People with mental illness are at greater risk for developing COVID-19 than the general population, and vice versa — meaning reverberations from the pandemic are likely to be felt long after the virus has been brought to heel.
And whether infected or not, minorities, underserved communities, and others experiencing health disparities are at double the risk of long-term mental health impacts from COVID-19.
That’s the warning from National Institutes of Health researchers, speaking during the first in a three-part webinar series hosted by the National Academies of Sciences Engineering and Medicine.
Mental Health and COVID-19
There are “bidirectional associations” between COVID-19 infection and psychiatric disorders, explained Joshua Gordon, MD, PhD, director of the National Institute of Mental Health.
One reason that people with psychiatric disorders are more at risk for COVID-19 than others could be that they are more likely to live in congregate settings, such as prisons. Or, maybe it’s because people with serious mental illness often have other comorbidities.
Conversely, those who contract COVID-19 and do not have a psychiatric disorder have an increased risk of developing one over the next few months, Gordon said.
Roughly 6% of all patients will have “a new onset of mental illness” following a COVID diagnosis, he said.
Several surveys “of varying scientific rigor” have shown increased rates of symptoms related to mental illness in the general population, said Gordon. Symptoms not diagnoses, he stressed.
He also noted that many of these surveys used convenience samples, though the most credible of these comes from the CDC.
Despite such limitations, “every single one” has shown increases in self-reported symptoms of anxiety, depression, and “starting or increased substance abuse, ” as well as trauma, stress-related symptoms, and suicidal ideation.
About 40% of adult respondents reported challenges with “one or more” of these symptoms, which is roughly twice previous rates, Gordon said.
One potentially positive finding, while tentative, is that while suicidal ideation has increased, suicide deaths and suicide attempts haven’t yet, according to data from Greg Simon, MD, MPH, who leads the Mental Health Research Network.
The absolute number of visits for suicide attempts or self-injurious behavior appears to be “fairly steady” across 2019 and 2020 up to June, he said.
While this steady state could represent true stability in rates, it could also mean that, in the context of a lower number of overall emergency department visits, there may be more incidents but people are not seeking care.
In certain states where timely data is available, no increase in suicide deaths has occurred through the early 2020 summer, Gordon said.
As for the long-term risks of the pandemic, Gordon said most people exposed to trauma improve with time.
“A lot of people will have a lot of symptoms in the context of a disaster, but only a minority, a significant minority … will go on to have long-term or chronic experiences with mental illness as a consequence of involvement in those disasters,” Gordon said.
Those most at risk are those who have few social supports; who have a history of trauma or mental illness before the disaster; who were exposed most directly to morbidity or mortality; who had a severe acute psychiatric reaction to the disaster; or who experience ongoing stressors such as job-related or financial strains, he said.
Moreover, social inequalities and health disparities “both predict and exacerbate” the vulnerability to these long-term negative outcomes among marginalized populations.
This pandemic has had an outsized impact on minority and undeserved communities, Gordon said, which puts them “essentially doubly at risk” for long-term mental illness; not only because they are more likely to be impacted but because they are more likely to have pre-existing risk factors that raise their chances for a mental illness.
COVID and Substance Abuse
Nora Volkow, MD, director of the National Institute of Drug Abuse, said researchers have gotten creative in identifying timely data on substance use and overdoses.
Data from Millennium Health and other testing laboratories early in the pandemic showed increases of 32% in individuals testing positive for fentanyl; 20% in methamphetamine positivity; 12% in heroin positivity; and 10% in cocaine positivity.
“We don’t know what has happened in the past 6 months. But even with that restrictive data set, you can see significant increases in the positivity rate of urine that are being sent to these laboratories,” she said.
That rise in positive drug tests was found across ages and genders, Volkow said.
One program called Overdose Detection Mapping Applications, which monitors areas of high drug consumption, found significant increases in the number of fatal and nonfatal overdoses, reaching as high as 42% in May 2020 versus the same month in 2019.
From April 2019 to April 2020, the CDC found a 13.2% increase in overdose mortality, according to the agency’s provisional data.
Like those with serious mental illness, people with substance use disorders are also at greater risk of contracting COVID-19.
This increased risk of illness is not only due to their social circumstances and living conditions, said Volkow, but also to drugs’ physiological effects on pulmonary, cardiac, metabolic, and immune function, all of which are targeted by COVID-19 as well.
As a result, people with substance use disorders who develop COVID are much more likely to be hospitalized and to die, compared with the general population, Volkow said.
She also highlighted the significantly higher rates of deaths among African Americans than whites, likely due to their higher rates of chronic medical conditions that lead to these poor outcomes.
