNS 2007). All of these sequelae are important to consider when caring for Brian both now and once the COVID-19 pandemic resolves.

What are the social contributors to Brian’s current presentation? From the vignette, it appears there are several: Like many individuals, he is facing increased tension with his family, with whom he is now confined in close quarters.

He is also engaging in regular social media use, some of which he reports has been hostile. The relationship between social media use and mental health is still unclear, with some studies reporting worse depressive and anxious symptoms in adolescents with increased use, while others do not show consistent relationships (Barry et al., J Adolesc 2017; Berryman et al., Psychiatr Q 2018). What is true is that over half of teens report having experienced cyberbullying; Brian as a young adult is not immune (Pew Research Center 2018). We are now seeing an increase in social media usage across many platforms (Kantar 2020). It is vital to ensure that our patients feel safe online and are utilizing online resources in a healthy way.

How can we utilize social media productively in this time?

  • Stay connected with friends and family;

  • Follow reliable resources, such as the CDC and WHO, to get accurate and current information;

  • Support individuals who may be experiencing cyberbullying. Additional resources can be found here.

Finally, Brian is facing financial strain and housing instability. We already know that both financial strain and housing instability are associated with worse mental health outcomes (Zimmerman & Katon, Health Econ 2005; Tsai, PLoS One 2015). We discuss housing instability and homelessness more in our discussion of at-risk populations sections here.

There are many changes in Brian’s life that threaten his mental health. It is still unclear from the current information whether he has a diagnosable mental illness. However, as healthcare providers, we work with all patients - both with and without mental illness diagnoses - to support their own mental health.

It will also be important to assess Brian’s risk for self harm and suicidality. Gun sales have increased during the pandemic, with March 2020 sales up 85% compared with March 2019 (Mannix et al., Annals of Int Med 2020). Given the known risk gun ownership on suicide and ongoing mental health stressors experienced by patients at this time, risk assessment is going to be of utmost importance in the months ahead.

Diane’s Case

Now let’s start thinking about Diane. Remember, Diane is a 72-year-old woman who has COPD, heart failure, depression, and anxiety. She’s proud to live on her own in an independent living facility for the elderly in the middle of the city, and doesn’t like to ask other people for help. She was planning on housing her grandson Brian after graduation from college until he could find a place to live, but she doesn’t think that is a good idea anymore given the COVID-19 chaos and fears. Over the last few weeks, she has watched the news carefully, becoming more and more alarmed with the dramatic rise in both cases and fatalities. In particular, she has heard that people who are older and have other health conditions are at greater risk of serious infection, and she is reminded of her late husband, who passed away last year due to complications from the seasonal flu. Making matters worse are her concerned children, who live across the country. They call her and plead that she isolate herself at home. But she can’t—she doesn’t have anybody to help her. So, Diane walks to her local supermarket to stock her pantry and purchase the necessities that are all over the news, including cleaning wipes, masks, and soap. At the store, her heart pounds. The home supply shelf is completely empty.

She reaches out to her primary care physician to schedule an appointment. She wants more information on resources for getting the supplies she needs and setting up medication delivery. (After learning all the communication tips discussed in Module 5, one of her grandchildren, who is a second-year medical student, broached some behavior-change conversations. Now, Diane is finally ready to accept outside help).

Before the call, her PCP reviews Diane’s chart to refresh herself on Diane’s history. Diane’s heart failure and COPD have been well-controlled medically for the past few years. Her medication list includes metoprolol, lisinopril, albuterol as needed, and fluoxetine. She first presented for mental health concerns at age 37, following the birth of her second child. At that time, she started an SSRI and attended a CBT-based group therapy program. Her mood stabilized, and she did not re-present for care until the death of her husband 14 months ago.

Diane and her husband had just celebrated their 45th wedding anniversary with all the family when her husband became ill with influenza. She had grown concerned about how sick he was getting, but he didn’t want to leave the house; finally they went to the emergency room when he started struggling to breathe. Over the next two days, Diane witnessed her previously healthy partner undergo intubation, and later chest compressions, before he passed away. She thought if she had been a better caregiver at home, or just made a more convincing case for going to the hospital, he might still be alive. In the months that followed, she agreed to restart fluoxetine and attended a community grief group at her church. She had just started to come back to her normal life again when the pandemic hit.

On the phone call, Diane asks a lot of questions about the outcomes for patients infected with SARS-CoV-2. She is very hard to redirect and insists that she wants all of the relevant scientific studies sent to her. Eventually, she becomes tearful. One of her friends from church recently became ill, and Diane feels guilty that she is not able to help. Diane says that she has always been the caregiver of her family and friends, and now spends all day worrying about her ill friend. Diane has also had trouble sleeping and often wakes up for hours in the middle of the night worrying about COVID-19. Then, she feels tired all day. Sometimes, when her family calls, she can’t even find the energy to talk to them.

Thought questions:

  • What might a one-line clinical summary be for Diane? Would you mention the current pandemic?

  • How would you address Diane’s request for medical information? Would you redirect her? If so, how?

