key: cord-0747697-s5vbkxsf authors: nan title: Statement on Mental Health and the Coronavirus Pandemic date: 2020-08-31 journal: Archives of Psychiatric Nursing DOI: 10.1016/s0883-9417(20)30509-4 sha: faa0618131fcb5dcbaefa2bac703edd32ec012e6 doc_id: 747697 cord_uid: s5vbkxsf nan The International Society of Psychiatric -Mental Health Nurses (ISPN) was officially inaugurated in 1999 from three existing U.S. professional psychiatric nursing organizations to support advanced-practice psychiatric-mental health nurses in promoting mental health care, literacy, and policy worldwide. This Statement on Mental Health and Coronavirus or COVID 19 pandemic highlights several areas: the recognition of those working with patients, clients and families; concerns with general population needs during and after pandemic; and research needed. The organization proposes to: reaffirm that mental health and well-being matter during and after the coronavirus crisis; to recognize and applaud the contributions that nurses and others working in all health care areas including the mental health fields during this time; and, to acknowledge the impact of the current crisis on psychiatric-mental health nurses, nursing students and educators and related research. No part of the world has been left untouched by the spread of the coronavirus . This is nothing like we have seen in 100 years. In the U.S. at this writing day 65 of self-quarantine, 1,479,459 cases have been identified and 91,900 deaths have resulted from COVID-19 disease (WHO, 2020; New York Times, 2020) . To date, there is no confirmed treatment and no vaccine available. Stay at home quarantines are in place in most states and globally. Streets are deserted, schools are closed and businesses have shut down. Unemployment has sky rocketed and food banks have overreached their capacity. Hospitals are repurposing care settings, elective surgeries are cancelled, and new emergency field hospitals have been set up in parks and convention centers in large cities. Volunteer retired health professionals are coming forward, relearning critical care skills for deployment to sites of greatest need. Hospital staff are working in situations compromising their own health and mental health; thus far 91 nurses have died as a result of caring for COVID-19 patients in the U.S. (Gruenburg, 2020) . Persons with mental health or substance use problems have been set aside. Because of the very nature of the disease, isolation, inconsistent availability of testing, and physical and mental exhaustion, there is reduced nurses' ability to function. At a time when the need for nurses is enormous, schools of nursing have difficulty obtaining clinical hours for degree completion (National Task Force, 2020). Looking forward there will be substantial need for mental health, psychiatric, behavioral and substance services. The COVID-19 pandemic has created national and international challenges related to mental health, with nearly 45% of adults in the United States reporting that mental health has worsened since the start of the pandemic response in March 2020 (Panchal et al., 2020) . Social distancing, isolation, and quarantine have been associated with adverse mental health outcomes (Hawryluck, Gold, Robinson, Pogorski, Galea, & Styra, 2004; Jeong et al., 2016) . COVID-19 has precipitated a public health response unlike anything seen in modern history. While quarantine reduced the number of people with the disease by 44-81%, the psychiatric and social sequelae related to the COVID-19 containment response includes an increase in depression, anxiety, and trauma-related symptoms, intimate partner violence and child abuse (Galea, Merchant, & Lurie, 2020; & Nussbaumer-Streit et al., 2020) . Specific groups may be at increased risk for COVID-19-related mental health sequelae, including those who have had direct or indirect contact with the virus, those already vulnerable due to biological and psychosocial stressors, and those in the health professional fields (Fiorillo & Gorwood, 2020) . Those with serious mental illness, including schizophrenia and bipolar disorder, may be impacted due to issues with care availability and access. Populations such as children/teens in the foster care system, pregnant women, older adults, immigrants, persons with serious mental illness, persons experiencing homelessness and incarcerated populations have unique vulnerabilities for mental health symptoms. These individuals may have higher risk of infection, increased risk of isolation, fewer social supports, and decreased access to mental health care services (National League of Cities, 2020). This is particularly problematic due to the present shortage of psychiatric treatment and bed availability on a national level (O'Reilly, Allison, & Bastiampiallai, 2019). Psychiatric inpatient units have responded by suspending noncritical admissions, limiting psychotherapeutic group therapy sessions, requiring patients wear masks and gowns, or isolating patients in their rooms (Li, 2020) . Many of the interventions negate the intended benefit of inpatient psychiatric care to promote social interaction and engagement in therapeutic interaction. Currently, no effective pharmacological interventions or vaccines are available to treat or prevent COVID-19 (Nussbaumer-Streit et al., 2020) . Other groups of clients/patients impacted by COVID-19includes patients with substance use disorders. Patients in need of pharmacotherapy are at-risk to face additional barriers for treatment. The Substance Abuse and Mental Health Services Administration (SAMHSA) has granted exemptions for initial in-person evaluation for treatment and allows a telehealth approach (SAMHSA, 2020). Patients with alcohol use disorder, may have increased risk for alcohol withdrawal symptoms. Pregnant patients with substance use disorders or psychiatric illness who test positive for COVID-19 require complicated and challenging care to optimize the prognosis for both mother and child (Qi et al., 2020) . Careful monitoring and harm reduction strategies, therefore, need to be in place. Historic underfunding of mental health care, unemployment and uncertain