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.
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.
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
Caring for today’s acutely ill hospital patients calls for a collaborative, interdisciplinary approach. When it comes to rating collaboration, however, physicians rate their collaboration with nurses more highly than nurses rate that collaboration, notes a recent study.
As the bar chart shows, some 63% of hospitalists rated the collaboration with nurses as high or very high, while roughly 49% of nurses rated the quality of collaboration with hospitalists as high or very high.
The article notes that the discrepancy between nurses’ and physicians’ perceptions of collaboration mirrors findings from other studies conducted in operating rooms, ICUs, and labor and delivery units.
The explanation for differing perceptions between nurses and physicians, the study notes, may be partially explained by differences in status/authority, gender, training, and patient care responsibilities. Workflow differences, poorly designed communication technology, and strained relationships also serve as barriers to collaboration. What’s more, the article notes, hospital-based physicians are often spread across multiple units, giving them little opportunity to collaborate with nurses and other professionals who work on designated units.
Healthcare Hierarchy: “Hint and Hope” v. Direct, “to the Point” Communication
Two forces may be at play in these different ratings of collaboration: the hierarchy of healthcare and the different ways doctors and nurses communicate, says Milisa Manojlovich, PhD, RN, one of the study researchers and Professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. “Whenever you have a hierarchical structure, it causes discrepancies in perception. So the physicians may perceive that they’re collaborative, but the nurses feel that they’re being told what to do. They’re not necessarily being invited to participate. And so this discrepancy is part of the problem.”
In addition, physicians use a “quick, to the point way of communicating,” notes Manojlovich. In contrast, nurses often use a form of communication known as “hint and hope” – hinting at what the nurse wants, in the hope of getting that from the physician.
Direct is Best
To address these issues, Manojlovich suggests that nurses speak more directly: “Directly ask for something that you want, and say why you want it.” The nurse then is doing more of the “cognitive work” needed, she notes.
Second, clinicians should develop a good relationship with each other, she notes. Once a good working relationship exists, “our collaboration actually improves.”
The results of this study are part of a larger project called the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) project, funded by the Agency for Healthcare Research and Quality. The project, notes the article, seeks to establish and disseminate the optimal model of care to improve interprofessional teamwork and outcomes for hospitalized patients.
Peggy Compton, Ph.D., RN, FAAN has been selected as one of the US nurses to be inducted into the International Nurse Researcher Hall of Fame, which will recognize 19 new members at the Sigma Theta Tau International (STTI) 31st International Nursing Research Congress on July 25.
Compton’s research—grounded in her practice as a neuropsychiatric nurse in different public treatment settings—specializes in the study of pain and opioid addiction, with a particular focus on the effects of addiction on the functioning of human pain systems. Her award from STTI recognizes her valuable contributions in the field, including the development of key tools such as family/personal histories of addiction and the consideration of psychiatric disorders and opioid use patterns to assess the presence of and potential for substance use disorders, as well as her study of opioid-induced hyperalgesia in patients on chronic opioid therapy. According to Penn Nursing Dean Antonia Villarruel, “Dr. Compton is one of the few nurses working in the area of pain, opioids, and addiction and how they intersect. She has built a significant program of research that includes one of the most widely used tools available to physicians and nurse practitioners to evaluate risk for misuse of prescription opioids in chronic pain patients.”
Compton is currently on the faculty of the University of Pennsylvania School of Nursing Psychiatric Mental Health NP program. She received her BSN from the University of Rochester before earning an MS from Syracuse University, a PhD from New York University, and completing a post-doctoral fellowship in substance use disorders at the University of California at Los Angeles. Of her award, she says, “I am honored to receive this most prestigious award, which represents a pinnacle in the career of a nurse scientist. Not only does it reflect the importance of nursing research in addressing critical public health issues, but also the profession’s commitment to meeting the needs of vulnerable, underserved and sometimes stigmatized patient populations, such as those with addiction and pain.”
For a full listing of the 2020 inductees into the International Nurse Researchers Hall of Fame, see the announcement at the Sigma Nursing site.
Palliative care nursing mainly revolves around enhancing the quality of life of seriously ill patients and their families during life-sustaining treatment and at the end of life. Whether or not they have been trained in palliative care, critical care nurses frequently have patients who are in need of such care. How prepared do they feel?
DailyNurse: What are some examples of palliative care nursing practices a critical care nurse might perform?
Alexander Wolf: Critical care nurses are regularly tasked with assessing and managing the distressing physical, psychological, and spiritual symptoms of critical illness. Those of us who are palliative care specialists can benefit from critical care nurses’ insight into patient/family dynamics, psychosocial situation, and cultural background.
In addition, these nurses frequently have a difficult job of bearing witness to suffering, providing a therapeutic presence in difficult circumstances, and employing two-way communication skills to help determine the treatment goals of the patient and family. These nurses must also be adept in ethical and legal aspects of care, for instance. They also need to be able to help interpret patients’ advance directives and to advocate for the wishes that patients have outlined, when appropriate.
Critical care nurses are also instrumental in providing expert, compassionate end-of-life care in the intensive care unit, which may involve the careful withdrawal of life-sustaining treatments such as dialysis and mechanical ventilation. This often requires thoughtful preparation and culturally sensitive communication with patients and family members, and skilled symptom management throughout the dying process.
