While most resources are directed at screening for COVID-19 and treating affected patients, there is another important aspect of the pandemic: the impact on your patients' mental health. Fear and uncertainty are driving the dramatic increase in stress, anxiety, and depression. While your patient's immediate physical well-being is the primary concern, you also must consider the potential legal liability that can come from failing to adequately screen patients for suicide risk and taking the proper steps when needed.¹

Anxiety is being exacerbated by patients' mistrust of the healthcare system and fear that they or their loved ones will contract the virus. A recent survey indicated that 67 percent of people have increased levels of stress since the start of the COVID-19 outbreak, 54 percent are emotionally exhausted and feel increasing sadness day to day, 50 percent are more irritable, and 42 percent have an overall decline in their mental health.²

As the sense of loss of control—fed by the daily news cycle—escalates, mental health concerns may intensify or reoccur if the patient has a prior history. Some reports suggest the greatest fallout from the COVID-19 virus may be the impact on mental health. Children may be even more affected than adults. (See the CDC article Talking with children about Coronavirus Disease 2019.) Elderly patients living alone or otherwise isolated may suffer significant problems with depression.

What are some warning signs or cues that show a patient is in emotional distress? Watch for the following signs when seeing a patient onsite or via telehealth:

• Changes in appetite, sleep, and/or behavior, including impulsive and dangerous behaviors.
• Nonverbal cues during an interview, such as an inability to sit still, often shifting weight in a chair, lack of eye contact, or wringing hands.
• Decreased or no energy.
• Changes in cognition, such as decreased focus or memory, or difficulty holding a conversation.
• Feelings of hopelessness/helplessness, being overwhelmed, irritability, fear/worry.
• Withdrawal from friends/family and activities.
• Increased conflict within relationships.
• Lack of follow-through with seeing therapist and/or psychiatrist (if patient has a mental health diagnosis / history / prescribed psychiatric medications).
• New somatic complaints.
• Excessive smoking, drinking, or using drugs, including prescription medications.

If these warning signs are missed and an adverse event—such as suicide—occurs, the healthcare provider may face the risk of a medical malpractice claim. Phillip J. Resnick, MD, in a presentation at the 2017 US Psychiatric and Mental Health Congress Conference, emphasized the importance of obtaining sufficient data for a thorough suicide assessment. Errors in the process of gathering assessment data through careful questioning may make it more difficult to successfully defend the care.

Evaluating suicide potential is a considerable challenge. Many who entertain thoughts of suicide may not follow through. A report from the Substance Abuse and Mental Health Services Administration (SAMHSA) showed that "almost 10 million U.S. adults seriously thought about committing suicide" during the year prior to the study.³

Using telemedicine during the pandemic makes it even more challenging to detect whether a patient is so stressed that they may harm themselves. The subtleties of body language may be difficult to discern. Especially in a telehealth session, it is important to probe further when you have a patient who has some history of depression, mood disorder, or suicidal ideation. Posing questions carefully may yield better information, e.g., not "Are you considering suicide?" but "Have you ever had thoughts about suicide?" While the vast majority of your patients who are anxious and stressed about the COVID-19 virus are not suicidal, it is important to keep in mind the possibility of suicide as you complete your assessment. A helpful resource is the Suicide Prevention Toolkit for Primary Care Practices from the Suicide Prevention Resource Center and the Western Interstate Commission for Higher Education Mental Health Program.

The following key elements of the Stress First Aid peer support model⁴ have been linked to better functioning during times of ongoing stress and should be used in discussion with patients showing signs of anxiety:

• COVER: Restore and support a sense of safety by asking:
  • Has the pandemic affected your sense of safety?
  • Are you safe at home?
  • Are you currently able to meet your needs?
  • What would help you feel safe?
• CALM: Calm and orient distressed persons by asking:
  • Have you experienced any changes in sleep, appetite, mood, relationships, energy level, or activities?
  • What are you doing to maintain a sense of calm?
• CONNECT: Connect in a helpful and respectful manner by asking:
  • Have you been able to stay connected with others?
  • Do you have a good support system?
  • Are you taking breaks from the media?
  • Have you known anyone that has done or said something that has helped?
• COMPETENCE: Remind them of skills that have worked in the past for them. Ask them:
  • Do you have any concerns about handling what is going on in your life today?
  • What things have you been able to do during this pandemic?
• CONFIDENCE: Foster a sense of hope, limit self-doubt and guilt, and help patients concentrate on strengths by asking:
  • Have you noticed any change in confidence in your ability to accomplish your daily tasks?
  • Are you feeling overwhelmed?

During these discussions, explain to patients the importance of self-care during times of stress and the importance of staying connected to their support system. Provide positive encouragement and reinforcement.

You may want to develop a handout for patients, including key websites that provide ideas on overcoming negative feelings. The following are some tips you may want to include:

• Limit consumption of news and social media.
• Focus on things you can control: "You can take care of yourself."
• Stay busy.
• Keep in contact with friends.
• Identify a friend you can talk to in order to vent your negative feelings.
• Seek out local resources such as churches, online support groups, and counselors.
• Consider apps like COVID Coach (Apple) or Sleep Sounds (Android). There are many others on meditation or mindfulness, like Chill.
• Set daily goals.

Additional websites you might find useful in communicating with stressed patients are:

• The Schwartz Center
• SAMHSA, "Warning Signs and Risk Factors for Emotional Distress"
• Mental Health America, online screening tools

References

1. Diamond R. Watch for the signs: Screen all patients for suicidal thoughts. The Doctors Company. Published November 2016. Accessed May 19, 2020. https://www.thedoctors.com/articles/watch-for-the-signs-screen-all-patients-for-suicidal-thoughts/
2. Qualtrics. The other COVID-19 crisis: Mental health. Published April 2020. Accessed May 19, 2020. https://www.qualtrics.com/blog/confronting-mental-health/
3. Dallas ME. 10 million U.S. adults seriously considered suicide last year. CBS News. Published September 15, 2016. Accessed May 19, 2020.
4. National Center for PTSD. For Leaders: Supporting Your Staff During the Coronavirus (COVID-19) Pandemic. Published April 9, 2020. Accessed May 18, 2020. https://www.ptsd.va.gov/covid/COVID_leaders_support_staff.asp