federal, state and private capacity or plans for addressing the economic consequences have led to predictions of a coming wave of unaddressed mental health care needs and increase in suicides (Meadows Mental Health Policy Institute, 2020). According to the Center for Disease Control (CDC), over 9000 health care workers tested positive for COVID-19 between Feb. A8 and April of 2020 (CDC, 2020). Psychiatric-Mental Health nurses play an essential role in caring for patients with mental health problems during the COVID-19 pandemic. They are on the front-lines in mental health settings and are experiencing a higher exposure to Covid-19 along with emotional distress and trauma during and most likely after the pandemic (Fiorillo and Gorwood, 2020; Miller, 2020) . Nurses working across the care continuum are at increased risk for exposure to COVID-19. They may experience acute stress, Post-Traumatic Stress Disorder (PTSD) and other trauma-related symptoms. Emerging evidence highlights the negative mental health outcomes in nurses potentially exposed to the virus, including mood-related symptoms (Kang et al., 2020 , Liu et al 2020 . Nurses are at-risk for the development of burnout, compassion fatigue, and moral injury (Alharbi, Jackson, & Usher, 2020) . They must also deal with decisions about the allocation of scarce resources (Khoo & Lantos, 2020) . In addition, mental health nurses are exposed to increased agitation and violence from patients struggling with mental illness and additional a high degree of isolation (Miller, 2020) . Some nurses are choosing to isolate from their families in order to protect them, which adds to and may result in depression, anxiety, insomnia, moral distress, including self-criticism and intense feelings of shame, guilt, disgust. All of which can contribute to mental unbalance or posttraumatic stress disorder (APNA, 2020; Liu, J et al 2020). It is critical that nurses engage in self-care practices, and paramount that employers and nursing administration support them in doing so. Self-care practices including mindfulness, adequate sleep hygiene, exercise and a healthful diet, selfcompassion can improve outcomes for nurses (Galea et al, 2020) . Thay should be provided with consistent schedules, reasonable length shifts, and most importantly, adequate personal protective equipment . There is a growing body of evidence that supports the engagement of peer to peer support as a way to combat the crisis that those working in healthcare are facing (Bellamy, Schmutte, & Davidson, 2017; Connors, Dukhanin, & March, 2019) . Many models exist for this type of support and it should continue to be promoted as an accessible, low barrier and sustainable form of lay mental health support for those experiencing difficulty coping with the current crisis. Among health care workers, peer models add the additional benefit of shared experience in the healthcare setting and feeling as if someone understands the challenges of the specific clinical environment (Van Pelt, 2008) . There are emerging models that such evidence works for nurses during the COVID-19 pandemic (Maben & Bridges, 2020) and several exemplar projects/programs (see Appendix 1) dedicated to these efforts. Health care organizations should be aware of the physical and emotional duress that nursing staff are enduring, and provide resources for them both during and after the pandemic (MHNUK, 2020; ICN, 2019). Included should be those to manage posttraumatic stress disorder (PTSD) experienced by the nurses, as well as burn-out and compassion fatigue (Galea et al, 2020) . These supports will be essential in ensuring the wellness of psychiatric-mental health nurses as they prepare for increased demands for mental health care that will undoubtedly present in the coming and future months. Psychiatric-Mental Health nurses should be encouraged to assess themselves, and ensure that they are performing self-care activities, taking time for spiritual practices, and limiting exposure to media can also decrease anxiety and the risk of negative outcomes while increasing a sense of well-being (Picco, L., Yuan, Q., Vaingankar, J., Chang, S., Abdin, E., Chua, H.C., et al 2017). Nurses can support their peers, and be cognizant of any potential signs of a mental health crisis or warning signs of suicidal behavior that must not be overlooked (Davidson et al 2019) . After decades of neglect and underinvestment in mental health services, the COVID-19 pandemic is now hitting families and communities with additional mental stress according to the UN Secretary-General (Guterres, A. 2020) . In regard to communities, social distancing and associated measures are precipitating significant economic decline. The fear of COVID-19, associated with drastic declining economic factors place an additional burden on families and communities. With greater numbers of psychiatric services transitioning to telehealth to adhere with social distancing recommendations, patients already underserved or vulnerable may face other economic disparities. COVID-19 may strain services in community mental health centers and inpatient psychiatric facilities (Druss, 2020) . COVID-19 has disrupted the education of over 90% of children, adolescents, and young adults enrolled in an educational program (Lee, 2020) . Students may no longer receive mental health services in school, including face-to-face services and peer support interventions. Eighty-five percent (85%) of children, adolescents, and young adults reported that the pandemic response had worsened their mental health symptoms (Lee, 2020) . Children now receiving school instruction at home disrupt family routines. Parents and caregivers are burdened with the task of managing and monitoring their child's education, while maintaining their own employment. COVID-19 and the associated response has significantly disrupted the education of nursing students. Nursing students may not be able to continue with clinical practicum experiences, face delayed graduation and results in financial burdens. Pre-licensure students are forced to transition to online instruction and may not have conducive home environments for such