The COVID-19 pandemic has introduced a number of new stressors and challenges to individuals and communities. Necessary infection control actions (such as physical distancing, quarantine, and isolation) can be stressful and psychologically impactful. Mitigation of harm in the context of pandemic response requires attention to the psychological needs of populations, families, and individuals (CDC).
Particular attention to the stressors of quarantine is warranted at a time when a very large portion of the global population is under quarantine. Quarantine of 10 days or longer is considered long-duration and is particularly stressful (adapted from Brooks et al).
Stressors associated with quarantine can include:
- Frustration, boredom, and loneliness
- Inadequate supplies and access to regular medical care
- Insufficient information
- Fears about becoming infected and/or infecting others
- Financial loss and socioeconomic distress
- Stigmatization and rejection from family, neighbors, co-workers or friends
- Challenges of resuming one’s “normal” routine
Updated Date: August, 2020
Literature Review (Anxiety and Depression): Gallery View, Grid View
Literature Review (Trauma and Stress- Related Disorders): Gallery View, Grid View
Literature Review (Psychosis): Gallery View, Grid View
Literature Review (Suicide): Gallery View, Grid View
Anxiety and PTSD are significant risks for patients with COVID infection. Meta-analyis of psychological studies on survivors of Middle-East Respiratory Syndrome (MERS) and previous SARS outbreaks has indicated a PTSD prevalence of over 30% (Rogers et al). As of November 2020, Lanzhou University researchers have established a living systematic review for accurate ongoing study on prevalence of PTSD and other mental health disorders in COVID patients (Shi et al).
See treatments for Nonpharmacologic and Pharmacologic Management of acute anxiety
Updated Date: August, 2020
In the United States, prevalence of self-reported depression in adults was four times higher at the end of June, 2020, than it was in the second quarter of 2019 (Czeisler et al). Symptoms of depression can include a dysphoric (unhappy) mood, difficulty concentrating, social withdrawal, disrupted sleep, decreased appetite, fatigue, tearfulness, and a sense of worthlessness, hopelessness, and helplessness.
Non-Pharmacologic interventions for Depression: see Coping and Support Strategies.
Tool: Supportive Resources (Hotlines, therapy resources, and mindfulness/CBT Training)
Pharmacologic interventions for Depression: Continue home medication regimen if one is in place. Starting a Selective Serotonin Reuptake Inhibitor (SSRI) may help, but will likely take six weeks to take effect. For depression with sleep disruption and low appetite, mirtazapine 7.5 milligrams is a good choice.
Clinicians have anecdotally noted significant changes in patients’ drinking habits during the pandemic in association with the stresses of isolation, with increased risk of relapse and dysfunctional drinking. Survey data in the United States indicated a 14% general increase in frequency of alcohol use above baseline levels, with a 41% increase in days of heavy drinking specifically in women (Pollard et al).
Alcohol Withdrawal: For unsupervised mild to moderate withdrawal, consider use of anticonvulsant medications such as gabapentin, topiramate or carbamazepine (SAMHSA Guidelines) or a short course of benzodiazepines.
If clinically appropriate for a COVID-19 positive inpatient, a scheduled benzodiazepine or phenobarbital taper may be preferable to a protocol requiring frequent assessment and administration of benzodiazepines (which is often more labor-intensive for the nursing team, requiring more PPE use and close patient contact for appropriate monitoring)
- Instead of scoring-based systems (e.g CIWA), consider less-frequent as needed or scheduled benzodiazepine tapers
- Consider phenobarbital load/taper if familiar, as this requires less frequent monitoring in most cases.
Updated Date: August, 2020
If opioid replacement therapy is available for addiction treatment in your practice location, make all efforts in accordance with local guidelines to prevent the pandemic from disrupting patient access to these medications.
The Harm Reduction Coalition has created a tip sheet for adapting services which can be viewed here. Recommendations include equipping program participants with extra supplies, if available (such as the overdose rescue medication Naloxone), and considering 1-month prescriptions for patients who are taking buprenorphine. In the USA the United States Drug Enforcement Administration (DEA) has changed guidelines during the pandemic to help reduce interruptions in care (Covid-19 Info Page).
