Written by Anna D. Bartuska, Arielle Eagan, MSW, LICSW, and Juliana Lynn Restivo, MPH
“Our minds rely on certainty and predictability of future events to be able to plan how to spend one’s time, and clearly this is exactly what has been turned upside down.”
– Vikram Patel, MBBS, PhD
The COVID-19 crisis is characterized by uncertainty. It began with uncertainty about the virus itself, where it originated, how it spread, and who was most vulnerable. Then came the uncertainty about which countries would be affected and how health systems would respond. Researchers within our community and around the world have worked rapidly to provide answers. Government officials have mobilized containment and mitigation efforts by implementing policies, allocating funds, and distributing resources. Within our Boston community, healthcare leadership has gone to great lengths to provide guidance and implement emergency preparedness plans. Yet, the current pandemic has brought forth an acute but increasingly chronic uncertainty that is rippling throughout the different domains of our lives.
Events have been cancelled, schools have been closed, and business have shut their doors. Individuals, companies, and cities are being asked to make life-altering changes to everyday activities, often with little notice and little time for preparation. At this point, we don’t have a clear idea of how long this new rhythm of life will last and what is still in store. In the haze, fear abounds. Fear is biologically adaptive. In response to threat, fear increases alertness and arousal needed to ensure survival. In this time of continued and almost overwhelming uncertainty though, the dampening effect of the prefrontal cortex is hindered and initial fear may become impairing anxiety. Dr. Karestan Koenen, a trauma expert and professor of psychiatry epidemiology at Harvard T.H. Chan School of Public Health, said simply, “uncertainty and lack of control are the two key drivers of stress. And we know that stress is related to increased anxiety and depression, particularly among people who are vulnerable.” As professionals and individuals interested in the mental health of our global community, it is understandable that uncertainty related anxiety is being felt by all to some degree – regardless of whether you would personally identify as having a history of mental illness or not.
The mental health impact of this pandemic has been universal. Dr. Shekhar Saxena, Professor of Global Mental Health Practice at Harvard T.H. School of Public Health shared with the World Happiness Fest’s webinar that the threat of this pandemic to the happiness and well-being of people is broader than initial estimates from the World Health Organization (WHO) and other agencies, whose samples were limited to individuals who tested positive for COVID-19 or were previously sick. Excluded from these reports are billions of people who are exposed to the escalating crisis through both factual and inaccurate reports they receive from the radio, TV, family, friends, employers and through social media. Dr. Laura Kubzansky, Professor of Social and Behavioral Sciences and Co-Director of the Lee Kum Sheung Center for Health and Happiness at the Harvard T.H. Chan School of Public Health, reflected on this universality “I have been struck by how unique in some ways this particular crisis is, from many of the disasters we are used to managing – the fact that everyone is affected, there is no safe place anywhere in the world, means there is no one with extra bandwidth that can be called upon to provide reserve capacity for empathy and assistance in ways large and small; and also there is no safety net.” With typical patterns of coping disrupted, access to psychological support further challenged, and stressors ever-present, many are left wondering what can be done to foster mental and emotional wellbeing.
Now, more than ever, preventative and protective measures for mental health are paramount to the pandemic response. To gain insight as to what we can do as individuals, communities, and systems to address mental health during these unprecedented times, we reached out to experts within our community. Our desire is for the information below to provide some preliminary guidance regarding mental health in the context of the current pandemic and how we can care for our communities, our loved ones, our patients, and ourselves while facing uncertainty.
“We need to get the word out about prevention, positive coping, things people can do for themselves or in their families that help support their own mental health. We can be proactive.” – Karestan Koenen, PhD
1. Stay Connected
As new guidelines and policies enforcing social distancing are released, it is important to remember that we are not emotionally alone. As Professor Shekhar Saxena shared on Twitter “Social Distancing may send a wrong message for some people. We should recommend Physical Distancing. Social interactions and social support are even more necessary during these times of stress”. Staying connected with colleagues, co-workers, friends, and family members is critical to the mental health of all, but particularly paramount for vulnerable populations including elderly, individuals living alone, and individuals with prior mental illness. Dr. Koenen encourages individuals and groups to “think proactively about people in your community, who may be living alone and be isolated, or become isolated and make plans to connect.” Planning could include scheduling check-in calls (both video and voice) with isolated colleagues, providing food for elderly neighbors, or regularly reaching out to family who struggle with emotional distress.
2. Learn from One Another
In this era of technology, connection is no longer constrained by physical proximity. During the course of the COVID-19 outbreak, digital connection has provided the opportunity to learn from our colleagues around the world. Dr. Koenen mentioned how email correspondence with her colleagues in Italy and China revealed fruitful mental health efforts that have been conducted in both regions. For example, psychosocial hotlines were quickly established in Italy and China to support individuals experiencing acute and impairing levels of stress, depression, and anxiety. Collective efforts, including government and healthcare response, to develop and disseminate information about mental health during the epidemic have resulted in numerous new self-help books, videos, pamphlets, and online-courses. In the United States, the Department of Mental Health is working to adapt the current system and considering novel uses of technology to maintain and strengthen psychological supports. Yet, Dr. Koenen and colleagues reiterate that a significant need still exists for the dissemination of tools to help individuals deal with stress, manage anxiety, and determine when to seek additional help as the number of people emotionally effected by COVID-19 continues to rise.
