Special Report: Lessons From a Pandemic—How Geriatric Psychiatrists Adapted to Meet the Needs of a Vulnerable Population

“Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky. There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.” —Albert Camus, The Plague

In the September 21, 1978, New England Journal of Medicine, Robert Petersdorf, M.D., an internationally renowned infectious diseases expert, wrote the following in reference to infectious disease fellows finishing their training: “Even with my great personal loyalty to [the specialty of] infectious diseases, I cannot conceive of a need for 309 more infectious diseases experts unless they spend their time culturing each other.”

We all know what happened in the decades that followed: AIDS, the 2002 outbreak of severe acute respiratory syndrome (SARS), and the emergence of antibiotic-resistant bacteria. They all present lessons that warn us not to be too confident about our ability to predict and manage infectious diseases. Some took the lessons to heart and recommended that we be prepared for new illnesses and the potential for pandemics. But the majority of us were taken by surprise when a new coronavirus first identified in Wuhan in fall 2019 spread across the globe in a matter of weeks, leading the World Health Organization to declare a pandemic and call for dramatic measures to contain it.

Many people became severely ill and many died. Apparent from the beginning was that those most susceptible to the virus were older adults and those with chronic illnesses. Nursing home residents were among the first to die in the United States. Since we knew of no effective treatment for the illness, prevention was of paramount importance. Many of the measures put into place resembled those used to curtail the spread of infectious diseases throughout history—isolation , masking, and quarantine. These essential interventions were somewhat effective, but they had a cost: among them, loneliness, isolation, and separation from sick loved ones in their final hours.

Health care and human services workers faced a baffling array of challenges: preventing disease transmission (to other patients and health care workers); treating patients for a poorly understood disease for which there were no established treatments; dealing with an unprecedented demand for hospital beds and equipment, especially personal protective equipment (PPE) and ventilators; helping those who survived deal with poorly understood sequalae of infection; ensuring equitable distribution of scarce health care resources; helping the larger community deal with the broad impact of the pandemic on vital social structures; and finding ways to mitigate the adverse health impact—especially the behavioral health impact—of the measures (for example, isolation and quarantine) required to stem the tide of contagion.

It was in the early days of the pandemic that APA’s Council on Geriatric Psychiatry conceived of assembling a volume on how to adapt mental health services to meet the treatment needs of a particularly vulnerable group—older adults with mental illness—in this unprecedented environment and provide guidance for future catastrophic events.

We confronted a number of questions:

• What had past pandemics taught us about what to expect and what would be needed?

• How could we adapt existing mental health services to the new and ever-evolving realities of the current crisis?

• What did the pandemic mean for psychiatric care in the emergency department, on inpatient psychiatric units, in medical/surgical environments, in nursing homes?

• What role could technology, such as videoconferencing and the lowly telephone (“telehealth”), play?

• What were the treatment implications of pre-existing health inequities related to race, ethnicity, economic factors, and other social determinants of health?

• How could we support the beleaguered health care workforce?

• What were the specific mental health treatment requirements of the new illness itself (that is, the psychiatric manifestations of COVID-19 infection) and of the adverse psychological consequences of the measures required to contain its spread, particularly for older adults with mental illness?

What follows are eight of the many lessons we have learned thus far in an evolving story. They were extracted from our book Geriatric Mental Health Care: Lessons From a Pandemic from APA Publishing.

Paul Fürst, Copper engraving of Doctor Schnabel [i.e Dr. Beak], a plague doctor in seventeenth-century Rome.

1. Past pandemics provided lessons about the broad impact of these calamities and the measures required to contain them.

Unlike many other kinds of calamities, especially natural disasters such as hurricanes and tsunamis, the effects of pandemics tend to be protracted, extending over months or years, punctuated by intervals of subsidence alternating with intervals of resurgence, challenging our resilience. They have both acute and enduring impact on general health, mental health, and social determinants of health. And those most affected include the socially marginalized, the elderly, and the chronically ill.

Some of our initial efforts to prevent the spread of a pandemic had their origins in a time when we had little understanding of the biology and epidemiology of disease. During the outbreak of bubonic plague in the 14th century, for example, infected people were removed from contact with others to die or recover. The isolation period, initially 30 days, was ultimately extended to 40 days, giving rise to the term “quarantine,” derived from the Italian word quaranta (“forty”). Primitive forms of PPE (for example, masks)—depicted in the art of the era—were used by physicians and others charged with the care of the ill.

