The COVID-19 outbreak will eventually end, but public health experts expect this will not be the last pandemic. Will we have learned the right lessons so we can more successfully weather the next one?
On the front cover of the 2020 March issue, Psychiatric TimesTM featured the story, “The New Game of Microbiology Clue: The Who, When, Where, & Why of the Novel Coronavirus.” When Nidal Moukaddam, MD, and Asim Shah, MD, began writing the story in January 2020, most of the public (and even much of the health care industry) knew very little of the virus that was devastating Wuhan and other parts of China. It seemed worlds away from our safe haven in the United States. By the time the issue arrived in our mailboxes, the country was on lockdown thanks to the coronavirus disease 2019 (COVID-19).
Approximately 83 million people have been infected by COVID-19 and 1.8 million souls worldwide were lost, according to The New York Times and several other news outlets. In 2020, the United States alone saw approximately 19 million cases of individuals infected with COVID-19 and around 350,000 deaths. The highest single-day death toll in the United States occurred on December 30, 2020, on which 3808 individuals died.1-3 The closest the country has ever come to that astonishing number was September 16, 1928, when about 3000 individuals died from the Okeechobee hurricane.4 Figure 1 puts the death toll in further perspective, by comparing death rates from other events.
Lessons Learned From My Recovery
I, too, became a part of these statistics—contracting COVID-19 in March 2020. After my hospitalization,5 I still had residual symptoms, including shortness of breath, fatigue, and decreased exercise tolerance. I was concerned that I would not be able to work and about the effect this would have on my patients. I wondered when—if—I would be able to work at the same pre–COVID-19 level of intensity. Would my symptoms be lifelong? Like so many Americans, I worried about the potential financial strain.
I knew that if I was to get back to being a psychiatrist, I needed to get my shortness of breath and fatigue under better control. To help improve my lung function, strengthen my exercise tolerance, and for my own mental health, I went for progressively longer walks with my French bulldog, Principe Azul. Gradually, my shortness of breath improved, but not to the point where I felt able to work onsite at the hospital.
Fortunately, I was offered the opportunity to work remotely. Not only was this my first time working in the realm of telepsychiatry, but I was the test pilot for my department. Suffice to say there was a learning curve, but I already had an interest in this area of psychiatry. Although I was not fully recovered, I improved enough to see my patients virtually. I believe work has multiple therapeutic benefits and is part of who I am.
My journey has been filled with one small step followed by another, each heading in the right direction. To date I continue to experience shortness of breath, chest tightness, periodic fatigue, and decreased exercise tolerance. My recovery has been a process, and the same will be true about our country’s slow and hopefully steady march out of this dark chapter.
A Cautionary Yet Hopeful Tale of 2 New Years
Although many of us were surprised by the severity and devastation of COVID-19, there is evidence that our top officials knew more in the early days of the pandemic than we suspected. Several news networks have reported that former President Donald Trump received warnings about COVID-19’s lethality and its serious political and economic consequences as early as January 2020, yet the administration purposely downplayed the virus’ threat.6,7 Unfortunately, this tactic resulted in the lack of a unified and scientific approach to address the pandemic.
On the other hand, 2021 kicked off with significant positive events: 2 mRNA COVID-19 vaccines (Pfizer/BioNTech and Moderna) continue to be rolled out,8,9 and 2 additional COVID-19 vaccines (Johnson & Johnson’s double-stranded DNA single shot and AstraZeneca’s chimpanzee adenovirus 2 shot COVID-19) are likely to be released as this issue goes to print.10 Newly installed President Joe Biden has embarked on initiatives to conquer the virus. Yet, there have been several days in 2021 for which the reported daily death toll surpassed 2020’s highest daily death toll. We still have a long way to go.
Here’s Looking at You, Kid: Health Care Workers
In March 2020, when New York City was the epicenter of the pandemic, both New York Governor Andrew Cuomo and New York City Mayor Bill de Blasio requested help from health care retirees and medical students to staff the front lines.11 Sure enough, one of the nurses who cared for me when I was hospitalized was a retired US Army nurse. I was relieved that a seasoned peer came out of retirement to help keep me alive.
We are a society that often dismisses and neglects its older and more experienced individuals (and yet they ran to our rescue). Perhaps that is why our most vulnerable citizens in nursing homes were first to be devastated by this virus. It is crucial that we protect the vulnerable and honor the experienced among us.