Buprenorphine in the USA: Practitioners who prescribe buprenorphine are now able to prescribe it to new patients with opioid use for maintenance treatment or detoxification treatment following an evaluation via telephone voice calls, without first performing an in-person or telemedicine evaluation, if deemed clinically appropriate and safe.
(US-centric, but some are more widely available)
- Online Alcoholics Anonymous (AA) Groups (Link)
- Dharma Online Meetings (Link)
- In the Rooms Online Support (Link) - A global recovery online community
- Al-Anon Online Meetings (Link) - Al-Anon is an organization for anyone who is affected by alcoholism in a family member or friend. Utilizes Twelve Step principles.
- Virtual Narcotics Anonymous (NA) Groups: (Online) or (Phone)
- Marijuana Anonymous Online Meetings (Link)
- Smart Recovery Online Meetings (Link)
- Tools for Smoking Cessation (Link)
- Herren Project (Link) - Meetings 7 nights per week at 7:30 PM EDT via Zoom platform for a peer support based live online recover meeting. Each meeting begins with a speaker, followed by fellowship and sharing.
- Connections - Free smartphone app for sobriety (Link) - features include sobriety tracking, access to e-therapy, messaging with trained counselors and peers, journaling, resource library including videos and testimonials
Literature Review: Gallery View, Grid View
Tool: The REMAP Framework. Reframe, Expect Emotion, Map Values, Align, Propose Plan (Childers et al)
Tool: Hospital Medicine #1: Goals of Care & Code Status (goals consistent with intubation)
Tool: Hospital Medicine #2: Goals of Care & Code Status (goals not consistent with intubation)
Tool: ED #1: Goals of Care & Code Status (goals not c/w intubation)
Tool: Experts at VitalTalk have created a COVID-19 Communication Guide. See also: Suggested Language for COVID-19 scenarios
Tool: Essential Package for Palliative Care (Medications, Equipment, Locations, Personnel).
Palliative care is ethically imperative care focused on prevention and relief of suffering of adult and pediatric patients and their families facing life-threatening illnesses, including COVD-19. Palliative care, including relief of symptoms and provision of psychosocial support, should be available to all patients with COVID-19 at all stages of illness.
Caretakers and family members should be given access to adequate training in caregiving and infection control and to appropriate personal protective equipment. They should have access to the same psychological, social and spiritual care as patients, and also bereavement support.
Oxygen and/or a fan on the patient’s face can decrease sensation of dyspnea
If pulmonary edema also may be present, consider furosemide. If the patient also may have COPD or asthma, use bronchodilators and consider steroids.
Respiratory Secretions at End of Life
Communicate with families to expect sounds. Reassure them that although the “rattling” sound is distressing to hear, the patient is not experiencing difficulty breathing or having to clear phlegm from their throat.
See here for guidance on respiratory secretions that are troubling for the patient
For mild pain: paracetamol/acetaminophen or other non-opioid agents
For moderate or severe pain: Opioid Agents
Nausea / Vomiting
Consider and treat other causes such as gastritis, constipation or anxiety
If pharmacologic treatment is needed, there are many options.
Haloperidol can be used if other drugs are not available or ineffective
Can be caused by slow transit due to opioid, anticholinergic medicines, immobility, volume depletion. Treat these first.
Some options include bisacodyl 5 – 10mg orally QD – BID or Lactulose 15 – 30ml orally QD - BID
Most common cause in patients with COVID-19 is dyspnea. Anxiety usually resolves when dyspnea resolves or is adequately relieved (see above)
If treating dyspnea is not adequate, there are many other options.
Delirium & Agitation
Use the Confusion Assessment Method (CAM) to help diagnose. Consider placing patient in a quiet location, frequent re-orientation, promoting normal sleep-wake cycles.
Pharmacologic management is covered in Delirium (including terminal delirium). Avoid benzodiazepines in most circumstances.
