Part 4. Final Common Pathway
This is the final installment of a four-part series on mental health issues and COVID-19. In Parts 1 and 2, the most common effects of SARS-CoV-2 on the respiratory system were reviewed along with a discussion of the implications for the potential impact of those respiratory changes on the brain and neuropsychological functioning. In Part 3, the more severe forms of COVID-19 illness were reviewed, including the immune system reaction — cytokine storms — and ischemic problems, which have been associated with cerebral-vascular disease. The common thread through the discussion has been the unexpected and, therefore, unpredictable ways that SARS-CoV-2 and COVID-19 have affected not just our bodies but also our psychological functioning, sense of well-being and sense of safety. These effects have permeated communities around the world, leading to a global experience of stress and trauma in the aftermath of the global pandemic.
Part 4, “Final Common Pathway,” considers the ways in which the pandemic has affected all our lives, creating additional stress and overwhelming the coping responses of individuals and systems alike, resulting in stress-related conditions, mood and anxiety problems and exacerbation of pre-existing mental health problems.
In the past few decades, most people have experienced a rapidly growing awareness of global issues and an increased sense of sharing of sociocultural experience. This has been largely due to increased availability of technology, which allows for greater international information sharing, travel and migration. The media exposes us to images of highly proficient technologies, and our children grow up accustomed to accessing these technologies daily. In a single generation, the common experience of technology has dramatically changed from a passive, receptive relationship of accessing global information to an active, expressive one in which even young children can reach out across the globe and share their thoughts in a nanosecond. Young adults who have developed in the context of this level of technology are no longer in awe of it. It is a commonplace experience to participate in sharing images and playing games with peers who may be anywhere on the planet, or getting on a jet to spend a few hours distracted by electronic media and arrive somewhere hundreds or thousands of miles away.
In the context of a reassuring, global technology that not only meets our needs but has also increasingly anticipated them, it has been immensely destabilizing to witness that system fail. Especially in the context of medical science, our modern culture entirely depends on reliable technology. Despite skeptics who are unhappy with some aspects of medical science or the pharmaceutical industry, most people in our culture have become accustomed to remarkable levels of scientific technology involved in the daily practice of medicine. We take it for granted that healthcare scientists can handle any problem society throws their way. Currently, 10 million people worldwide have been diagnosed with COVID-19, and half a million have died. That number is still growing, and in the United States, it is showing a major resurgence. Despite our healthcare system being the odds-on favorite to beat COVID-19 in the first round and despite the heroic efforts of healthcare providers and the advanced technology at their disposal, the pandemic has us against the ropes going into the second round.
Clearly, in public health as well as in healthcare technology and communications, much will be learned in the process of overcoming the COVID-19 crisis for our social and technology leaders, but this is also true for individuals. One of the main effects of the pandemic has been to isolate individuals and reverse the natural tendency for us to join together in times of crisis. Aside from the threat of harm and loss, the most significant impact of the pandemic has been the rapid erosion of already crumbling social support networks. A potentially very positive response to that problem has been the emergence and rapid expansion of telemedicine technologies, including telemental or telebehavioral health.
For mental health providers, our highly advanced technologies have been a double-edged sword. They have allowed us to rapidly and fairly transition smoothly to telemental health at a crucial time in order to continue to provide the assessment, intervention and continuous feedback loop of evidence-based treatment during this crisis. They have also exposed us and our clients to daily experiences of feeling overwhelmed, helpless and afraid. I’m sure I’m not alone in recently making an effort to actively avoid the news, but that is not as easy as it once was. This creates a great sense of ambivalence: media have become both a source of common experience and bonding as well as a source of fear and dysphoria. This is what puts mental health and, in particular, telemental health in such a critical position in the pandemic recovery process.
Important changes in mental health practices have resulted from the pandemic, some of which involved policy changes and others that were made out of necessity at the level of individual practitioners. Federal guidelines were initiated that allowed for state and private insurers to moderate the reimbursement rates of telehealth services. Similarly, state-based licensing requirements were relaxed to allow for interstate telehealth service. Finally, HIPAA regulations were temporarily suspended with regard to the use of telehealth technology for service provision. These and other changes allowed for a rapid response to the pandemic by mental health providers across the country. Within months, the percentage of psychologists who were actively participating in telemental health went from under 30% engaged in part-time online or telephonic practice to over 80% of providers conducting almost all of their work via remote technology.
This adaptive utilization of available technology has allowed mental health providers to significantly benefit the public in a number of key ways. First, we have been able to support the public health agenda of social distancing and risk prevention. In a system that too often appears to be reactive as opposed to proactive, in this instance, there has been a meaningful implementation of preventative strategies: mental health providers have emphasized and can continue to emphasize the critical thinking, impulse-control and rational behavior that demonstrates human values over economic issues. We also play a critical role in decreasing the negative impact of COVID-19 illness on the exacerbating impact of social isolation and stress.
There is ample scientific evidence to show the negative consequences of stress – coping with change and new challenges – in combination with feelings of helplessness and social isolation. Neuroendocrine changes, such as elevated cortisol levels, have known negative consequences for tissue regeneration and healing. Similarly, the decreased cardiovascular efficiency and COVID-19 respiratory problems that were discussed in previous parts of this series negatively impact recovery from the intracellular level up. Telemental health sessions focused on both self-care and recovery provide both reassurance and support as well as breathing techniques and muscle relaxation that can speed healing for those with significant residual COVID-19 symptoms.
