The ongoing public health crisis has impacted every aspect of our lives. From the staggering case counts to dire economic situations, COVID-19's impact is widespread and all-encompassing. The amalgamation of COVID-19 and its effects on our communities leads to another crisis: deteriorating mental wellbeing.
According to the National Alliance on Mental Illness (NAMI) Texas, around one in five Texans were struggling with mental illness before the pandemic. Now, that number is closer to two in five. JPS Health Network in Fort Worth has seen a 30% increase in behavioral health outpatient services. Texas Children's Hospital in Houston has seen an onslaught of suicidal ideation in the kids coming through their doors.
Texans are experiencing increased levels of isolation and grief stemming from the pandemic. COVID-19 is leading to anxiety, depression, drug and alcohol use and insomnia. In a July 2020 survey of over 5,000 people by the Journal of the American Medical Association, 40.9% reported at least one adverse mental health condition. Even more severe, 10.7% reported seriously considering suiciding within the last 30 days.
There are numerous aspects of COVID-19 that are having negative impacts on mental health. Alan Podawiltz, M.D., chair of behavioral health at JPS Health Network says that the most significant issues stem from quarantine, financial stress, fear of illness, self-esteem damages, alcohol and substance use and a lack of awareness that they are even facing a mental illness.
"I'm most concerned about those who may have never experienced depression and overwhelming anxiety and are not seeking help soon enough, resulting in catastrophic consequences. People not knowing what is wrong with them or knowing to seek help are more likely to commit suicide due to their pressures. At another level is anxiety, and the associated irritability that may come with can create significant conflict within the family, sometimes resulting in domestic violence," said Dr. Podawiltz.
Mental health symptoms accumulate over time. A patient may start with mild anxiety and depression, but the longer it goes untreated, the worse it tends to become. "Because of how pervasive COVID-19 is in our lives, the trauma associated with the illness and the unknowing of how long this will last, I worry about people's mental health getting progressively worse over time," said Greg Hansch, LMSW, executive director of NAMI Texas.
Hansch said what worries him the most is that we currently don't have the infrastructure needed to care for the rapid uptick in patients needing mental health treatment. That's why early intervention measures are crucial.
"We work to close gaps in mental health care access by doing outreach within the communities we serve. We know that certain populations are impacted disproportionality – younger adults, minority communities, essential workers – these are the groups that we need to invest in," said Hansch.
The advent of telehealth has been critical to mental health providers across the state. Since two-thirds of Texas' counties don't have a licensed psychiatrist, NAMI Texas has been using telehealth and plans on making it a big part of their strategy going forward. "Giving people access to behavioral health services remotely can be a game-changer for rural communities," said Hansch.
JPS Health has made it a point to provide telehealth services – both in in-patient delivery of service and subsequent follow-up visits. "Mental illness is chronic; patients need routine follow-ups. With over 25,000 patients, telehealth became the only strategy to provide those individuals with care. We prioritized the purchase of telehealth equipment. We now have a solid telepsychiatry service," said Dr. Padowiltz.
Kids are Facing Emotional Distress
Children have been hard hit by the pandemic's mental health impact as well. According to a study from the Centers for Disease Control and Prevention, disruptions in daily life during the COVID-19 pandemic, anxiety about getting sick and social isolation takes a toll on children's mental health.
According to Stephanie Chapman, Ph.D., a psychologist at Texas Children's Hospital's Center for Women and Children, anxiety and depression have been the most common pediatric mental health diagnoses since the onset of the pandemic. She attributes this to the isolation and inactivity that came along with COVID-19. "We’re seeing kids, who maybe had anxious temperaments, but suddenly have developed full-blown panic disorders and agoraphobia. There is much emotional distress among our patient population,” said Dr. Chapman.
In March of 2020, UT Health’s McGovern Medical School in Houston developed Texas Child Health Access Through Telemedicine or TCHATT. Knowing that pediatric mental health would be a big issue throughout the COVID-19 pandemic, program leaders quickly reworked and adjusted the program to accommodate this new normal.
TCHATT connects kids to mental health resources through the public school system in Houston and surrounding communities. According to Elizabeth Newlin, M.D., vice chair for child and adolescent psychiatry at the McGovern Medical School at UTHealth, the program is still seeing an uptick in referrals – even with remote learning.
Dr. Newlin attributes an increased number of referrals for anxiety and depression to quarantine and social distancing measures. “The early data shows that it’s not good for young people to be quarantined. Adolescents need to be broadening and building relationships with their peers. They’re learning who they are. Being a full-time virtual student and not having that socialization is hard on them,” said Dr. Newlin.
Studies show that children do best with structure and routine. It creates security and promotes healthy behaviors. COVID-19 has disrupted these routines for many families. Whether kids are doing all their learning virtual or going to class in-person sporting masks and skipping recess – things have changed. Many schools have cut out extracurriculars and PE classes for in-person learners. Dr. Chapman says that this lack of exercise and sunlight also harms a kid’s general wellbeing.
Even more troubling than an increase in depressive and anxious episodes, a CDC survey found that one in four young Americans said they had considered committing suicide. The survey also showed a dramatic rise in emergency department visits for pediatric mental health.