Tool: Pallicovid.app for one-page guides, pocket cards, nursing resources, and related information.
Signs and symptoms of imminent death include:
- Warmth, and later cooling and mottling of extremities
- Change in respiratory pattern, intermittent apnea, Cheyne-Stokes pattern
- Gurgling sounds from oropharynx (often more distressing to family than patient)
- Should follow the guidelines provided in sections above
- See common questions from families and general Principles of Communication
- ICU Conversation #1: Sharing concern illness may get worse
- ICU Conversation #2: Discussing Illness getting worse/GOC
- ICU Conversation #3: Talking about Dying
In some settings there is a legal and social framework for cessation of ventilator support if families prefer it or if it is no longer in the patient’s best interest. If this is pursued, for staff and visitor safety, we do not recommend physical extubation, but rather patient should be weaned down to PSV 0/0 with FiO2 0.21 to maintain a closed circuit
Tool: Ventilator withdrawal protocol: Von Gunten and Weissman, Palliative Care Fast Fact 33
Tool: Palliative sedation: Salacz and Weissman, Palliative Care Fast Fact 106
Assess Understanding & Delivering Information
Key Skill: Pairing hope and worry (Jackson et al).
E.g. “I hope you will improve AND I am also worried because your oxygen level is getting worse.”
Updated Date: December 20, 2020
Capacity is an essential part of consent and the process of decision-making. The evaluation of capacity is decision-specific and time-specific, and involves a need to balance autonomy and beneficence. A capacity assessment can be completed by any physician. There are four decision-making abilities that patients must demonstrate in order to have decision-making capacity:
- Ability to understand relevant information
- Patient must be able to understand basic information about their current condition, possible options, and risks/benefits associated with these options
- Ability to understand the situation and its consequences
- This is the ability to recognize how the information provided by medical professionals is related to one’s own situation
- Ability to reason
- Ask the patient to describe how they reached their decision, and which factors influenced this decision-making process
- Ability to communicate and express a consistent choice
“Competency” is a legal status based on a global assessment of a patient’s ability to perform actions important to their health and survival. “Capacity” refers specifically to the ability to make decisions, and is based on functional assessment by a clinician. Capacity can change over time and in relation to different decision-making scenarios. Competency may be defined differently depending on the legal system.
Tool: Several structured tools for capacity assessment exist including the Aid to Capacity Evaluation (ACE)
- Assess urgency of intervention and consequences of refusal. The clinician needs to distinguish between tolerable (acceptable) risks and intolerable risks. Only intolerable risks require Assessment of Capacity. Intolerable risks might include behavior that is new and unprecedented (not consistent with past behavior as best as can be determined by obtaining collateral from the patient’s chart or associates) and behavior that is causing significant harm to self or others.
- Assess different possible causes for refusal: delirium, anxiety, agitation, volitional (lack of motivation, for example in the context of depression), and psychosocial stressors
- Patients who refuse testing or COVID-19 isolation precautions will likely require a Capacity Assessment. Given that symptomatic patients seem to transmit the virus to others, the patient will need to demonstrate that they understand the risk to themselves and to the people around them.
- If the patient has capacity and the decision harms only themself (for example, refusing testing), this is within their rights. Note that if a patient is living in a congregate setting, this may interfere with their living situation.
- If the patient has capacity and the decision is endangering others (for example leaving their isolation room without precautions and exposing other patients), try first to reason with them. Many hospitals have policies around rearranging or declining care to a patient who is harming others.
- If a patient lacks capacity and is harming others, safe use of restraints is allowed in most hospital settings.
- Identify psychosocial stressors and address them as thoroughly as possible. For patients with unstable housing, do your best to call any available shelters. Local departments of health, departments of housing, and non-governmental organizations may have specific isolation options for undomiciled patients.
- Patients with COVID who request to leave AMA will likely require a Capacity Assessment.
