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PTSD during COVID-19

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HIV & Post-Traumatic Stress Disorder During COVID-19
September 18, 2020

Damir Huremovi, MD, MPPDirector of Psychiatry, North Shore University Hospital, Manhasset, NY
Assistant Professor, Department of Psychiatry,
Donald and Barbara Zucker School of Medicine
at Hofstra/Northwell, Uniondale, NY

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Disclosures
"This [project/publication/program/website] [is/was] supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,960,119 with xx percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government."

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Disclosures continued
Presenter does not have relationships to disclose
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Learning Objectives
Understand the current pandemic in the historical context
Recognize unique features of a pandemic as a disaster and as a traumatic experience
Identify logistical and emotional challenges associated with providing care during a pandemic
Recognize the role teams and individuals play in prevention of emotional distress and burnout
Utilize tools for fostering resilience and addressing traumatic stress

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Time lag - pandemic outbreaks have predictable epidemiological models that allow reasonable time for planning and preparation as the pandemic progresses.
Burden on caregivers - health workers in pandemic outbreaks are both at increased risk for infection and trauma.
Burden on facilities and healthcare system - facilities may transform from points of care to nodes of transmission.
Quarantine and isolation.
Psychiatric sequelae of surviving the illness, its complications, or complications associated with treatment.
Public perception, fears, expectations, and misconceptions result in a process that epidemiologically often mirrors the epidemiology of the infectious disease itself
Understanding pandemics: Features

A rapidly spreading outbreak of an infectious disease leaves little time to fully comprehend mental health aspects of such illness, yet its social impact may be immense.
Intermittent outbreaks of potentially deadly infections fan public interest to the point of mass hysteria, stirring up anxiety and uneasiness across continents, but quickly subside
In earlier stages of civilization, such events had been considered inevitable and a nuisance
Public emotional reactions develop its of pandemic course, yet
Out of sight out of mind

Rapidly spreading pandemics

PUBLIC INTEREST quickly wanes
Google Trends; search term coronavirus (2020)
Google Trends; search term COVID19 (2020)

Started in Wuhan (Hubei, China) in December 2019
Designated by WHO as a pandemic March 11
Affected nearly all countries in the world
30 million confirmed cases
Close to 1 million deaths

COVID-19 Pandemic

Registered in the US in January (Washington State)
Late Sept. approaching 7 million cases, over 200,000 fatalities
True case fatality ratio (CFR) unknown (initially assumed 2%, now 0.3%)
New York State 480,000 cases, over 33,000 fatalities
Metro NYC most of the cases in the state
15 percent require hospitalization
5 percent require ICU and ventilation
22.7% of the population have antibodies (NYC), 12.5% of health workers
Minority communities and disenfranchised populations disproportionately affected: seroprevalence 29% for Hispanics and 20% for AA in metro NYC
68 percent of population of Corona, Queens, have antibodies

COVID-19 Pandemic in the US

Last truly global pandemic took place a century ago (Spanish flu 1918-19)
Pandemics affected the course of history, likely affected the way modern psychiatry was shaped
Psychiatry, in turn, gave little consideration to mental health aspects of infectious diseases
Largely focused on infectious diseases that impose significant public health burden on the society (e.g. HIV or Hepatitis C), no interest in rapid outbreaks
Result? Fighting a 21st century outbreak with 19th century tools
Current knowledge is limited

"A comprehensive review of the literature yields no empirical studies addressing the behavioral or emotional consequences of [] pandemic influenza." (New Jersey Division of Mental Health Service, Disaster & Terrorism Branch brochure)
There is almost no data on the mental health impacts of outbreaks of disease. (Center for the Study of Traumatic Stress in its Mental Health and Behavioral Guidelines for Response to a Pandemic Flu Outbreak)
Like individuals, communities may be traumatized by both actual AND perceived exposure

Existing studies are scarce

People are unpredictable: research from 2004 ("Redefining Readiness") suggests that the general population may not react to a public health crisis in the manner anticipated by emergency management professionals.
Unanticipated behavior can complicate the management of a disaster situation and lead to higher rates of long-term mental health problems
Redefining Readiness (from 2004): Americans are twice more worried about smallpox vaccine than about contracting smallpox themselves (in an imagined scenario)
Existing studies are scary