The level of professionalism and dedication among health care workers shined throughout the pandemic. With loved ones no longer allowed to visit patients, health care workers took on the role of surrogate family, comforting patients with COVID-19 and other medical issues as they confronted their own mortality. They also went the extra mile to update families and loved ones, so they did not feel so alone and helpless.
This level of commitment has not come without cost. Stress, anxiety, depression, and grief are among the constellation of symptoms affecting health care workers.12-14 They have faced the constant fear of contracting the virus and bringing it home to a loved one. They witnessed the suffering of people with COVID-19, as well as prolonged separation from family and loved ones.15,16
Although there has been some recognition of the efforts and risks, support comes in waves. Early in the pandemic we heard and saw nightly clapping for health care workers in New York City and around the country. It remains unclear what the new administration will do to meaningfully recognize this service via financial and nonfinancial compensation (ie, hazard pay, tax incentives, student loan forgiveness, a national monument to commemorate those we lost to COVID-19 and recognize our frontline workers, etc).17
“COVID Karens,” Antimaskers, and Pandemic Deniers
The pandemic also put the spotlight on those who refused to listen to science. Our country saw the proliferation of antimaskers who vocally denied the severity of the virus. They defied social distancing recommendations, gathered in large numbers, and caused superspreader events.18,19
As psychiatrists, we have explored and discussed the multitude of reasons for the antimask campaigns.20 Some of these individuals closely followed the lead of President Trump, who continued to dismiss the severity of the virus, even when he contracted it. Some have a sense of entitlement—the “COVID Karens,” who appeared regularly in videos on the news. Others suffered from pandemic fatigue or experienced significant financial or jobs loss because of the pandemic, or simply did not want to have to confront the fear and ramifications of COVID-19.21
Unfortunately, many of these individuals took their plight to the ones fighting the virus on the front lines. There are documented incidents of COVID-19 nonbelievers blocking, harassing, and interfering with health care workers’ jobs, adding insult to injury. Health care workers have had to not only rise above this noise but also manage their own countertransference.
Perhaps COVID-19 has taught us the importance of sharing clear information from the onset as well as teaching our country about science and health care.
Science and Strategies for the Long Haul
Since the onset of the pandemic, we have learned a great deal more about this virus. We now know clinical presentations are variable in severity, ranging from asymptomatic to more severe cases.22,23
Similarly, we recognize that the effects of COVID-19 is not limited to an acute insult; sometimes the virus haunts its host long after infection apears to be gone. Huang et al published a cohort study of patients 6 months after their acute infection.24 They found patients continued to suffer from fatigue, muscle weakness, sleep difficulties, anxiety, and depression. Further studies are needed to gain insight into and understanding of the long-term effects of the virus and how to address them. Like my recovery, this will require small, continued steps.
Unraveling Neuropsychiatric Manifestations
Regardless of COVID-19 infection or history of mental illness, there has been a communal experience of posttraumatic stress disorder, anxiety, depression, hopelessness, and despair.12,13,15 These symptoms may not necessarily reach DSM-5 diagnostic thresholds but nonetheless have been present for many people throughout the pandemic.25
In addition, there is growing literature that suggests some acutely ill patients may also develop neuropsychiatric symptoms.13,26,27 Multiple potential mechanisms have been proposed by which severe acute respiratory syndrome coronavirus-2 (SARS - CoV-2) induces mental status changes.23,26 Currently, there are no official guidelines on the management of these symptoms in patients with COVID-19.28
Mental Illness During the COVID-19 Pandemic
Researchers have found that individuals with psychiatric disorders are more susceptible to COVID-19 and its complications. In one study, for example, investigators found that patients with a recent diagnosis of a mental disorder had a significantly increased risk of COVID-19 infection. The effect was strongest for depression and schizophrenia, with an adjusted odds ratio of 7.64 and 7.34, respectively.29 To protect our patients, we need to do more to secure their overall well-being, such as ensuring proper housing, teaching coping skills, and boosting resilience.