- If a patient with COVID is found to have capacity to leave AMA but poses significant infection risk to others (is unable or unwilling to self-isolate, lives with high-risk individuals), discuss this with the legal and/or risk team at your hospital if you have one. In many (but not all) places the Department of Public Health will have to be alerted, and they will pursue potential contact tracing or notification of susceptible contacts. Facilities should put in place plans to notify the local or state health department, ideally with an established system and not a case-by-case basis.
- Note that in most places it is illegal to share medical information about the patient with his or her contacts without permission, though some places make exceptions to this rule if the contact is imminent danger (e.g. if the person has made a credible threat of bodily harm), and many local laws (like HIPAA) has exceptions for communicable disease. If you suspect that a specific susceptible person may be placed at grave risk by your patient, it may be appropriate to call and report (WHERE?)
- If a patient is tested but leaves AMA before receiving their results, every attempt should be made to inform them of their results status, and the information needed to prevent transmission.
Updated Date: September, 2020
Vulnerable groups are those needing additional psychological, social, and material support in order to adapt to the pandemic. Groups in need of support are identified by conditions which render individuals potentially more vulnerable to the effects of pandemics (such as poverty or pre-existing mental health conditions). They can also be identified on the basis of quarantine/hospitalization status or occupation. This section suggests some ways in which vulnerable groups may be assisted by health providers, local governments, service organizations and/or community leaders and members.
Vulnerable populations include (IASC with PIH adaptation):
- Older adults, especially those with cognitive decline or dementia;
- People living with disabilities with pre-existing health conditions; people living with disabilities, including psychosocial disabilities;
- People living with disabilities in crowded living conditions (e.g. prisoners, people in detention, refugees in camps and informal settlements, older adults in nursing homes, people in psychiatric hospitals, inpatient units or other institutions);
- Homeless individuals or individuals with unstable housing
- People living with disabilities at particular risk of discrimination or violence, such as those at risk due to COVID-19-related stigma (e.g. specific ethnic groups, health workers)
- People exposed to gender-based violence, including sexual violence;
- Pregnant, postpartum or in post-abortion, and lactating women;
- Children, adolescents and their caregivers;
- People with difficulties in accessing services (e.g. migrants).
Older adults, People with Disabilities, and people with severe mental illness may be particularly vulnerable and in need of support. For example, older adults with cognitive deficits, decline, and/or dementia may become more anxious, agitated, and withdrawn during the outbreak and while in quarantine. People with severe mental illness may need additional support from organizations, communities, and family members to enhance treatment success, stop the spread of the virus, and maximize prevention.
- Assist people with accessing information. Messages should be shared in ways that are understandable to the individual.
- If caregivers need to be moved into quarantine, plans should be made to ensure continued support for those who need it.
- Engage families and other support networks in providing information and promoting infection prevention measures (handwashing, universal face covering, etc.)
- Assist people in continuing to access necessary medical care.
- People requiring caregiving and their caregivers should be included in all stages of the outbreak response.
Tool: See This Document From WHO for more recommendations for supporting both general and specifically vulnerable populations.
Psychological first aid (PFA) is a structured way to have conversations that allows anyone (citizens, mental health care providers, community health workers, etc) to provide humane support to a fellow human being. PFA involves helping people to feel safe, connected to others, calm, and hopeful; have access to social, physical, and emotional support; and feel able to help themselves, as individuals and communities. These efforts must respect the safety, dignity, and rights of participants (WHO Outline). PFA does not need to be done by a professional, and it is not professional counseling.
The recommended length for a PFA training is 3 hours and topics include: principles of PFA, special considerations for vulnerable populations, and referral pathways for additional psychological care (as required). PFA training materials and activities should be adapted to the context.
- Anyone, mental health care providers, community health workers, general healthcare workers, support staff, etc., can be trained in and provide PFA.
- PFA training can be standalone or adapted to be a part of existing COVID-19 related trainings. Additional trainings can be conducted as needed.
Tool: WHO PFA Manual (available in multiple languages).
Tool: PFA and MHPSS training materials developed by Partners In Health are available upon request. Please click here to complete the material request form.
All emotions and stress responses are “normal”. The following strategies can be used by healthcare workers to support distressed people who have been recently exposed to a serious crisis event.