For those recovering from COVID-19 illness as well as for an even larger number of individuals whose lives have been significantly impacted indirectly by the pandemic, the key issues that can be addressed by mental health providers include the following:
- Informed and reasonable information about the virus and preventative measures, such as PPE, social distancing and hand-washing;
- Providing strategies to improve coping and stress tolerance, such as mindfulness and meditation exercises, sleep, hygiene and ways to maintain social connections;
- Return-to-work readiness determinations from a mental health point of view and with appropriate work-restrictions and accommodations as indicated by the particular needs of essential workers;
- Grief and loss counseling;
- Telemed-based trauma-focused CBT or other evidence-based treatment approaches for treatment of COVID-19 related PTSD;
- Through frequency or duration of therapy sessions, increased intensity of treatment for acute exacerbations of pre-existing mental health issues, e.g., depression, PTSD, social anxiety, agoraphobia, generalized anxiety, major depression, etc.
Mental health providers with specialized training in neuropsychology and behavioral medicine/health psychology will be especially helpful for those COVID-19 survivors who have had the more severe illnesses described in this section. It will be particularly important to have providers aware of breathing strategies to improve respiratory efficiency without increasing risk of injuring vulnerable lung tissues (in general, easy in, hard out – i.e., a slow, steady intake of air to avoid injuring alveoli, and a hard, fast breath out to release as much CO2 as possible while not overtaxing the respiratory musculature). Reducing stress and improving hopefulness, resiliency, sleep and social support are all key strategies that behavioral health practitioners are familiar with. Assessing the neurocognitive impact of illnesses is also an important skill domain that most psychologists are uniquely able to contribute.
In particular, recent advances in computer-administered neurocognitive testing have allowed psychologists and neuropsychologists to be able to administer psychological and neurocognitive assessment instruments by telemedicine. The publishers of many psychological tests have adapted their administration for co-monitoring by examiners, and there are now many more neurocognitive assessment batteries available to aid in the detection and quantification of neuropsychological functioning deficits. IMCS has been pioneering the use of the MMPI-2-RF, SCL-90-R and the CNS Vital Signs in workers’ compensation assessment of neurocognitive features of concussion and post-concussion syndrome, but these instruments are also now available via telemed for assessment of post-COVID-19 neurocognitive features.
For survivors who have had prolonged periods of dyspnea (shortness of breath), hypoxemia (decreased blood oxygen levels) and hypoxia (decreased oxygenation of organs), neurocognitive screening and ongoing monitoring of mental status will be helpful. In addition, individuals should be prepared to monitor their own blood O2 saturation levels using a pulse oximeter if they are having continued symptoms of hypoxemia and hypoxia (dizziness, headache, muscle fatigue, dyspnea and decreased concentration). Periodic neurocognitive screening may also be useful, such as the CNS-VS, ImPACT, MOCA or other tools. This may be especially important for those with COVID-19 issues since it is associated with silent hypoxia, which can result in more neurocognitive symptoms with fewer overt signs of respiratory distress.
It will be important for everyone during this time to maximize their amount of social contact and support in order to overcome the natural social isolation due to the necessary social distancing regulations, but it will be especially important for individuals recovering from COVID-19 illness to have additional social support. Those who have recovered from the illness may be especially vulnerable to distress, resulting from re-exposure prior to or after returning to work. This is especially likely for healthcare workers who may be in early recovery from COVID-19 and yet are required to work with infected patients. Use of a peer or buddy system for monitoring exposure risk as well as to alleviate anxiety and stress will be key for sustained return-to-work success for many workers at risk of re-exposure.
For many providers, this may be the first time that they are working with individuals who are not presenting with anxiety, but with fear. Anxiety is a state of worry or anticipated negative outcomes, dread or pre-occupation that is not rational or is exaggerated or excessive. Fear is the emotional reaction to an actual threat to one’s health or safety, as well as that for others. Although many of us work with clients who face actual danger in their jobs (e.g., active duty military, first responders and those in hazardous occupations, like mining, forest or construction industries), most people do not typically face life-threatening conditions at work. For the first time in our lives, this has completely changed due to COVID-19. This is the first time in recent history that all of humanity has faced a common threat. However, for as much as it poses a threat, it also provides an opportunity. That opportunity is to find common ground through mutual effort and to ignore social, cultural and national differences so we can focus on the unifying experience of overcoming this crisis.
Dr. LeGoff is a licensed neuropsychologist with more than 25 years of clinical experience, having held many prestigious clinical and teaching positions at Ivy League universities and government and healthcare institutions nationwide. A world-renowned speaker, author and expert in personal development and cognitive behavioral therapy, Dr. LeGoff has conducted professional trainings worldwide.
IMCS – Integrated Medical Case Solutions – is the premier behavioral medicine network for pain and trauma response with evidence-based outcomes and a proven track record for transforming workers’ compensation cases. IMCS makes intervention efficient with a national network of 1,200+ psychologists and psychiatrists in all 50 states.