"The concepts discussed in this program are considered evidence-informed assumptions about [] the likely emotional and behavioral responses to such events." (New Jersey Division of Mental Health Service, Disaster & Terrorism Branch brochure)
While there have been relatively few large outbreaks to inform an appropriate response to a potential pandemic [] flu, the existing data on infectious disease outbreaks, data from natural disasters, and public mental health principles can be brought to bear on the development of such a response. (Center for the Study of Traumatic Stress in its Mental Health and Behavioral Guidelines for Response to a Pandemic Flu Outbreak)

Existing guidelines are"best guesses"

Contagion is more than an epidemiological fact
It is also a foundational concept in the history of religion and society; with long history of explaining how beliefs circulate in social interactions
The outbreak narrative in its scientific, journalistic, and fictional incarnations follows a formulaic plot that begins with identification of an emerging infection, includes discussion of global networks throughout it travels, and chronicles the epidemiological work that ends with its containment.
Contagion as apsychological concept
Wald P. Contagious: cultures, carriers, and the outbreak narrative.
Durham, NC: Duke University Press, 2008.

Panic is related to the perception that there is a limited opportunity for escape, a high-risk of being injured or killed, or that help will only be available to the very first people who seek it.
Media likely play a role in public panic
Panic is unlikely in other disasters; panic is likely in a pandemic
Panic IS likely a pandemic

Panic in Pandemic

Timeline of panic during a pandemic
Panic In Pandemic

Individuals with pre-existing mental health issues may experience setbacks, relapses, and impairment of function
Patients with anxiety disorders may experience worsening of their symptoms (paradoxically may lead to proactive, protective behaviors)
With increased strain on the society, patients encounter obstacles to care (in case of travel bans or isolation)
With breakdown in social services during a severe pandemic, or during severe precautions, mental health system may fall apart - Liberia's only mental health hospital (E.S. Grant in Monrovia) closed in October 2014, with patients released in to the streets
There may be no specialized services for the increase in need (e.g. counseling for survivors or bereavement counseling for the relatives)
Effect of pandemic onexisting mental patients
Ebola's mental-health wounds linger in Africa, Reardon, S. Nature 519, 1314
(05 March 2015)

Approaching pandemic puts a strain on healthcare professionals
Their primary concerns are:
Increased workload
Safety of their families
Own safety
Anxiety among healthcare workers precedes that of general public
Healthcare workers may tend to UNDERESTIMATE and DOWNPLAY the seriousness of a pandemic
This changes if they have small children at home

Burden of a pandemicon healthcare personnel
Impact of the 2009 influenza A(H1N1) pandemic on public health workers in the Netherlands.
Vinck L et al; Euro Surveill. 2011 Feb 17;16(7). pii: 19793.

Preparing for a possible pandemic outbreak requires significant financial, material, and human resources
Shifting priorities may affect other aspects of care or other projects
Liaison with local authorities, local and state health departments and regulatory agencies becomes a priority
Education and training play a big role
Psychosocial and mental health component are often overlooked
There is never enough time

Burden of a pandemic on healthcare institutions

Lack of information and rumors tend to incite anxiety and panic
Shortages of various kind may take place
Major disruptions in society can happen in advancing pandemic
Different populations and cultures may have different ways of understanding the scope and the nature of the pandemic and idiosyncratic ways of preparing
Attitudes towards immunization come into play including safety and availability
Burden of a pandemic on communities

Patients in isolation can experience despair and hopelessness
Patients in isolation tend to receive less face time with providers than non-isolated patients
They perceive or are being stigmatized, even by the healthcare personnel
Intense suffering may serve as a foundation for trauma and PTSD
Mental health Issuesassociated with isolation

Some aspects of a pandemic and public health response may complicate grief and loss reactions:
Inability to see loved ones or say "good-bye" to those who may die in the hospital or while separated from family.
Inability to retrieve the body for timely burial or funeral rituals or to prepare and bury the deceased according to rituals
Inability to bury or dispose of the deceased altogether
Families of the deceased may be stigmatized as well
Families may be quarantined themselves
Mental Health issues inloss to epidemic

Quarantine, although practiced for centuries, has received surprisingly little attention in mental health literature.
Being quarantined imposes significant psychological, social, and economic toll on individuals and communities.
Prolonged isolation and separation from families and their community can have profound effect on quarantined individuals.
Quarantine in Toronto during SARS was associated with 30 percent rate of PTSD and depression.
Being quarantined can result in social stigma during and well after the isolation is over