- Be attentive to safety and basic needs: offer immediate assistance by looking for ways to make people feel safe and comfortable (blankets, water, somewhere to sit, etc). If directing quarantine or isolation, keep it as short as possible and restricted to what is scientifically indicated.
- Be attentive to how you communicate: provide clear, practical communication about the nature of disease, reason for quarantine and treatment, and other essential information. Information will often need to be repeated and must be developmentally, culturally, and language appropriate.
- Do not pressure the person to tell you what they have been through or how they are feeling.
- Allow for sharing silence. When possible, allow people to talk as little or as much as they want to.
- Validate (show acceptance towards) feelings and thoughts. Avoid temptation to judge the rightness or wrongness of people’s reactions to experiences.
- Help people feel calm: keep your tone of voice calm and soft; make eye contact; remind them you are there to help and they are safe (if it is true). If feeling disconnected from their surroundings, it may help them to make contact with the environment and themselves.
- Guide them to place and feel their feet on the floor.
- Ask them to tap fingers or hands on their lap.
- Guide them to notice some non-distressing things in the environment (such as things they can see, hear, or feel).
- Focus together on breathing, and breathing slowly.
- Encourage healthy coping habits: for a list of these, see the bottom of this section.
- Connect people with other supportive individuals: connect them to available therapy resources, spiritual practitioners, and family members. Provide telephone and video resources, as available, to facilitate connections.
- Support emotional re-adjustment after the crisis, by encouraging: acceptance of the event and the losses; identification, labeling, and expression of emotions; and recovery of a sense of control and mastery over our lives.
The following is adapted from the Center for the Study of Traumatic Stress
- Manage uncertainty and elevated distress: remind family that their loved one is being cared for, and that the majority of hospitalized individuals are successfully treated and are able to return home.
- Support connection and communication: create opportunities for the family to communicate safely with the hospitalized family member. Set expectations for frequency of updates from healthcare providers.
- Support advance planning: recommend obtaining ready access to the patient’s medical, legal, and financial documents during hospitalization should the need arise. If health status deteriorates, encourage important conversations prior to the need for intubation to understand last wishes and provide opportunities to say goodbye.
Tool: My Hero is You, Storybook for Children on COVID-19, IASC
Tool: Responding to the Mental Health and Psychosocial Impact of COVID-19 on Children and Families, UNICEF
Tool: Early Childhood Focused COVID-19 Resources
Updated Date: April 23, 2021
Frontline workers, including nurses, doctors, ambulance drivers, case identifiers, community health workers, and others are experiencing new occupational stressors during the pandemic. Identifying and reducing sources of stress and hardship is a shared responsibility of organizations and individuals.
- Reduce stress by taking every possible measure to reduce risk of physical and psychological harm to healthcare workers and their families.
- Include frontline workers in designing interventions to reduce workplace stress and moral distress.
- Show empathy and be available: understand that everyone is likely to be feeling overwhelmed.
- Ensure good quality communication and accurate information updates to all staff.
- Provide opportunities for additional education so that healthcare workers can adapt to new patient needs. See psychological first aid section.
- Rotate workers from higher-stress to lower-stress duties.
- Partner inexperienced workers with their more experienced colleagues, especially when doing community outreach.
- Initiate, encourage, and monitor work breaks.
- Protect staff from financial harm when needing to quarantine or care for sick family members (provide paid time off whenever possible).
- Implement a flexible work schedule/time for workers. Staff may need extra time to attend to personal matters.
- If you are a team leader or manager in a healthcare facility, facilitate access to mental health and psychosocial support services.
- Managers must be able to role-model self-care strategies to mitigate stress
Specific suggestions are available in other sections for:
- Frontline Workers
- Intimate Partner Violence
- People with Disabilities
- People with Substance Use Disorders and Addiction
Tool: Supportive Resources (Hotlines, therapy resources, and mindfulness/CBT Training)
- It is normal to feel sad, distressed, worried, confused, or angry. Talk to people you trust about your feelings. Social distancing does not mean emotional distancing; use technology to connect with loved ones.
