key: cord-0909831-or2xbvaf authors: Espinel, Zelde; Shultz, James M. title: Using guidance from disaster psychiatry to frame psychiatric support for cancer patients during the COVID‐19 lockdown date: 2020-07-10 journal: Psychooncology DOI: 10.1002/pon.5464 sha: 53c0334f38f39d097eb28a8bf9ed341c2032bd8c doc_id: 909831 cord_uid: or2xbvaf nan Providing effective psychiatric support for cancer patients during the COVID-19 pandemic benefits from guidance developed in the past 20 years, following natural and anthropogenic disasters. In 2004, disaster mental health experts convened a symposium to examine the scientific underpinnings of early psychological support for communities exposed to extreme events. The product of their endeavors was a landmark paper entitled, "Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence." 1 The five principles, each grounded on a breadth of scientific evidence, are safety, calming, connectedness, selfefficacy, and hope. Each of the five are psychologically beneficial. Collectively, they assist survivors to cope with the stressors of large-scale, potentially traumatizing events. This framework was adapted for psycho-oncology consultations with cancer patients at Sylvester Comprehensive Cancer Center during the initial online encounters with patients after shifting to telehealth delivery of care. For cancer patients, the arrival of the COVID-19 pandemic has been an extreme event. In addition to their cancer diagnosis, our patients tend to be older and frequently immunosuppressed, with multiple underlying conditions -the precise attributes that amplify risks This article is protected by copyright. All rights reserved. for severe or fatal COVID-19. COVID-19 is easily transmissible through direct patient contact, touching contaminated surfaces, and airborne spread via bioaerosols and droplet clouds. 2,3 Viral spread from asymptomatic or presymptomatic individuals has been extensively documented. 4 Cancer patients must take extraordinary, life-changing precautions to prevent infection and illness. Understandably, many patients were highly distressed during the initial online consultation sessions, trying to adhere to their cancer therapy regimens and supportive lifestyles in a COVID-19-transformed world. Helping cancer patients deal with the compounding stressors of their cancer treatment and the overlay of COVID-19 required a new framework -and the five principles provided the heuristic needed for devising a practical approach. Reissman and colleagues envisioned the five principles as dynamic pathways. 5, 6 Think of safety, calming, connectedness, self-efficacy, and hope as desirable endpoints. When COVID-19 arrived in the community, so too did danger, distress, physical distancing, helplessness, and despair. So, the mission of early mental health and psychiatric intervention is to move cancer patients along five pathways to help them cope with COVID-19. Effective intervention places cancer patients who are grappling with COVID-19 on a glide path (1) from perceived danger to perceived safety, (2) from fear to calming, (3) from isolation to connectedness, (4) from helplessness to self-This article is protected by copyright. All rights reserved. efficacy, and (5) from despair to hope. These principles are helpful in a practical sense as well as being psychologically beneficial. Here is how the framework was applied within a series of telehealth sessions. We began the session by identifying urgent patient needs and prioritizing these for immediate solution. At that time, we also gathered information regarding perceived sources of stress related to COVID-19. During the first weeks using this framework, we compiled a list of stressors reported by the patients; the expanding list was used to provide examples and stimulate discussion about stressors with each subsequent patient encounter (Table 1) . A portion of the initial session used problem-solving to identify, list, and triage patient concerns. Patients selected one priority solvable problem as a focus for the session, followed by brainstorming, identifying helpful strategies for managing the problem, and developing an action plan. Then we embarked on the five principles. Infectious disease outbreaks can challenge individuals' psychological sense of safety, leaving them worried about infection and death. Promoting a sense of safety and comfort can reduce distress and minimize psychological consequences. Strategies included providing education This article is protected by copyright. All rights reserved. about how COVID-19 spreads and actions that individuals can take to protect themselves. Science-based information and resources were provided. This principle was especially amenable to guided, participatory practice via telehealth. Calming strategies make a stressful time feel less turbulent. The psychiatrist guided patients in deep breathing and participated with patients in listening to a brief mindfulness podcast. Psychiatrist and patient practiced a "grounding" technique, redirecting their focus toward non-distressing things in their environment that they can see, hear, or touch. Patients were advised to refrain from watching excessive media coverage about COVID-19 and instead to stay informed through once or twice daily news updates. Population-level mitigation strategies -stay-at-home orders, physical distancing -are antithetical to social connectedness, but learning how to use available technologies can restore some aspects of social support. These include the online consultations with providers, telephone support groups, text messaging, web-based chat rooms, and video calling. During the initial sessions, psychiatrists took on the unusual role of "tech coach" to their patients. As patients gained mastery over the new modalities of virtual communication, they reestablished connectedness -and connectivity. This article is protected by copyright. All rights reserved. For many patients, COVID-19's arrival into the community engendered a sense of vulnerability, helplessness, and lack of control. Self-efficacy is the principle where a psychiatrist can be most proactive. Strategies focus on countering helplessness with "can-do-ness." The mainstay here is the promotion of positive activities, tailored to the