Margaret Emerson, DNP, APRN, PMHNP-BC

Many US health care institutions have established mandatory 

 vaccination policies to protect employees, patients, and the community, as well as to comply with the Occupational Safety and Health Administration’s anticipated emergency temporary standard requiring health care providers with 100 or more employees to ensure that staff are vaccinated.

 In response, some health care workers are submitting vaccine exemption requests for religious, medical, and mental health reasons, and organizations are challenged with determining the validity of these requests with little precedent to inform current policy. The purpose of this article is to discuss how behavioral health (BH) experts in one organization conceptualized anxiety-related medical exemption requests for the COVID-19 vaccine, in an effort to inform others confronted with similar circumstances.

 for health care workers protect public health, promote workplace safety, and minimize risk of harm to vulnerable patients. The exemptions, in turn, are important to protect the ability of workers to carry out their chosen occupation without being disqualified by their health status, a widely recognized ethical value. Granting or denying an exemption thus warrants a heavy burden of justification. That difficult standard can be met in some cases, such as exemptions for risk of allergic reaction to the COVID-19 vaccine. Given that serious allergies to COVID-19 vaccines are relatively rare, the degree to which potential exemptions for this reason undercut public health is minimal, particularly under conditions of staffing shortages in which retaining the services of health care workers with serious allergies is itself an important goal. Furthermore, risk to workplace safety can be mitigated through regular testing, masking, and social distancing.

Given the rapid implementation of COVID-19 vaccine mandates, there has been limited time for professional societies to develop guidelines for how such requests should be handled, leaving organizations to independently navigate this space. To evaluate and determine dispositions for COVID-19 vaccine exemption requests, many health care organizations have formed committees consisting of representatives from human resources, legal affairs, ethics, and relevant medical specialties. This has been the case for one academic medical institution, whose committee received several exemption requests citing anxiety about the COVID-19 vaccine. A workflow had been developed for other medical conditions, such as allergic reactions, as well as for religious concerns; however, psychiatric exemption requests had not been anticipated and, thus, no workflow had been established.

The committee reached out to the institution’s BH leadership for consultation on handling these anxiety-related exemption requests. The BH leaders convened a team consisting of psychiatrists, a psychologist, and a psychiatric nurse practitioner. The team felt it was crucial to seek guidance from professional societies and experts in anxiety disorders. At the time, none of the professional or health care organizations contacted had developed a policy for such exemptions.

Initially, the BH team considered if exemption requests for anxiety should mirror requests based on other medical conditions. Employees requesting exemptions due to allergies, for example, are given a short (no longer than 6-month) extension of the vaccination deadline and the opportunity for evaluation and treatment at the medical center’s allergy clinic at no cost, or with a different allergist of the employee’s choosing at their own expense. A list of possible outcomes from such requests is available in the 

 Possible Outcomes of Requests Made by Employees for Exceptions From Vaccine Requirements Due to Allergies

In all cases, the allergist—with the consent of the employee to release the information for purposes of processing the exemption request—makes a recommendation to the vaccine committee. The BH team felt that several questions needed to be answered to determine if the allergy model was appropriate for anxiety.

Is Anxiety a Legitimate Reason Not to Be Vaccinated?

A foundational principle in the treatment of anxiety disorders is that one must overcome avoidance and directly confront the source of anxiety to fully recover. This taps into the folk wisdom of “facing your fears,” and it is backed by decades of psychological research and clinical neuroscience. Exposure therapy, a cornerstone of cognitive behavioral therapy (CBT) for anxiety, aims to help individuals conquer their anxiety by repeatedly and strategically exposing them to personalized fear-inducing cues or scenarios.

 The underlying mechanism most likely relates to formation of an inhibitory pathway to calm the amygdala, which generates the fear response; the process is called fear extinction.

The efficacy of exposure entails a lesson in what not to do for someone with an anxiety disorder—which is to facilitate an avoidance strategy as part of their management of anxiety. Accommodating someone’s fear will perpetuate it by preventing both the opportunity for learning and the creation of inhibitory pathways. It is therefore antithetical for clinicians specializing in the treatment of anxiety disorders to consider anxiety as a reason for exemption. This would, in effect, endorse avoidance of something—in this case, a vaccine—that is widely considered to be safe for individuals without medical contraindications.

It is noteworthy that the management of both allergies and anxiety involves exposure to the offending stimulus in order to achieve desensitization. The difference is that allergies may actually be life-threatening, whereas anxiety—although it may result in fears of harm or even death—is not. In fact, and in contrast, anxiety is most harmful when exposure to the source of the anxiety does not occur. Hence, vaccine anxiety is very unlike a vaccine allergy. The allergy policy previously outlined balances the important benefits of vaccine mandates against the therapeutically appropriate handling of individual employees’ allergies. But in this case, it is difficult to see how one can justify risking the important benefits of vaccine mandates by offering permanent exemptions for vaccine-related anxiety, given that the avoidance behavior being facilitated would, if anything, be more likely to exacerbate than to ameliorate the underlying problem. Taken on its own, facilitating problematic health behaviors is an inadequate reason to forgo the important benefits of a mandate.

What Are Some Strategies for Handling Such Exemption Requests?