Mental Health issuesassociated with Quarantine
SARS control and psychological effects of quarantine, Toronto, Canada.
Hawryluck L et al; Emerg Infect Dis. 2004 Jul;10(7):1206-12

Being in quarantine is associated with high degree of personal distress:
Loneliness and boredom
Social deprivation and loss of social utility
Loss of control
Anxiety and worry about own health and health of the loved ones
Irritability
Insomnia
Depression
Anger and acting out
Most likely to break or defy quarantine orders:
Teenagers and
Health workers

Mental Health issuesassociated with Quarantine

70 percent of health workers report increased workload during an epidemic
Anxiety about getting infected is NOT their primary concern
Healthcare workers DO get traumatized by caring for infected patients, with rates of PTSD among healthcare personnel reaching 20 percent during the 2003 SARS outbreak.
Anxiety about infection tends to subside over time
Families of healthcare workers are neglected

Effects of pandemic onHealthcare Workers
Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care
workers in a medium size regional general hospital in Singapore.
Chan AO et al. Occup Med (Lond). 2004 May;54(3):190-6

Anxiety in health workers is increased by:
Direct contact with infected patients
Having children at their household, and
Having doubts about the effectiveness of the personal protective equipment (PPE).
Having friends and relatives contract the infection may have deleterious effect on healthcare workers.
Having been quarantined or having worked on a high-risk unit has been associated with significantly higher rates of alcohol and substance abuse 3 years after SARS.

Effects of pandemic onHealthcare Workers
Impact of the 2009 influenza A(H1N1) pandemic on public health workers in the Netherlands.
Vinck L et al; Euro Surveill. 2011 Feb 17;16(7). pii: 19793.

Psychiatry of Pandemics
RECOMMENDATIONS

IDENTIFY

ISOLATE

IMMUNIZE

INFORM
Psychiatry of pandemics

Diminish the sense of loneliness
Acknowledge the implications and frustration
Provide support and reasonable hope
Provide timely and adequate information both about treatment and about outside events
Treat psychiatric complications:
Delirium
Insomnia
Depression
Anxiety
Facilitate virtual visitations from friends and families
Facilitate spiritual and cultural support
Care for Patientsin Isolation

Provide grief and loss counseling
If traditional burial is unavailable, help families explore alternative ways of getting closure
Be ready to address the shroud of stigma that may envelop families of the deceased
If quarantined, help them maintain reasonably optimistic attitude
Provide pharmacological intervention if situation calls for it
Support for the familiesof the Deceased

Acknowledge frustration, praise those who are quarantined for acting socially responsible
Help mitigate cost and losses incurred by quarantine (starting with food and basic supplies)
Help regain sense of control by allowing them make important decisions (e.g. whether to be quarantined at home, if possible)
Support attempts to establish structure and routine
Enable "work from quarantine" and "study from quarantine"

Support for quarantined individuals

Minimize loneliness and boredom
Actively address irritability, acting out, and breaking the quarantine
Treat psychiatric complications particularly anxiety and insomnia
Provide information about outside developments
Facilitate virtual visitations
Facilitate and monitor use of social media
Enlist charitable organizations and local community to help family members outside the quarantine
Support for quarantined individuals
Addressing Needs of Contacts of Ebola Patients During an Investigation of an Ebola Cluster in the United States Dallas, Texas, 2014 Smith, CL et al. MMWR, February 13, 2015 / 64(05);121-123

Hospitals and other health agencies are required to render and be able to execute emergency operations plans
No preparation plans for massive contagion outbreak, including:
Institutional/community isolation and quarantine, shelter-in-place
Bioterrorism
Vaccination hesitancy and other immunization issues
Vulnerable populations
Plans should be developed in collaboration with Nursing, Infectious Disease Departments, and with Public Health officials
(Development and) activation of contingency preparedness plan

Four areas were classified as important using factor analysis:
health and relationship with the family
relationship with friends/colleagues
work and
spirituality.
The areas for coping strategies were:
clear directives/precautionary measures
ability to give feedback to/obtain support from management
support from supervisors/colleagues
support from the family
ability to talk to someone and
religious convictions.
Support from supervisors/colleagues was a significant negative predictor for psychiatric symptoms and PTSD. Work and clear communication of directives/precautionary measures also helped reduce psychiatric symptoms.
Support for HealthCare Personnel
Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care
workers in a medium size regional general hospital in Singapore.
Chan AO et al. Occup Med (Lond). 2004 May;54(3):190-6