patient's physical capabilities and adapted to the constraints of limited mobility during lockdown. Problem solving was used to inventory the activities the patient enjoys, and adapt selected activities to current realities. All patients were encouraged to maintain daily routines, eat a healthy diet, and observe regular sleep/wake patterns. Keeping physically active is critically important, so session time was spent on how to adapt an exercise routine to the patient's environment. Patients considered, and then selected, enjoyable and edifying activities that could be done comfortably at home. The psychiatrist can instill hope throughout each online encounter, reassuring the patient that professionals and caregivers are available and accessible. Patients whose survival horizon extends for several years could be assured that COVID-19 vaccine development is progressing a peak speed and, as soon as late 2020, vaccines may become available for distribution. Conveying that the current COVID-19 crisis is time-limited is a hope-filled message. Patients can be told about what their own medical centers are doing on the front lines to improve patients' lives. This article is protected by copyright. All rights reserved. Clinicians can infuse the entire encounter with hope through their positive demeanor, capability for establishing rapport, and realistic reassurances that mental health support is readily available. This five-principle framework was implemented with dozens of patients during the first months of telehealth consultation and seems to be a promising approach that can be flexibly adjusted according to the future progression of the COVID-19 pandemic. Shifting to telehealth consultations and interventions was essential for patient and provider safety due to the ease of transmissibility of COVID-19. [2] [3] [4] Fortunately, recent reviews of studies conducted in the pre-COVID-19 era have found that digital interventions appear to facilitate patient-provider communication in cancer care. 7 At least throughout the remainder of 2020, until an effective and immunogenic vaccine is developed and widespread population vaccination is achieved, these approaches will need to be maintained for supportive cancer care. As a possible offshoot of this exploration into using disaster psychiatry principles for supporting cancer patients during COVID-19, it is possible that this approach may have more mainstream applicability in cancer care. The trajectory of cancer care is not uncommonly punctuated by a series of highly-stressful crisis points, starting with the moment when the patient receives the initial cancer diagnosis. 8, 9 Other inflection points that are fraught with distress, and may signal This article is protected by copyright. All rights reserved. life threat, include being informed that the cancer has spread within an organ or metastasized, that a hopeful therapy has not worked, that remaining life expectancy is short, or that hospice care decision-making is at hand. Handling stress, distress, anxiety, and possible depression at some of these crisis points might potentially benefit from problem-solving and support using the safety, calming, connectedness, self-efficacy, and hope framework. 10 This article is protected by copyright. All rights reserved. No funding was received for this study. Data sharing is not applicable to this article as no new data were created or analyzed in this study. This article is protected by copyright. All rights reserved. Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence Turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of COVID-19 Small droplet aerosols in poorly ventilated spaces and SARS-CoV-2 transmission Prevalence of asymptomatic SARS-CoV-2 infection: A narrative review Disaster mental and behavioral health Psychological impacts of natural disasters This article is protected by copyright. All rights reserved Digital interventions to facilitate patient-provider communication in cancer care: A systematic review The impact of a cancer diagnosis on health and well-being: a prospective, population-based study Clinical diagnosis of mental disorders immediately before and after cancer diagnosis: A nationwide matched cohort study in Sweden Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and metaanalysis This article is protected by copyright. All rights reserved  Fears about their own health  Fears about family members becoming infected with COVID-19  Fears about being infected by family member who had to work during the pandemic  Fears that their physical symptoms (e.g. cough, sore throat) might be COVID-19  Fears about being at elevated risk for severe or fatal COVID-19 (older age, cancer diagnosis, immunocompromise, other underlying conditions)  Fears about receiving treatments in hospitals or clinics due to perceived risk of contracting COVID-19Limited quantities of survival supplies  Lack of access to face masks and gloves  Not having access to nutritious food during the quarantine  Concerns about family members not having enough food or supplies  Distress related to excess time spent watching news about COVID-19  Misinformation and disinformation/conspiracy theories  Insufficient information regarding prevention of COVID  Lack of trust in the media and politicians  Limited access to internet, smartphones, tablets, PCs, and social networks  Difficulty navigating websites and applications (especially older adults who needed to use cellphone rather than laptops  Difficulty connecting to loved ones in other countries  Financial losses (e.g. money lost in the stock market)  Job loss / unemployment  Loss of health insurance due to job loss  Disruption of daily routines (physical inactivity, inability to attend PT, disruption of sleep wake cycle)  Reduced social interaction  Reduce physical contact with loved ones  Being enclosed Disrupted access to health care  Concerns about accessing routine care (especially appointments in which a physical exam is required)  Concerns about access to cancer therapies  Concerns about access to home health care and PT  Concerns about their physicians being targets of discrimination, bullying or physical violence Accepted Article This article is protected by copyright. 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