Ultimately, the team concluded that anxiety was not a reason for granting permanent exemptions. To take this stance is not to say that anxiety should not be handled as seriously or compassionately as any other request for a medical exemption. It does not work to say “just get over it” to someone whose innate (ie, subcortical, nonconscious) survival mechanisms are sounding an alarm, any more than it works to tell someone with an essential tremor to “just hold still.” Although we may not be able to approve a vaccine exemption request for the reason of anxiety, we can and must still consider a reasonable medical accommodation.

The response that this group recommends is to allow a standardized delay in the deadline for vaccination that would enable the employee with anxiety to receive treatment from a resource of their choice, such as an employee assistance program or a psychiatrist and/or therapist who specializes in anxiety disorders. The goal would be to help the employee to get vaccinated by the end of treatment, if that is the individual’s ultimate goal as well. The average number of sessions of CBT for anxiety is 8 to 12, which, with weekly meetings, would mean 2 to 3 months of treatment. There is some evidence that more sessions may lead to further improvements in anxiety,

 but 3 months could strike a balance between the time-sensitive need for immunity and allowing adequate time for therapy with a clear and specific goal. Similarly, a medication response can be expected within about 3 months.

At the end of the prespecified delay, the employee will have to decide to be vaccinated or not. This solution takes employees’ concerns seriously and affords time to treat anxiety that may make vaccination difficult. It also avoids disincentivizing the employee to work on their anxiety because the extension period is limited.

Should We Be Concerned About Claims Made in Bad Faith or Abuse of This System?

We can never know someone’s true motivations, and in this case, there are 2 individuals whose intentions are relevant: (1) the employee submitting the vaccine exemption request and (2) the medical provider signing it. Unfortunately, we can assume that there will be individuals who will seek a loophole to circumvent this new requirement, and anxiety might be easier to malinger than an allergy, given the lack of measurable biomarkers. There will also be those who do not have an anxiety disorder as defined by the DSM-5, but instead are suffering from distress related to the mandate itself. The very need for the mandate comes at least in part from the fact that the COVID-19 vaccine rollout has been fraught with political polarization, ideological flame-fanning, and outright misinformation. To the average person caught in this maelstrom, making a decision may feel nearly impossible, with the stakes being one’s employment and livelihood. The medical provider signing the exemption is also not excluded from misunderstanding or conflicted interests, including wanting to support the patient making the request.

By excluding anxiety as a reason for exemption, claims made in bad faith can be minimized. Based on our experience, most physicians have not been signing exemption requests for reasons related to mental health. It would be reasonable for organizations to initially grant a 3-month delay as previously described. Organizations could then monitor outcomes and sequelae, such as the success of this accommodation in maintenance of employment and the number of exemption requests for anxiety over time (eg, determining whether requests increase if word spreads among individuals seeking a delay for any reason). If organizations detect an increase in requests among the employed population, one strategy might be reaching out to the signing medical provider for additional information prior to granting the accommodation. We would also recommend keeping this policy confidential so that it will not be readily utilized by those looking to delay vaccination.

Do Behavioral Health Conditions Constitute a Valid Reason for Exemption?

One of the challenges of this question is the lack of precedent. To the knowledge of these authors, there is no reason to believe that any behavioral health condition would constitute a valid reason for exemption. On October 1, 2021, the ethics committee of the American Psychiatric Association (APA) made a public statement, which is excerpted here

Psychiatrists should not provide vaccine exemptions for those with anxiety or other mental health symptoms, nor should institutions accept such exemptions written by nonpsychiatric physicians, absent compelling evidence that the individual’s mental health condition is so extreme that it rises to the level of a medical reason which prevents the individual from receiving vaccination. The individual preference or request of a patient cannot justify departure from a psychiatrist’s public health responsibilities to support vaccine mandates. Instead, any patient with anxiety or other mental health symptoms related to vaccination should be offered support and treatment as needed to enable them to receive vaccination.

We recommend that interested individuals and organizations review the APA’s opinion in its entirety and look for updates. It is critical to have an ongoing conversation about the humanitarian, scientific, public health, and ethical factors involved in a new medical mandate. Like the scientific method or any good dialectic, this conversation about ethics and strategy is just a start and may evolve substantially over time.

 is an assistant professor in the Department of Psychiatry, University of Nebraska Medical Center College of Medicine, in Omaha. 

is vice-chair for clinical services, Department of Psychiatry, and a psychologist in the University of Nebraska Medical Center College of Medicine, in Omaha. 

 is an assistant professor of philosophy and a member of the medical humanities faculty of the University of Nebraska College of Arts and Sciences, in Omaha.

Disclosures: Dr Edwards has partial salary support as a site private investigator, funded by a federal research grant given to Theranova LLC, which is paid to her institution. Dr Emerson has received payment as a Severe Mental Illness Advisor Presenter and also has a role on the American Psychiatric Association’s Advanced Practice Provider Expert Advisory Panel. Dr Cates has a contract paid to his institution by way of Emory and UNMC from the US Department of Health and Human Services, Assistant Secretary for Preparedness and Response. Dr Steel has no disclosures.

1. Path out of the pandemic: President Biden’s COVID-19 action plan. The White House. 2021. Accessed October 27, 2021. 

Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials

A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders

4. Hermans D, Craske MG, Mineka S, Lovibond PF. 

Optimum number of sessions for depression and anxiety

7. COVID-19 related opinions of the APA Ethics Committee. American Psychiatric Association. May 5, 2020. Last updated October 1, 2021. 

https://www.psychiatry.org/psychiatrists/practice/ethics

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