- Maintain a consistent routine and a healthy lifestyle as much as possible, including eating, drinking, sleep, bathing, and exercise.
- Keep routines consistent but flexible: don’t allow anxiety to dictate an overly rigid schedule for children and others.
- Maintain a positive tone within households to manage tensions and provide a sense of safety, power, and responsibility to children, elders, and others.
- Seek help from someone you trust if you or anyone in your home is in danger of experiencing violence or abuse.
- Avoid using tobacco, alcohol, or other drugs to cope with negative emotions.
- Consume television and internet news from reliable sources and only once or twice per day. After checking news, engage in another activity or focus on something you enjoy.
- Engage in relaxation activities and/or spiritual exercises, such as mindful breathing, meditation, or religious practice.
- Find safe ways to help others in the crisis and get involved in community activities.
- If you feel overwhelmed, talk to a healthcare worker, social worker, or another trusted person in your community (such as a religious leader or community elder) by phone or video. Make a plan about where you would go to seek help for physical, mental, or psychosocial healthcare if needed.
Updated Date: April 23, 2021
The following guidelines, drawn from a collaborative effort of the Inter-Agency Standing Committee (IASC), Partners In Health (PIH), and 55 other humanitarian agencies part of the IASC Reference Group, help teams to mount a mental health and psychosocial response to the COVID-19 pandemic.
Tool: IASC Guidance on Operational considerations for Multisectoral Mental Health and Psychosocial Support Programmes during the COVID-19 Pandemic. (Resources available in several languages)
The IASC Guidelines recommend that multiple levels of interventions be integrated within outbreak response activities. During the first acute emergency stage, the focus of mental health and psychosocial support response should be to work closely with the broader health and public health system to strengthen efforts of Ministries of Health on infection risk management and treatment, including: 1) prevention of COVID-19 transmission; 2) support of surveillance, case triage and contact tracing; 3) support of persons testing positive and those in quarantine/isolation, as well as their family members; and 4) support for health care workers
Recommended Initial Actions:
- Assess available resources for COVID-19 response (human, financial, and other).
- Facilitate collaboration between government agencies, non-profit organizations, and community organizations to ensure a coordinated response.
- Develop a plan to assist existing mental health and psychosocial services in adapting to pandemic conditions in order to meet new and ongoing population needs.
- Establish a strategy for supporting specific groups affected by the pandemic, including individuals testing positive for COVID, people in quarantine/isolation, the elderly, people with disabilities, and children.
- Ensure Community Health Workers and other front-line workers have the most up to date information about infection control and prevention and locally available resources.
- Train all front-line workers on essential psychosocial care principles, including communication techniques, and referral pathways.
- Develop a monitoring and evaluation system for mental health and psychosocial service activities
- Ensure community health workers and traditional healers have adequate PPE for home visits.
- Create a list of the most vulnerable patients in care and determine an essential social support package.
- Create a list of high-risk patients to ensure remote care, safety plans, and/or sufficient medication supply is provided.
- Maintain at least a 2 meter distance between the patient and caregivers, except when medically necessary. Explain to patients and caregivers the need for this prevention measure.
Health facility level
- Limit the need for patients to come to the health facility by shifting to remote services, particularly for those at high risk for contracting COVID-19 and home visits to the most vulnerable patients. See additional guidance below on remote services.
- Ensure seating areas in the waiting room are adequately spread out.
- Limit the number of people accompanying a patient to the health facility.
- Work with the pharmacy team to obtain extended medication supply for stable patients.
Remote services and supervision
- Determine the best, most accessible platform for calls with patients considering costs and network reliability.
- Ensure a private and safe space is available for both the provider and the patient.
- Utilize safe, secure, and appropriate channels of communication.
- Establish referral pathways with supervisors for those with severe psychological distress.
- Allocate resources for talk time to ensure staff and patients connect via phone and video call remotely.
- Define clear times when providers will be available for sessions.
- Schedule times for regular clinical supervision with staff.