Shirah Vollmer MD

The Musings of Dr. Vollmer

COVID-19: Mentally Suffering: Before and During

Posted by Dr. Vollmer on April 18, 2020

Let’s talk about symptoms. Symptoms are a sign of the existence of something, especially of an undesirable situation. Examples of symptoms include not eating well, not sleeping well, apathy, and ruminative thinking. When mental symptoms cluster and persist, then psychiatrists sometimes suggest that a particular cluster of symptoms warrant a diagnosis of, for example, major depression, anxiety disorder, or obsessive compulsive disorder.

Symptoms are subjective. They are told to us by our patients. Mental health providers try to alleviate symptoms both pharmacologically, with our tool box from psychopharmacology and with our psychotherapeutic tool box which includes cognitive-behavioral therapy and insight oriented psychotherapy.

When symptoms are relieved, then the patient has more energy and more vitality. Generally speaking, the patient with manageable symptoms can engage with the world in a deeper and more meaningful way, through engaging in relationships and/or creative projects. There can be a fluidity to symptoms meaning that they come and go, depending on the general stressors of life, including health, economics, and family dynamics. Bouncing through these stressors challenges coping skills, and so patients learn to deal with unforeseen events to minimize symptom formation.

COVID-19 introduces multiple stressors at once, making it almost inevitable that prior symptoms will re-emerge and/or worsen. Coping skills are useful, but may be overwhelmed, making them only partially effective in symptom management.

Let’s first talk about the stressors which COVID-19 brings to our functioning status. First, there is the threat of disease, a potentially fatal disease. Life could be over in a short period of time. For a young, relatively healthy person, how do they face this new reality? Second, there is the threat of being a vector, transmitting this disease to one or more loved ones. For a person, who in general feels guilty for both conscious and unconscious reasons, this idea of being a vector, may simply be intolerable. Third, for many, there is the economic stress of no work and no opportunity to work, along with the uncertainty as to if/when work will return. This economic stress can lead to further guilt of not providing for a family, and thereby causing further feelings of guilt about causing harm to innocent others. Fifth, there is the social distancing, which for many means they cannot draw on the support of their children, their grandchildren, or their community. Yes, technology aids with helping folks feel connected to loved ones, but for some, not being able to hold their grandchild, for example, is a particularly painful reality which no technology can make better. The absence of touch in general, is another source of stress, which is poorly studied, but intuitively we know that touch is vital for a sense of well-being.

Now, let’s talk about how those with mental suffering, those with mental symptoms of distress before COVID-19 might be dealing with the pandemic. Essentially, prior symptoms are likely to worsen. For example, a person with obsessive compulsive disorder, who washes their hands frequently, could increase this compulsive behavior to the point where they cannot engage in any other activity, including not being able to sleep. Another example, a person with an eating disorder who is restricting eating in order to gain control over their life, will increase the restriction since life feels more out of control than it did before. A third example, a person with depression, who has fought a deep sense of apathy, might feel even more apathetic in the face of a safer at home mandate.

In other words, although COVID-19 might create new symptoms, the more likely outcome is that folks will experience an exacerbation of their pre-Covid-19 symptoms.

What does this mean for the primary care professional or for a loved one who is concerned for another? This means that general questions, such as “how are you doing in this pandemic” are ok, but might lead to a superficial/socially acceptable response. In that case, the follow-up question, needs to be, “I know in the past you have struggled with obsessive thinking, how is that going for you now?” This questions suggests deep understanding that Covid-19, although stressful for all of us, is going to hit each individual differently, and more specifically, it will hit each person in their vulnerable area, which means their area where they have exhibited symptoms previously.

If I could make a wish today, my wish would be for all primary care professionals to initiate contact with each patient to ask them how they are coping, and more specifically, to ask based on the history with the patient, knowing how they have previously coped with stress. If that wish was too grandiose, then my second wish is for all primary care professionals to initiate contact with each patient that they have ever prescribed a psychotropic drug, including anxiety medication, and sleep medication, and reach out to those patients inquiring about how they are coping during this time. In other words, do not wait for the patient to reach out to you. The initiating of contact would by itself be enormously therapeutic. The understanding of how they have coped in the past, and reminding them that you are concerned that their previous symptoms may now be worse, is also therapeutic. My third wish, given the constraints of time, is that for patients who reach out to primary care for mental health assistance, then there is a deep understanding that symptoms are likely to be prominent, and that understanding symptoms is the first step to take, before initiating symptoms management tools.