Diane’s Biopsychosocial Formulation

What biological factors are contributing to Diane’s current presentation? Diane’s age, underlying medical illnesses, and trauma history are likely contributing. Like those with many chronic conditions, individuals with COPD and heart failure are at increased risk for mental illnesses, such as depression (Schneider et al., CHEST 2010; Rutledge et al., JACC 2006). It is unclear how the current COVID-19 pandemic will interact with these two disease processes to alter this association. Traumatic exposures, such as the untimely death of her husband or witnessing a medical code, have also been shown to contribute to an imbalance in neural circuitry. with effects on decision-making, cognition, mood and anxiety and on systemic physiology via altered cortisol levels and other mechanisms (McEwen, JAMA Psychiatry 2017). This imbalance can make Diane more vulnerable to decompensation during the acute stress of the pandemic.

It also appears that our elderly population may face an increased mental health burden at this time. Special considerations on addressing the mental health needs of our older patients are discussed in Section 3 of our module here.

What psychological factors are contributing to Diane’s current presentation? For one, she appears to have ongoing anxiety about getting ill. This feeling is ubiquitous. Nearly half of Americans are anxious about getting coronavirus, and 62% are anxious about a loved one becoming ill (APA 2020). This anxiety is a double-edged sword. On one hand, some anxiety at this time may actually be protective. A recent study found that individuals consistently under-predict their own risk of COVID-19 infection (Wise et al., PsyArXiv 2020). Perceived likelihood of getting the infection was found to be the only factor that predicted adherence to physical distancing measures. If true, some level of societal anxiety may actually be necessary to preserve physical health. However, too much anxiety can also be detrimental, and we need to balance the need for physical distancing with the need to protect emotional wellbeing. Here, it appears that Diane’s anxiety surrounding the virus may have reached a level where it is counterproductive to her overall health.

Diane is psychologically predisposed to distress due to her husband’s recent history with the medical system. Even though she has worked hard to heal—between seeking peer support at church and engaging her doctor—constant reports about deathly ill patients, ventilators and hospital conditions, and the recent illness of her friend, may trigger her trauma history. Therefore, listening to the news or reading about the symptoms of COVID-19 may induce a stress response in Diane greater than someone without a similar history (see below for further discussion on trauma).

Lastly, what social factors are contributing to Diane’s current presentation? Social changes place large stressors on Diane at this time. At the most basic level, Diane has lost many of the social supports and networks on which she relies due to the institution of physical distancing measures. In addition, her orientation as a caregiver to friends and family may amplify the distress that she feels, much in the same way that healthcare professionals may experience the trauma of COVID-19 both directly and via the people for whom they are caring (see “Care for Self and Others During Crisis” in Module 6).

Thought Question:

  • Think of two patients you’ve cared for recently in the hospital or clinic. Can you think about ways the COVID-19 pandemic may exacerbate their pre-existing biopsychosocial challenges and affect their mental health?

COVID-19 as Traumatic Exposure

Above, we discussed how COVID-19 dramatically changed Brian and Diane’s daily lives and altered their sense of safety and control. For them and for many patients, the pandemic and its consequences may represent significant traumatic exposures. Trauma is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (SAMHSA 2014)

Traumatic exposures may occur at an individual, interpersonal, or collective level, as shown in the figure below. The pandemic may affect individuals at any or all three levels. At the individual level, for example, Diane feels a heightened sense of vulnerability and is reexperiencing past traumatic experiences. At the interpersonal level, Brian experiences a deterioration of his relationships with friends and family. At the collective level, Brian and Diane are constantly exposed to the illnesses of those around them as well as a societal grappling with deaths and other losses.

The experience of trauma has been documented to impact mental and physical health across the life-course. In the landmark Adverse Childhood Experiences study, childhood exposures to trauma were linked with adult health outcomes such as depression, substance use disorders, and cardiovascular disease in a dose-dependent fashion. The mechanism by which trauma leads to poorer health outcomes is still under investigation, but is thought to be mediated by neurohormonal and metabolic adaptations to stress that change both physiology and behaviors (McEwen, JAMA 2017).

Module 6 addresses how the traumatic exposure of COVID-19 is doubly burdensome for healthcare providers, as well as approaches to mitigate those impacts and skills to care for yourself and those around you.

Review

To review, in this section we have discussed the biological, psychological, and social forces that contribute to worsening mental health outcomes during the COVID-19 pandemic. They include:

  • Biological: age, heightened stress response, coexisting medical and psychiatric comorbidities, increased substance use;

  • Psychological: changes in available coping skills, quarantine increasing feelings of anger and confusion, anxiety of contracting the illness, triggering of past traumas;

  • Social: housing insecurity, changes to family dynamics, transition to online communication and social media use, loss of social networks and community supports, additional weight of caring for others who are suffering.

Thought Questions:

  1. This list is far from complete. What other factors do you think are playing a role at this time?

  2. How might a personal history of trauma impact the mental health needs of our patients now and the health needs of our population in the long term?