News in late April of the suicides of an emergency department physician and an EMT in New York City drove home the gravity of the many stressors associated with frontline caregiving during the COVID-19 pandemic. The resulting emotional exhaustion, anxiety, depression and even post-traumatic stress disorder are already apparent among healthcare workers — and are expected to continue indefinitely.
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Staff in Cleveland Clinic’s Center for Behavioral Health and Department of Psychiatry and Psychology are helping design new approaches to these unprecedented mental health challenges among their colleagues. They’re also finding that new practices prompted by the pandemic promise to enhance their care offerings to their colleagues and general patients alike even after the crisis subsides. This post outlines progress on both fronts.
Singular challenge with a daunting scope
“The psychological impact of COVID-19 for healthcare providers involves a whole confluence of things,” says Leslie Heinberg, PhD, Vice Chair for Psychology in the Center for Behavioral Health. “It starts with the fear, anxiety, distress and dysphoria related to the disease itself — either becoming infected, having loved ones become infected or losing people.”
“The very nature of the work done by healthcare staff in ICUs and emergency rooms puts them at a higher risk of behavioral health disorders, whether from a surge in COVID-19 or the chronicity of the disease,” says Leo Pozuelo, MD, Section Head of Consultation Psychiatry. “We will see a higher vigilance for these folks around how they are doing in the weeks and months to come.”
He adds that while many providers are accustomed to dealing with a host of diseases that can be very severe, “they don’t worry about bringing cancer or a heart attack home. Now they are worrying about bringing COVID-19 home.”
But the stressors extend beyond medically related apprehensions to the psychological and economic consequences of actions to mitigate the disease — impacts that extend to the general population as well. “There’s the increased stress of being caged up with your family during shelter-in-place mandates,” says Donald Malone, Jr., MD, Chair of Psychiatry and Psychology and Director of the Center for Behavioral Health. “There are also concerns over unemployment and financial hardships, which are among the biggest socioeconomic factors in the development of depression.”
Ways to enhance care for caregivers
Cleveland Clinic’s behavioral health professionals are working diligently to provide services during the pandemic, including pivoting approximately 98% of appointments to virtual visits. Fortunately, Cleveland Clinic’s Neurological Institute, which includes all behavioral health providers, had deep experience in telehealth.
One particular focus has been providing services and resources to Cleveland Clinic’s 53,000 employees, particularly those in the trenches fighting COVID-19. Newly adopted components, which piggyback on Cleveland Clinic’s existing Caring for Caregivers employee assistance program, include the following:
- A 24/7 employee hotline. “The emotional support hotline offers half-hour virtual visits with one of our counselors, social workers, psychologists or psychiatrists, with no need for documentation and no bills,” says Dr. Malone.
- Immediate access to counseling appointments. Psychologists and psychiatrists have earmarked telehealth slots for caregivers treating COVID-19 patients and for COVID-19-positive patients themselves. “Just like we can quickly turn around a medical unit to be ready for COVID-19 patients, we offer quick access for people who urgently need mental health care,” says Dr. Heinberg.
- Monitoring caregivers during virtual visits. A few weeks ago, the behavioral health professionals began screening caregivers for signs of potential trouble by using four questionnaires during telehealth appointments: a depression questionnaire (PHQ-9), an anxiety questionnaire (GAD-7), a quality-of-life questionnaire (PROMIS-10) and a PTSD questionnaire (IES-R).
Enduring lessons from the rapid shift to virtual visits
Converting from in-person to online visits has created challenges, but also opportunities. “The silver lining in all of this is that it forced us overnight to think more creatively about how we provide care,” says Dr. Heinberg.
In the past several weeks, behavioral health professionals at Cleveland Clinic have learned some lessons that can continue benefiting their practices after the pandemic eases:
- Meaningful connections can be built virtually. “We’ve been surprised by the receptivity of healthcare professionals, existing patients and new patients,” says Dr. Pozuelo. “You can connect via video and still have verbal and nonverbal communication, which is important in our relationships with patients.”
- The backdrop provides valuable insight. “There are so many insights to seeing people in their home environment,” says Dr. Heinberg. “You get a more accurate picture of who patients are. They may say everything is fine, but then you can see their house is in disarray or there’s a pack of cigarettes on the desk of someone who said they quit smoking.”
- Discovery is a two-way street. “Providing telehealth remotely allows our patients to see us as more human,” says Dr. Heinberg. “They hear our dogs barking or hear kids in the background. It might help reduce barriers.”
- Flexibility in delivery methods is key. “What we are learning from reports in Europe is that you’ve got to tailor mental health delivery to the needs of recipients,” says Dr. Pozuelo. “For some people, that’s virtual visits and hotlines. For others, it’s education and webinars. This is a very fluid situation, and we have to be flexible.”
- Data is king. “We are learning as we go, so you want to track data,” says Dr. Pozuelo. “That’s why screening for and measuring depression, anxiety and PTSD is important.”
Perhaps most important in the midst of the pandemic is continued communication with behavioral health colleagues. “There are core tenets we all subscribe to, but we are going to have to learn from our colleagues in Italy, Spain, New York and other hard-hit areas,” says Dr. Pozuelo. “We will learn how behavioral health professionals adapted, what they could have done better, and what works for frontline caregivers and other patients. It’s shared knowledge that will benefit us all.”