Let me conclude by reminding all the symptoms of distress that we need to look out for in our patients and our loved ones, with the reminder, that these symptoms were likely there before Covid-19, and now, might be much worse.

  • Feelings of numbness, disbelief, anxiety or fear.
  • Changes in appetite, energy, and activity levels.
  • Difficulty concentrating.
  • Difficulty sleeping or nightmares and upsetting thoughts and images.
  • Physical reactions, such as headaches, body pains, stomach problems, and skin rashes.
  • Worsening of chronic health problems.
  • Anger or short-temper.
  • Increased use of alcohol, tobacco, or other drugs.

Once these symptoms are identified, then please refer to podcast 6, about referring for online mental heath care. The take-away point for today is that mental health symptoms during Covid 19 are most likely previous symptoms that were previously well-managed but are now sprouting again. Covid 19 is an unprecedented experience in our lifetime, and yet, old-school principles of helping others with mental suffering still apply. That is, understanding symptoms in context, both past and present, is the key to a good provider/patient relationship, and thereby to alleviating suffering.

4 Responses to “COVID-19: Mentally Suffering: Before and During”

  1. Shelly Tannenbaum said

    Wonderful explanation, Shirah. I like how you explain that what we are feeling–this loss of control over the environment and our futures, economics, social distancing, etc. causes strain on all of us. What I wonder, though, is if PCPs will take up the challenge and will be in contact with their patients to see how they’re doing, especially since this is non-billable time, and it basically is opening up many a Pandora’s box? Your wish is a lovely one, and in a perfect world, I’m sure all PCPs would do so. But after speaking to several internists, the last thing they want to do is call patients.

    • Yes, Shelly…I agree that in the short-term this is money losing endeavor, to reach out to patients with unclear reimbursement for such encounters. However, with the long view, this reaching out would create a stronger clinician/patient bond and as such build a loyal practice. I know a loyal practice is an old school notion, in that if insurance is employer-based, when someone loses their insurance they may not be able to follow up with their trusted clinician, and so consequently, there is little incentive for the clinician to build loyalty. On the other hand, that kind of reaching out by clinicians builds job satisfaction and mitigates against burn out, so each clinician must weigh the short-term pain vs. the long-term gain. I agree that clinicians have children and parents to care for, and so adding an extra burden to them may seem unfair and insensitive. At the same time, many clinicians are bored at work since patients are staying away for fear of contracting the virus and so maybe reaching out to patients is a good use of their time. I would think so, but higher management would have to support that. Thanks, as always.

      • Shelly Tannenbaum said

        Thanks for your thoughts on the matter. At least where I live, it is the opposite: PCPs are calling us up NOT to come in once we book appointments, asking us if “our visits are really necessary, and can we delay the appointment for another few weeks.” I think it would be wonderful to have our physicians calling us to see how we’re doing…; again, after speaking to some general practitioners (and not psychiatrists, of course!) they aren’t looking for extra phone time after work hours. You are definitely right, though about building up the loyalty factor.

        • Hi Shel…yes, the model of care is fire-setting and not relationship building…that of course makes me sad on two levels. First, patient care is compromised and second, the job of the physician seems less satisfying to me. Medicine with Covid-19 is undergoing another transition, one which no one quite understands yet. In general, there is a move towards automation and eliminating in-person visits, whenever possible. This might be efficient, and cost-effective, but again, not as rewarding for the patient or provider. I wonder who is checking on people these days? Is this the job of religious leaders, and if so, what if one is not religious. Who checks on them? Family members, maybe, but not everyone has a loving family. We all need people to check on us. Physicians were a secular group who could serve that role, no matter what the crisis. Sadly, as you say, that role is no longer viable in a busy practice with too many demands. Thanks, as always.

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