modalities. Nursing faculty face intense workload stressors, extended hours, new virtual techniques, creative curriculum changes for practicum experiences. They are called on to provide support to their students, including flexibility and additional mentoring/tutoring. Multiple states have allowed for early graduation of nursing students in order to buttress the workforce in light of the pandemic. These new graduates are being tasked with orienting and transitioning from novice to competent in the midst of the pandemic which may not be ensuring quality care. These new graduates must be supported not only by academic institutions, but also by health care systems. Research is a required component in providing services to the public because it can either confirm the current practice is accurate and working or is inefficient and needs to be changed. In the current COVID-19 crisis, there are several critical A9 interdisciplinary research priorities pertaining to mental health and psychological wellbeing (Homes et al., 2020). The first research priority is the increased need for data at the local, state, and federal level. Not yet systemically studied is the impact of quarantine, media exposure to messages on the pandemic, decreased ability to obtain in-person services, social distancing, and uncertainty on mental health surrounding the pandemic and varied symptoms of individuals and community (Homes et al., 2020; Brooks et al., 2020) . Due to the urgency of preventing the transmission of COVID-19, clients are being barraged with change that add stressors and anxiety to a population that needs stability. Will the client engage more efficiently with virtual or telehealth treatment because of being in their own environment or will the virtual visit impact communications? These are some of the unknowns that need to be researched. It is critical that data be systematically tracked, analyzed, and used to shape policy for the needs of the most vulnerable. Evidence is mounting that there are neurological as well as neuropsychiatric symptoms among individuals previously infected with COVID-19; further research is warranted to assess the long-term impact of COVID-19 on patients recovering from infection. Unanswered is whether depression and anxiety following COVID-19 infection are directly related to infection or to the clinical and occupational exposures associated with infection or to the increased burden of psychiatric symptoms faced by clinicians serving on the frontlines (Lai, Ma, & Wang, 2020) . A common goal is with increased services there is more opportunity for bridging the digital divide and our collective response to the COVID-19 pandemic will increase equity rather than deepen disparities. The "new normal" is inserting telehealth as the primary platform for health and mental health care. As research supports telehealth treatment, guides will become compulsory to protect all parties involved (CMS, 2020). Costeffectiveness, patient outcomes, payment processes and structures are also critical to evaluate if new modes of treatment provide an effective solution to delivering mental health care. Nurses have a duty to care. ISPN has supported national and international efforts to assist with educating and reaffirming that mental health and well-being are critical components of all lives. The Coronavirus pandemic has precipitated a crisis with large segments of the global population under shelter-in-place or selfisolation orders. During the best of times clients with mental or substance use problems are the most vulnerable people in society. Without a pandemic, they already compete for limited housing, healthcare support, and other resources needed to survive. Demands have required many mental health and substance use programs, to either reduce their services or close temporarily, leading to layoffs and redeployment of psychiatric mental health nurses to different areas of practice. These changes create additional stresses for the psychiatric-mental health nurse and also create concerns related to their patients not being able to receive the care they need. Now more than ever Psychiatric-Mental Health Nurses require and deserve support. • Specific groups may be at increased risk for COVID-19related mental health sequelae, including those who have had direct or indirect contact with the virus, those already vulnerable to biological and psychosocial stressors, and those in the health care delivery professions. • Psychiatric-Mental Health nurses play an essential role in caring for patients with mental health problems during the COVID-19 pandemic. They are on the front-lines and experiencing a high exposure to potential COVID-19, along with emotional distress and trauma during and after the pandemic. • The psychiatric and social sequelae related to the COVID-19 response includes an increase in depression, anxiety, and trauma-related symptoms, in addition to intimate partner violence and child abuse. Crisis does not change professional standards, or the Nursing Code of Ethics. Each nurse is accountable for clinical competence and values driven care. • Nurses are working across the care continuum and it is vital to prioritize self-care. They experience acute stress, burnout, compassion fatigue, moral injury and other trauma related symptoms. Self-care practices including mindfulness, adequate sleep hygiene, exercise, a healthful diet, and self-compassion may each improve outcomes for nurses. • Parents and caregivers are burdened with the task of managing and monitoring their child's education, while maintaining their own employment. • The fear of COVID-19, associated social distancing guidelines, and declining economic factors place an additional burden on families and communities • COVID-19 and the associated response has significantly disrupted the education of nursing students and calls for difficult decisions. • Research is a required component in providing services to the public with clients' goals and input. It allows nurses to formulate best practices to achieve mutual goals, provide hope, and gives strength to the healthcare community. 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