That further underscores the role of health disparities and the multiple factors that worsen outcomes in disadvantaged groups, Volkow said, stressing the danger of stigma, which keeps people from getting treatment, exposes them to high-risk behaviors, and leads to worse outcomes.
Volkow also warned against underestimating the “devastating” impacts of social isolation.
She cited studies showing that in “complex environments with multiple behavioral choices,” animals will not press a lever to receive drugs, whereas animals in social isolation will.
One 2018 experiment offered rats the choice between pressing a lever to get a drug and pressing a lever which enabled interaction with another rat, Volkow explained.
“When they have that choice, the animals … don’t take heroin. They choose the social interaction,” Volkow said.
When the researchers added another factor and shocked the rat for pressing the lever that offers the social reward, the rats began choosing the heroin lever instead. Volkow said the shocks’ parallel in humans represents stigma.
“If we want people to actually be able to achieve recovery, if we want to be able to prevent drug use, then we need to ensure that we are able as a society to provide social interactions that are rewarding and that are meaningful.”
By Shannon Firth, Health Policy and Washington Correspondent, MedPage Today
Nurses in North Dakota came out against a new policy that allows healthcare workers with asymptomatic SARS-CoV-2 infections to continue working at hospitals and nursing homes.
The policy was issued Monday by North Dakota Gov. Doug Burgum, who announced an amended order that allowed coronavirus-positive health workers to work in the COVID unit of a licensed healthcare facility as long as they remain asymptomatic and additional precautions recommended by the CDC and the North Dakota Department of Health are taken.
In a statement released Wednesday, the North Dakota Nurses Association objected to allowing nurses with the virus to continue working, emphasizing that a choice to work while infected should be up to individual nurses, not their employers.
The group also said all other public health measures to reduce the demand on the healthcare system should be implemented first, including a statewide mask mandate, which North Dakota does not have.
Neither the North Dakota Medical Association nor the North Dakota Hospital Association reacted publicly to the new policy as of press time.
On Wednesday, the North Dakota Department of Health announced a record number of active COVID-19 cases. “At this point, every county in our state is at high risk level,” said Tessa Johnson, MSN, RN, president of the North Dakota Nurses Association. “The governor has put this policy out and still, no masks are required. It feels like a slap in the face to nurses right now.”
“We really feel like if we’re going to make a big change, it needs to start with that,” Johnson told MedPage Today. “The governor has very much left it open to individual cities and counties, and some have chosen to have a mask mandate, but there’s no teeth behind it.”
On paper, the new policy appears to have protections built in for patients and co-workers, but that’s not the case in the real world, Johnson said.
“It’s not as simple as just putting a COVID-positive patient and staff member together,” she said. “There are shared spaces in hospitals, nursing homes, and clinics to be concerned about — bathrooms, break rooms, hallways, elevators.”
And in rural areas of the state, small facilities are connected to one another, Johnson pointed out. “You may have a long-term care facility, an ER, and a hospital all attached to each other, and the same RN may care for all those patients. How’s that going to work? No one has answers and there’s a lot of fear surrounding that question.”
When the governor’s statement was issued on Monday, the association reached out to nurses throughout the state and received immediate feedback. “A point they emphasized was make sure that, even with this order, nurses and their employers must have a choice: you cannot mandate any nurses to do this,” Johnson said.
The message the policy sends to the community is troubling, too, she noted: “We are a very ethical, trusted profession and people look to us for guidance. In this whole time, we’ve been saying wear your mask, socially distance, and stay home if you are in close contact. So how can we continue to be credible sources and tell people to stay home if we’re not?”
What’s happening in North Dakota may be due in part to the changing shape of COVID-19 patterns throughout the country, observed Cheryl Peterson, MSN, RN, vice president of the American Nurses Association, the national professional nursing organization based in Silver Spring, Maryland.
Early in the pandemic, nurses could move from one COVID-19 hotspot to another to help, but that’s no longer the case, she noted. “Because of how widespread the disease is circulating, there’s no place for that now,” she said.
“There’s no give in the system now to get more resources to these hospitals, and I think that is going to play out,” Peterson told MedPage Today. “We see it now in North Dakota,” she said. It wouldn’t surprise her if similar policies spread to other states “as we move higher up the spike or further into the pandemic,” she added.
“The piece we want to really focus on is that hospitals recognize it is up to the nurse as to whether or not they are interested in working when they are COVID-positive,” Peterson said.