3. Disseminate Evidence-Based Mental Health Strategies
Experts across our community have already begun to create materials to equip individuals and communities with the information and skills to increase mental and emotional wellbeing. Efforts from Dr. Koenen and her team have culminated in live webinars with over 100 attendees interested in discussing mental health in the context of the COVID19 crisis. These webinars will now be weekly starting March 18th, more information can be found here. Dr. Koenen also emphasized the need for open-source materials with specific evidence-based skills that individuals can learn and use during this time. She noted that Harvard Medical School is producing a webinar series developed with Dr. Luana Marques, a clinical psychologist at Massachusetts General Hospital and associate professor at Harvard Medical School, to equip viewers with cognitive-behavioral skills to regulate emotions and build resilience during the current outbreak. Dr. Giuseppe Raviola, Associate Director of The Chester M. Pierce, MD Global Psychiatry Division, Massachusetts General Hospital and Director of Mental Health at Partners In Health, along with feedback from his patients, developed a list of practices that can be applied to ourselves and easily disseminated to help others to gain steady emotional footing through this time (see box titled Managing “Acute on Chronic Uncertainty”). Dissemination will be an even more difficult and crucial task for many low-resource settings in high-, middle-, and low-income countries where the economic, physical health, and mental health repercussions of this pandemic will likely be felt for a long time.
4. Seek the Silver Linings
As the current pandemic evolves, our experts remind us that this new socially distant phase, although trying, is lined with potential positives.
Extraordinary support. We have already seen healthcare workers, neighbors, and communities come together to support one another. Italy has cast a beautiful picture of coming together with a ‘flash mob’ of balcony musical performances. Throughout Boston, our hospital and community-based services are scaling up and adapting to ensure that mental health and psychosocial support for patients, both those facing COVID-19 and those with unrelated health and social needs, are not left behind in this period. Arielle Eagan, one of the authors of this piece, shares her experience as a Clinical Social Worker in a Boston-based hospital this week “While COVID-19 is a critical focus right now, patients’ pre-existing and comorbid health and psychosocial needs still need to be assessed, met, and prioritized as we react to COVID-19. These needs include other acute and chronic medical needs (such as stroke, cancer, or accidental trauma), acute psychiatric illness, substance use and addiction, domestic violence, child protection concerns, homelessness, etc. As social workers in the emergency department and throughout the hospital, we are trying to support our interdisciplinary colleagues in making sure that these needs aren’t forgotten while also supporting our patients and families facing COVID-19”.
Revolutionary work. “If 2007 was the year of the iPhone, it may be that in 2020 that much of the professional world, the world of education, and the world of healthcare, including mental health care, goes virtual” comments Giuseppe Raviola, MD, MPH as this unprecedented shift to virtual and remote work has required adaptation to novel work environments and healthcare delivery systems. Clinicians across the globe have transitioned their practice to digital and telehealth platforms. Prior to the outbreak, technology had been gaining increased recognition as a critical and effective tool for increasing access to mental health care and support, yet, many providers continued to solely offer in-person care. The necessitated development of online materials and digital platforms has catalyzed innovation and learning to support future technology-assisted mental health care. Harvard T.H. Chan School of Public Health has also just announced a collaboration with Thrive Global to launch The Health and Wellness For All Program. This evidence-based digital behavior change program will be a resource that acknowledges the challenging realities in which public health workers are operating but help them navigate them with less stress and more resilience. The programs will focus on ways to improve the mental and physical well-being including a focus on sleep, naps, movement, nutrition, stress management, and relationships with colleagues through this time.
New opportunities. For many, the idea of working from home was a distant and unrealizable reality, and the sudden shift out of some people’s normal work routines has disrupted well-established practices. Yet, without commuting to in-person offices, time saved is ripe for new rhythms of living. As Professor Vikram Patel, Pershing Square Professor Global Health in the Department of Global Health and Social Medicine, Harvard Medical School states, “we should start planning to spend this bonus time with our kids, dogs or garden, writing that chapter or book we have so long ignored, take a walk along the river every day, enjoy the unique pleasure of a siesta and test our culinary skills. It’s time to hunker down, slow up one’s routines, and spend time doing the simple things which matter to you. That’s what I plan to do!”. For those individuals who have shifted to remote schedules, this may provide the opportunity to engage in healthy and meaningful activities that frequently get sidelined during typical work-life rhythms.
Finally, as we orient ourselves to new norms that this period will bring, let’s pause and remind ourselves about the importance of self-care. Both for those of us who are frontline—continuing to work in hospitals, psychiatric urgent care centers, crisis response teams, and beyond—as well as for those of us who are shifting to new, innovative forms of remote support, healthy mental health strategies are imperative. Preemptive response includes each one of us, our households, and our communities.
The threat is real. The challenge is real. But as a community and as individuals, we also have a real opportunity to be proactive about mental health. In order to care for others and be there to support the mental health and wellbeing our communities, we have to be sure that we are taking care of ourselves. We are facing truly remarkable times that warrant a remarkable response now and in the future.
“Try to see this time in your life as a different period with a different rhythm, not necessarily a bad one even though you didn’t choose it” – Karestan Koenen, PhD sharing advice from a colleague in Italy
Authors:
Anna D. Bartuska, Program Coordinator, Community Psychiatry PRIDE, Massachusetts General Hospital
Arielle Eagan, MSW, LICSW, Associate, Department of Global Health and Social Medicine, Harvard Medical School; Clinical Social Worker, Tufts Medical Center
Juliana Lynn Restivo, MPH, Program Coordinator, GlobalMentalHealth@Harvard Initiative, Department of Global Health and Social Medicine, Harvard Medical School
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