Fortunately, not all patients with mental illnesses have experienced a worsening of their psychiatric symptoms.30-32 In my clinical practice, for example, some patients with anxiety spectrum disorders have reported no appreciable worsening of their anxiety during the pandemic. Instead, they noted they felt like the rest of the world was catching up to their baseline daily level of anxiety. Perhaps the pandemic has taught us to better help our patients celebrate their strengths.
Technology’s Lifeline to a Brave New World
So much has been said about the boom of telepsychiatry. The COVID-19 pandemic gave medicine (and government regulators and insurance companies) the gigantic push we all needed to leap into this brave new world. There is still much to be learned, but it looks like telepsychiatry is here to stay, in one form or another. Hopefully, we will continue to see the support needed to keep this option open not only for our patients, but also for ourselves. As Nathaniel P. Morris, MD, commented, “By allowing clinicians to work remotely, telepsychiatry may not only help existing hospital-based staff provide care during the COVID-19 pandemic, but may also attract new cohorts of mental health professionals who might otherwise not consider working in these settings.”33
The Deepening Divide of Discrimination
Although the virus does not discriminate, it has disproportionately negatively affected minorities.33,34 Black people and Latinos have died at 3.6 times and 2.5 times, respectively, the rate of White people (Figure 2, Figure 3).13,34,36 Although this is a travesty, it serves as a wake-up call. American Psychiatric Association chief executive officer and medical director Saul Levin, MD, MPA, stated: “It is time that the FDA [Food and Drug Administration] convene an expert group of minority experts to create a road map of implantable steps to address the illnesses in which health inequity has exponentially increased morbidity and mortality in underrepresented minorities.”13,36
The death of Jamaican-born physician Susan Moore, MD, gained national attention. Moore died of COVID-19 related complications 2 weeks after posting a video on social media on December 4, 2020.13,36,37 She wrote that her physician dismissed her complaints, made her feel like a drug addict, and conveyed that he did not respect her as a fellow physician.35,37
Moore’s experience made me reflect on my own when I was hospitalized for COVID-19. As a Puerto Rican and cisgender gay male psychiatrist, I am blessed to live, receive medical care, and practice psychiatry in one of the most liberal and ethnically diverse cities in the world: New York City. I was lucky that the team who treated me was ethnically diverse.
Most of my patients are African American and Latino, who are in the low socioeconomic status bracket. Many underrepresented minorities often are working in jobs that are not amenable to teleworking, and they use public transportation that puts them at risk for exposure to COVID-19.38,39 Several of my patients have lost their jobs or have been offered fewer hours. The financial strain that this causes has had negative impacts on my patients’ mental health.5
This pandemic has brought to light the inequity in health care services minorities receive throughout the United States. It serves as an opportunity for the medical and psychiatric community to better address the needs of this patient population, while maintaining appropriate safety precautions and public health measures.38
Missed Opportunities, Family, and Travel
Throughout the year, we were asked to avoid family gatherings, holiday functions, and unnecessary travel. Leisure escape time was no longer safe. Public health officials, including Anthony Fauci, MD, pleaded with Americans to stay home and only socialize with their pods. Unfortunately, time and again, Americans did not listen. We saw spikes in cases, hospitalizations, and deaths after each of the summer holidays and even more so after Thanksgiving and Christmas. According to the New York Times, the daily death toll for the US during the second wave of COVID-19 started to pick up in early November and has been steadily increasing since then.1
On the other hand, some Americans did listen, and many stayed home. The year 2020 was not the year to travel. For the safety of our elderly and immunocompromised friends and family, we had to embrace creative ways to “see” each other. The COVID-19 pandemic forced us to embrace virtual communication in almost every aspect of our lives—from how we work, receive, and give our medical care, and connect with loved ones. It is not everything. It is not the same. But it is the hand the world was dealt. It is encouraging that many of us are trying to do the best we can under such challenging circumstances. It is imperative that we work together so that we may move into calmer waters and brighter days.
The Next Chapter
It has been 1 year since COVID-19 turned our world upside down. The COVID-19 outbreak will eventually end, but public health experts expect this will not be the last pandemic. Will we have learned the right lessons so we can more successfully weather the next one?
Dr Tirado is a forensic psychiatrist at Lincoln Medical Center in the Bronx, New York, and assistant clinical professor of psychiatry at Weill Cornell Medicine, New York, New York. The author reports no conflicts of interest concerning the subject matter of this article.
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