Support for healthcare personnel
Education and preparation are important
Leadership, structure, and clear delineation of duties and responsibilities are critical
Someone needs to care for caregivers
Burn-out prevention
Reasonable rest and relief of duties
If needed and possible, providing for the families of caregivers significantly relieves pressure and stress

Best Stress Prevention is NOT a Psychological Intervention
A number of organizational and logistical actions help reduce the risk for burnout and stress:
Organizational - Restructuring the staffing matrixand modifying schedules to address the increased workload while ensuring safety and limiting burden of emotional stress.
Organizational Redefining the workflow to minimize exposure and burnout risk and to allow the staff time off to rest and provide for their families.

Stress Prevention Organization and Logistics
Logistics - Optimizing safety-adequate and sufficient PPE, combined withcomprehensive and repeated training increases the confidence of the workforce that their personal safety will be maintained.
Logistics Maintaining safety - periodic health assessments to ensure physical well-being (e.g. testing and serological testing).
Logistics - Support beyond PPE(on site and off site) - providing adequate tools and equipment beyond PPE (e.g. medications, ventilators) so team can provide best available care (it minimizes the sense of helplessness, demoralization, and despair).

Stress Prevention - Communication
Clear and consistent communication of directives:
Explain the situation and the actions (what, why, and how)
Define individual team members' roles in the overall context
If changes why, and what goals and objectives are expected to be reached by changes in the approach. This minimizes uncertainty and ambivalence and strengthens the team approach.

Stress Prevention - Education
Leadership education on traumatic stress- team leaders should understand:
Basic concepts of emotional stress and distress
Changes in team members' behaviors, interactions, and performance that can signal distress and burnout.
Recognize maladaptive coping styles, including substance abuse.
Referral process when to refer, how to refer, where to refer

Stress Prevention - Education
Team education on emotional well-being:
Materials and resources on what healthcare workers might expect in the course of their duties, including:

The goal of such intervention is to foster hope and optimism while not denying risk.
Common stressors and
Common stress reactions
Patients
Colleagues
Family
Self

Stress Prevention - Support
Leadership support and availability:
Support from supervisors and colleagues is a significant protective factor in developing psychiatric symptoms and PTSD.
Ability of team members to give feedback to the leadership and be aware that they have a two-way communication
If they feel included, appreciated, and protected team members do not feel being left alone in the context of pervasive disruption and isolation.

Stress Prevention - Support
Peer support- ranks high as a positive experience and a factor that helps avoid traumatic stress.
Formal or informal peer groups/encounters are helpful. An example: a buddy system, pairing more and less experienced workers helps transfer skills, but also reducessocial isolation and promotes a sense of support and belonging.
Recruiting spiritual support- reaching out tofaith-basedcommunity to provide spiritual guidance

Stress Prevention - Support
Support for team members' families:
Help with child care or care for the elderly
Making sure that family members are safe and taken care of
Assisting with providing supplies
Identifying and addressing other needs
Allow team members to focus on their task at hand.

Stress Prevention Team Building
Team appreciation:
Programs promoting well-beingincorporating mindfulness and relaxation techniques.
Workforce resilience programs and self-care strategies.
Organizingstaff-appreciation events
Verbally and materially acknowledging ongoing teams' efforts

The Spectrum of Distress

Identifying Team Members at Risk
Always check with team members to see how they are doing!
Be mindful of events/stressors/losses in their life
Look for changes and departures from normal' self (in the same or opposite direction e.g. previously happy, now sullen)
Observe behavior, interactions, workflow, performance, adherence to safety measures
Try to identify coping skills (e.g. dark humor, venting out to peers, using substances).

Approaching a Team Member at Risk
Use what comes naturally to your style or:
Validate situation ("This outbreak has sure dragged on, and they said only a few weeks, huh?")
Normalize through self-disclosure ("It sure is taking a toll on my health, I've gained 10 lbs. Everyone seems to be gaining weight/losing hair".)
Inquire about individual's state ("How about you? How are you doing? What do you think of this?")
Follow up with coping questions ("How do you deal with this? What do you do to take the edge off?")