Dr. Chapman echoed the CDC study, saying that she, too, has noticed an increase in pediatric mental health ED visits and kids with suicide risk factors. “We are seeing increased rates of suicidal ideations and attempts,” she said.
TCHATT works to catch mental illnesses before they become so severe that they escalate and require a trip to the ED. Dr. Newlin says that it’s not uncommon for pediatric mental illness to go untreated for long periods. “The average delay between onset of symptoms and treatment is 11 years. And this is despite knowing that early identification and intervention of mental health concerns can dramatically improve academic performance, social skills and quality of life,” she said.
When asked if TCHATT has helped keep kids from taking trips to the ED, Dr. Newlin said she believes it has. “Our clinical experience tells us that there have been cases referred to us that we know it’s an excellent thing that we got to this kid when we did. They were right at that point where if intervention did not happen, it would have been a bad outcome,” she said.
Without early identification and intervention, the potential of long-term, adverse mental health impacts from the persistent stress and trauma created by COVID-19 is severe for Texas’ youth. These impacts could be even more detrimental for kids who are already at-risk for mental illness.
“I worry about kids with developmental delays, young children with autism who are missing out on speech and occupational therapy. We know that elementary-aged kids’ brains are at a critical stage. These disruptions might cause delays in their entire developmental trajectory,” said Dr. Chapman.
Dr. Chapman also expresses concerns about teenagers falling behind academically, obesity due to disruptions in school nutrition services and ongoing mental health issues. A year of chronic, untreated anxiety and depression can change how a child’s cognitive and emotional functioning develops, according to Dr. Chapman.
Dr. Newlin says that adults in children’s lives can play a significant role in mitigating the long-term mental health impacts of COVID-19. “Adults – whether it be parents, teachers or mental health professionals – need to help kids make sense of these experiences and help them have a lens through which they can view it that allows it not to be devastating,” she said.
Caring for Our Care Givers
We can’t underestimate the toll that COVID-19 has taken on those on the frontlines. Physician burnout has been a growing problem for several years; the pandemic has only made it worse. Almost 64% of the U.S. physicians surveyed by Medscape this year said the pandemic had intensified their sense of burnout.
Addressing caregiver burnout is essential not only for the hospital staff's wellbeing but also for providing optimal patient care. When doctors or nurses feel stressed, overwhelmed or burnt out, they can’t respond to challenges and care for patients as well as they usually would.
“We have to understand that this is a unique, unprecedented challenge in our lifetimes. COVID-19 brings significant stressors and is perhaps the greatest challenge in our careers. But we must be absolutely at our best to provide care for our communities,” said David Callender, M.D., CEO at Memorial Hermann Health System in Houston.
Bita Kash, Ph.D., FACHE, is a professor of health and policy management at Texas A&M University’s School of Public Health. She also serves as the director of the Houston Methodist Research Institute. Dr. Kash has been studying physician burnout for a number of years. “Physician and nurse burnout, especially in the ICU, was already there before COVID-19,” she said.
In 2017, Dr. Kash and a team of researchers began studying sources of stress, fatigue and burnout in the ICU. The innovative study looks at three different data collection sources; glasses that show what the subject is seeing, a wearable device that measures heart rate and self-reporting of stress. When the COVID-19 pandemic hit in 2020, they were well prepared to continue their studies at Houston Methodist.
“A major issue going into the pandemic was that our essential workers were already burnt out. COVID-19 led to higher workloads, more patient mortality and often a lack of personal protection equipment. The pandemic also added a new stressor – worry about spreading the illness to their families,” said Dr. Kash.
Memorial Hermann knew early on that it would be crucial to implement programs to ensure employees' mental wellness. “This battle is going to go on for some time. We came up with additional forms of support for our staff. We already had assistance programs in place, but we needed to do more,” said Dr. Callender.
Dr. Callender stresses the importance of taking a proactive approach instead of waiting for employees to realize that they are struggling. At the onset of the pandemic, Memorial Hermann launched a program to help its employees tackle the stress of working during the era of COVID-19.
A big part of the support program is having teams of chaplains, social workers and other mental health professionals moving around to different units to identify staff members who may be struggling. These teams can respond to calls for help, offer encouragement, boost morale and reduce stress.
“We all need to look out for each other. When we have a challenge with a patient, we call for help. As physicians and nurses, we need to do the same if we see that one or more of us are facing significant stresses. We need to know that it’s okay to ask for help,” said Dr. Callender.
It’s Okay to Not Be Okay
The unique thing about the COVID-19 pandemic is that everyone is going through it together. People all over the globe are facing the same struggles and often being more open about it.
As we begin to treat the pandemic's mental health side effects, it’s clear that we need to expand access to behavioral health services. It’s particularly critical that we focus on preventative and outpatient treatment.
Hospitals are not alone in treating the side effects of this pandemic. Nobody is alone in their feelings of depression, anxiety and general hopelessness. Mental health is fundamental to our overall health and wellbeing, and Texas hospitals are working to continue treating patients, both body and mind.