“The CDC guidance says they have to be willing to work. It’s up to them whether they’re going to work and if they say, yes, they’ve made a decision. If they say no, that, too, is a decision and it must be respected by the facility and there should be no retaliation.”
By Judy George, MedPage Today
The first wave of COVID-19 forced hospitals to get creative when treating patients, and they can apply these lessons as the next wave of the pandemic approaches.
“This is teaching us that no one is immune and no one is going to be omitted from this,” said David Ferraro, MD, of National Jewish Health in Denver, during a presentation at the virtual CHEST conference, the annual meeting of the American College of Chest Physicians.
“We all have to … learn how to surge and stock supplies. Be prepared to have a plan A, a plan B, and a plan C,” Ferraro said.
Innovative solutions, such as using alternative drugs from another drug class; using an equivalent within the drug class family; or changing the route of administration can help to alleviate medication shortages, which are an ongoing public health crisis, even pre-COVID-19, he said. The pandemic only upended an already vulnerable supply chain, battling lack of incentives to produce less profitable drugs, and a market that had difficulty responding to disruptions.
Because medication production surges do not occur quickly, and the FDA previously acknowledging the potential for drug shortages, this becomes a problem in an ongoing public health crisis, with over 50,000 COVID-19 cases per day in the U.S., Ferraro said.
In particular, sedatives, analgesics, and paralytic agents are among those agents at risk of shortages. Ferraro said, specifically citing propofol, fentanyl, dexmedetomidine, and midazolam among the medications in short supply.
To preserve commonly used critical care drugs, Ferraro cited examples such as using benzodiazepines or phenobarbital for sedation, and ketamine for sedation and/or analgesia, saying, “alternative drugs from other classes can achieve the same effects.”
Ferraro also said changing “route of administration was my eye-opening experience,” as switching to an enteral route opened up many more options. He also discussed potentially using the transdermal route, as “certain medications may be used for this route to reduce IV dosing.”
Prioritization was also key to conserving supply, with drug rotation (“changing practice frequently to avoid overreliance”) and using the lowest necessary dose, as well as the appropriate vial size to minimize drug wastage, Ferraro said.
Early COVID-19 studies found 22%-27% of patients ended up in the ICU and, of these, 29%-90% required mechanical ventilation, he said, and this type of care tends to utilize medications, personnel, and equipment.
Ferraro said based on available data on number of patients requiring mechanical ventilation, duration of mechanical ventilation, and ICU admissions, an estimated 10-27 million ventilator days may be required.
And while there may now be a glut of ventilators in the Strategic National Stockpile, Ferraro noted that sharing of ventilators across local and national hospital networks, as well as learning that timing of intubation, is critical. He said using “heated high flow” nasal cannula and noninvasive techniques could ensure patients are not intubated too early if it’s not necessary.
“Staving off intubation for later if it’s safe might be a good tactic so ICUs are not becoming too top-heavy,” he stated.
Ferraro discussed utilizing anesthesiology as a consultative service during COVID-19 surges, as it “helped with drug conservation and freeing up intensivists from one aspect of patient care.”
But he warned that staffing, especially in terms of patients on ventilators, may continue to be one of the biggest “pinch points” for critical care, along with “stuff” (likely equipment and medications) and hospital “space” to house patients.
“The most likely limiting factor is human staff to safely manage the number of patients that will require mechanical ventilation,” he said.
By Molly Walker, Associate Editor, MedPage Today
Adults started drinking more alcohol during the COVID-19 pandemic, but women not only drank more frequently but also reported significant increases in heavy drinking and alcohol-related problems, a national survey found.
Overall frequency of alcohol consumption among adults ages 30-80 increased 14% versus 2019, with increases of 17% for women, reported Michael Pollard, PhD, of RAND Corporation in Santa Monica, California, which administers the survey, and colleagues.
Other demographic groups experiencing increases in frequency of alcohol consumption included non-Hispanic whites (up 19% vs 2019) and adults ages 30-59 (up 10%), the team wrote in a research letter in JAMA Network Open.
Nielsen surveys showed a 54% increase in national sales of alcohol for the week of March 21 versus a year ago, Pollard and colleagues noted, as stay-at-home orders began in U.S. states and the World Health Organization warned that alcohol use during this time may “exacerbate health concerns and risk-taking behaviors.”
“Health systems may need to educate consumers through print or online media about increased alcohol use during the pandemic and identify factors associated with susceptibility and resilience to the impacts of COVID-19,” Pollard and co-authors wrote.
They examined data from the RAND Corporation American Life Panel, a nationally representative probability-sampled panel of 6,000 English or Spanish-speaking participants, weighted to match certain demographic characteristics. In this study, the investigators looked at 2,615 panel members ages 30-80.