Approaching a Team Member (at Risk)
Identify stressors ("What is the most difficult thing for you?" or "What are you most concerned about?" or "What do you miss the most?")
Identify strengths and orientation towards the future ("What is the first thing you are going to do when this is over?" or "What are you most looking forward to after this?")
Allow the team member the time and space to talk be ready and willing to LISTEN
It is OK to ask: "Do you think you need help?"
What can we do to help?

Assisting a Team Member at Risk
Individuals under stress will need reminders to take care of their own health and limit potentially harmful behaviors.
Assigning a buddy, breaking down steps (with closer guidance or supervision), frequent checks
Discuss safety/performance/team cohesion issues or disruptions with the team member
Offer further assistance know where to refer
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Levels of Support for Team Members
Universal support
Apps
Webinars
Websites
Daily mindfulness
Yoga classes
Employee Discounts
Financial Support
Mini-Marts in cafeterias
Grocery delivery
Social Connectedness
Recognition program
Tranquility tents

Selective Support

Peer Support Individual/ Groups
Spiritual Care Services
24/7 Emotional support hotline

Indicated Support
Stress First Aid
EAP- short term counseling
Linkage to services within health system
Linkage to community services

Identification of at-risk individuals
Early treatment

Frequent and accurate updates are the best way to reduce panic and rumors (in case of bioterrorism, rumors can be intentionally spread)
Remind the community of reasonable measures of protection give detailed information on what precautions individuals can take
Inform what emergency supplies/kits may be needed
If social distancing is effective, it should be promoted
Set up a hotline and have the media announce the contact numbers to handle questions and concerns
Establish the time for next communication or announcement

Working with the Public

Identify communities at risk and provide appropriate attention (including language)
Identify at-risk population and provide additional information (in case of children, provide information to caregivers)
Give consideration to the elderly and medically compromised
Address the issue of stigma associated with infection, quarantine, and survival
Honor the memory and the sacrifice of the deceased
As the pandemic subsides, provide mental health surveillance

Helping Communities

National Academy of Medicine (NAM) Action Collaborative on Clinician Well-being and Resilience a list of strategies and resources to support the health and well-being of clinicians.
American Medical Association (AMA) Resource center including specific guidance for managing mental health needs during the pandemic.
American College of Physicians (ACP) COVID-19 guide including section dedicated to clinician well-being.
American Hospital Association (AHA) regularly updated resources for healthcare clinicians and staff including special COVID-19 section.
Mental Health Association (MHA) Online self-screening tools to evaluate emotional/psychological/psychiatric status.
Massachusetts General Hospital (MGH) Resilience training for healthcare workers: 3-session video course on building resiliency skills.
Academy for C-L Psychiatry (ACLP) COVID -19 Resource Center
COVID-19 RESOURCES FROM PROFESSIONAL GROUPS

Additional Resources
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Behavioral Health

Crisis Hotline - provides mental health services and emotional support for individuals going through crisis.
1-877-870-4683

NYS COVID-19 Emotional Support Helpline - helpline for people who are experiencing anxiety, stress and depression during the coronavirus emergency.
1-844-863-9314

Suicide Prevention Hotline - provides 24/7, free and confidential support for people in distress, prevention and crisis resources for individuals or their loved ones, and best practices for professionals.
1-800-273-TALK (8255)
https://suicidepreventionlifeline.org

Care for your Coronavirus Anxiety - resource toolkit for anxiety and mental health.
https://www.virusanxiety.com/

The Relational Center Online Support groups - schedule (based on PST hours) for free video chat support group; open to the public.
https://www.relationalcenter.org/onlinesupport/

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www.psychologytoday.com/us - provides information on Mental Health diseases, Personality Disorders, tips on personal growth, relationships & family life, database for mental health specialists and other services.

www.inclusivetherapists.com - provides a database of therapists, counselors, and services for underserved populations by providing access to culturally responsive care.

www.talkspace.com - provides an assessment tool to assist in choosing the appropriate therapist based on service needs and budget.

www.betterhelp.com - provides a counselor directory of licensed, trained, experienced, and accredited psychologists (PhD / PsyD), marriage and family therapists (MFT), clinical social workers (LCSW), or licensed professional counselors (LPC).
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Additional Resources