DN: What is the phenomenon of “moral distress” that affects many palliative care providers?
AW: Nurses and other providers frequently report episodes of moral distress, in which an individual identifies the morally correct action to take, but feels unable to take it due to some type of constraint. Helplessness or frustration are just a few of the many emotions that an individual might feel as a result — others might include outrage or guilt, among others.
“Critical care nurses tend to experience frequent and intense moral distress in situations pertaining to the end of life, such as providing treatment perceived as inappropriate or futile, prolongation of life or death and lying to or withholding information from patients or family members.”
Alexander Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019
Previous studies have also indicated that these feelings don’t seem to entirely go away either. “Moral residue” often remains, and repeated episodes of moral distress often remind an individual of the previous episodes, causing their distress to intensify. As a result, an individual may try to protect themselves by avoiding or withdrawing emotionally from ethically challenging situations, or by quitting their job.
DN: Is palliative care training appropriate only for certain providers?
AW: Palliative care has evolved so much in recent years — it is no longer solely a subspecialty — now it is an important skill set for all healthcare providers, including nurses and physicians.
In addition, there is a continued shortage of specialists relative to the number of patients with palliative care needs. This really underscores the importance of nurses and other healthcare providers to be proficient to provide basic palliative care. In 2014, the National Academies of Medicine recommended taking measures to improve the palliative care knowledge base of all clinicians.
Numerous medical professional societies recommend timely access to palliative care, including for patients in the intensive care unit, but the lack of provider training remains a significant barrier. Our study indicates that many critical care nurses have not had much palliative care education, so we still have to work hard to better prepare nurses to meet patients’ care needs.
DN: Ideally, what changes would you like to see result from your study?
AW: There are many changes we would love to see, but here are a select few.
Bedside nurses — particularly those who have had palliative care education — need to be empowered as leaders for integrating palliative care in their practice environment. They would be in an ideal position to educate their peers and interprofessional team members. We need to better recognize nursing excellence. Physician and nurse leaders need to collaborate to ensure that bedside nurses have a voice when they feel their patients’ needs are not being met.
The critical care nurses in our study seemed to highly value palliative care, but few felt highly competent, and even fewer reported having any recent education in palliative care. Many nursing programs have done a great job in recent years to include palliative care in school curricula and in student clinical experiences, but it cannot just be “squeezed in”. There is clearly still a lot we need to do to integrate palliative care as a key competency area for nurses across specialties, particularly in critical care.
“Nearly half of respondents [in this study] rated themselves as not competent or somewhat competent in knowledge of advance directives, living wills, and do-not-resuscitate order policies. Previous studies have illuminated knowledge gaps among acute and critical care nurses in this domain…. Given the legal and ethical implications, this knowledge gap should be a key focus of palliative care education initiatives…”
Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019
Additionally, the nurses in our study placed a high value on interprofessional collaboration. In continuing education for nurses it would be wise to be inclusive of other healthcare professionals. This could help foster increased recognition of patients’ palliative care needs by all team members.
For more information on Critical Care Nurse and the AACN, visit http://ccn.aacnjournals.org/.
Thanks are extended to Alexander Wolf, DNP, RN, APRN, Nurse Practitioner, Palliative Care, at TriHealth
While some nurses have an ardent passion to become
researchers, Elizabeth Johnston Taylor, PhD, RN, FAAN, a nurse researcher at
Loma Linda University Health in Southern California, admits that she kind of fell
into it. But that doesn’t mean she doesn’t love her job. In fact, it’s quite the
“I find great joy in doing research,” she says.
According to Taylor, nurse researchers will begin a
research project by looking for an answer to a problem. For example, she says, “How
can we improve the quality of life or decrease depression among people with
disease X? or “How can the health care system better provide care for those
with condition S?” S/he will identify something that needs further study. She
says that once they decide what question needs to be answered, they design a
study using scientific methods that will best answer it—whether they are
quantitative or qualitative, use a small sample or big data, are biological in
nature or psychological, etc.
“Each phenomenon you want to study obviously is going to
require its own unique approach,” explains Taylor.
Oftentimes, nurse researchers will get others to help them with data collection, and then may work with a statistician or a team to analyze the data that is collected. Once they’ve found information that may or may not completely answer the question, it’s important to write about the results to disseminate the findings. “What good is it if you don’t share it with the world and allow the world to benefit from it?” she points out.
Taylor’s program of research—which is a researcher’s area of expertise or what s/he often studies—explores patients’ spiritual responses to illness and how nurses can support or nurture spiritual well-being. “From attending some conferences and just having conversations with chaplains, I got anecdotal evidence that some chaplains believe nurses are inappropriately providing spiritual care and/or doing things with patients that they think are within their purview, but a chaplain doesn’t think it is,” explains Taylor. “I’m doing an exploratory study where I’m asking chaplains to tell me more about these kinds of phenomena.”
For nurses thinking about getting into research, Taylor says that they need to realize that this isn’t a part-time job or something you take on with only minimal interest. They will need to earn a PhD and then obtain funding to pursue a program of research. “It really takes a lot of effort,” says Taylor. “Most academics who have a successful program of research probably work anywhere from 40 to 60 hours plus a week. So it really requires a great deal of commitment as well as a great deal of curiosity and passion.”