Overall, 1,771 completed the wave 1 baseline survey from April 29 to June 9, 2019, and wave 2 data were collected from May 28 to June 16, 2020. The completion rate for wave 2 was 58.9% of all wave 1 invitations.
Heavy drinking was defined as five or more drinks for men and four or more drinks for women within a couple of hours and the average number of drinks consumed in the last 30 days. The 15-item Short Inventory of Problems looked at adverse consequences tied to alcohol use in the past 3 months.
The current sample of 1,540 adults had a median age of 56, about 57% were women, and 71% were non-Hispanic white.
Frequency of alcohol consumption in the past 30 days among adults increased by 0.74 days over the baseline of 5.48 days in 2019. Women had a 2019 baseline of 4.58 days, with a 0.78 day increase in 2020, and non-Hispanic whites had a baseline of 6.46 days, with a 0.66 day increase in 2020.
Mean heavy drinking days for women increased 41% (0.18 days) from the 2019 baseline of 0.44 days per month. Women also showed a 39% increase in Short Inventory of Problems scores — “indicative of increased alcohol-related problems independent of consumption level for nearly 1 in 10 women,” the researchers wrote.
Limitations to the data, Pollard and co-authors said, include that it was self-reported and subject to social desirability bias, and that not all baseline respondents contributed to wave 2 data.
“Nonetheless, these results suggest that examination of whether increases in alcohol use persist as the pandemic continues and whether psychological and physical well-being are subsequently affected may be warranted,” the researchers concluded.
By Molly Walker, MedPage Today
Patients with symptomatic COVID-19 were more likely than uninfected controls to report some form of restaurant dining — including indoor, patio and outdoor seating — in the 2 weeks prior to symptom onset, CDC researchers found.
Compared to controls without COVID-19, case patients were more than twice as likely to have reported dining at a restaurant (adjusted OR 2.4, 95% CI 1.5-3.8), reported Kiva Fisher, PhD, of the CDC, and colleagues.
When the analysis was restricted to case patients with close contact to anyone with confirmed COVID-19, case patients were still more likely to report having visited a bar/coffee shop (aOR 3.9, 95% CI 1.5-10.1) or restaurant (aOR 2.8, 95% CI 1.9-4.3) than control patients, albeit with wider confidence intervals, Fisher’s group wrote in the Morbidity and Mortality Weekly Report.
Not surprisingly a substantially larger proportion of case patients reported close contact with a person with COVID-19 versus controls (42% vs 14%, respectively).
This data was previewed at the National Academy of Sciences and Medicine (NASEM) workshop on airborne transmission as part of the growing “circumstantial evidence” suggesting airborne transmission may play a role in COVID-19 spread.
“Reports of exposures in restaurants have been linked to air circulation,” the authors wrote. “Direction, ventilation, and intensity of airflow might affect virus transmission, even if social distancing measures and mask use are implemented according to current guidance.”
Researchers examined data from adults tested for SARS-CoV-2 at one of 11 Influenza Vaccine Effectiveness in the Critically Ill (IVY) Network sites in July. COVID-19 cases were confirmed via PCR testing for SARS-CoV-2 from respiratory specimens. For every case, control patients who tested negative for SARS-CoV-2 were matched based on age, sex and study location. The investigators then followed up with phone interviews. After screening, Fisher and colleagues had 154 case patients and 160 controls for analysis.
Controls were significantly more likely to be non-Hispanic white, have a college degree or higher and report at least one underlying chronic medical condition compared to cases. Self-reported mask compliance was high in both groups, with 71% of cases and 74% of controls reporting always using face coverings in public. About half of close contacts reported (51%) were family members.
About half of all participants reporting going shopping or visiting someone inside of a home with 10 people or less at least once in the 14 days prior to symptom onset. However, there was no difference between cases and controls in reported shopping, gatherings in homes irrespective of the number of guests, going to an office or salon, using public transportation, patronizing a bar or coffee shop, or attending church/religious gatherings.
Overall, 107 participants said they’d gone to a restaurant and 21 to a bar or coffee shop. Cases not only outnumbered controls in these groups, but were also significantly more likely to report that “almost all patrons” at the establishments weren’t wearing masks or maintaining safe distances.
“Implementing safe practices to reduce exposures to SARS-CoV-2 during on-site eating and drinking should be considered to protect customers, employees, and communities and slow the spread of COVID-19,” Fisher and colleagues concluded.
By Molly Walker, Associate Editor, MedPage Today