Modern adaptations of these and other primitive “public health” interventions were the bedrock of measures implemented during more recent outbreaks, including the 1918 influenza and the 2002-2003 SARS events.

2. Demographic factors, health inequities, and medical comorbidities interacted to exacerbate the impact of pandemics.

We saw from the beginning that older adults were at particular risk of becoming ill and dying from COVID-19; early outbreaks in the United States were clustered in long-term-care (LTC) facilities. Over time we learned that while age itself did not appear to influence the risk of contracting the virus, it was a risk factor for poor outcomes. This was at least partly a result of medical comorbidities in this age cohort. But the clustering of cases in LTC facilities highlighted the importance of living circumstances, physical proximity to others, employment setting, and other nonmedical social factors in the risk of contagion. These and other social determinants of health proved to be the most potent drivers of disease spread and outcome. People living in large multigenerational households, dependent on public transportation, employed in jobs that required in-person presence in the workplace, and/or had inadequate access to health care resources were among those at the greatest risk. The result was higher rates of infection and death among the poor, the chronically ill, and most racial and ethnic minority communities. And those who were elderly and belonged to more than one of these high-risk groups were in greatest peril.

3. COVID-19 challenged us to change our models and methods of mental health care and psychosocial support.

The need to minimize the risk of person-to-person transmission of COVID-19 forced us to find effective ways to provide care without face-to-face contact. The response of psychiatrists to this imperative was the rapid and widespread adoption of telepsychiatry in all our practice settings. Telepsychiatry was employed as early as 1959 at the Nebraska Psychiatric Institute, and convincing evidence of its effectiveness and acceptability accumulated over the subsequent decades. Yet its incorporation into everyday practice was slow due to a host of factors, including concerns about technological limitations, privacy, safety, and significant limitations on reimbursement. Although primary care telemedicine visits frequently touched on mental health topics, mental health professionals used telepsychiatry in only about 1% of their encounters. As we all know, that changed radically during the pandemic. Telehealth—including audio-only methods—became a tool of vital importance in virtually every setting where mental health services were offered, affording access to care that would have otherwise been unavailable or involved unsafe situations. Critical to this radical transformation in service delivery were long-overdue changes in reimbursement policy by Medicare, Medicaid, and other payers.

Outpatient care shifted rapidly to this modality of care. No-show rates and cancellations plummeted as patients were able to attend appointments without the costs and inconveniences of travel to offices. Clinicians could work from home. Telehealth clearly afforded access while minimizing infection risk. But this didn’t work for everyone, especially those who lacked the technology or know-how for videoconferencing. The poor and the elderly were among those most often disadvantaged by these limitations. While novel “digital literacy” programs helped some people acquire the skills to participate in telemedicine, most patients did not have access to such resources. For these patients, telephone-only contact—now covered by Medicare and some other payers—was a critical lifeline.

Hospital-based psychiatric care took advantage of videoconferencing as one of many adaptations required to meet the challenge of caring for patients—those infected and those not—presenting for mental health care. Telepsychiatry proved helpful as a mode for consultation in the emergency department (ED). Initially, psychiatric visits to EDs decreased because of sheltering in place and fears of infection. Some of those who did present for evaluation had psychological distress or substance use problems exacerbated by the pandemic. Most of these patients did not require admission, but referral to outpatient resources was difficult because many mental health and substance use disorder outpatient programs had closed or were significantly limiting admissions. At the same time, many who presented to EDs had severe symptoms requiring inpatient care, and this led to logjams in the ED, particularly for patients testing positive for COVID-19. General psychiatric units by and large were not prepared to care for such patients, forcing those who needed admission to remain in the ED, occupying beds that were needed for medical and surgical patients. COVID-positive patients frequently ended up admitted for psychiatric care to medical-surgical units, where nursing staff, who were already stressed, were asked to care for patients they had never had to manage before. These patients were treated by consultation-liaison psychiatry teams working creatively to serve patients as safely and effectively as possible in spaces lacking the specialized architectural elements built into psychiatric environments and without the support of a therapeutic milieu, group therapies, and experienced psychiatric nurses. Some of this work could be accomplished through videoconferencing technology, but some patients needed to be evaluated and treated in person because of special clinical circumstances or resource limitations. To serve these patients, consultation psychiatrists donned PPE and made their best effort to establish rapport from behind masks and face shields with patients who were also masked and might have been severely depressed, psychotic, delirious, or demented.

Patients testing negative were admitted to inpatient psychiatric units when space became available. Early experience with COVID-19 made clear the importance of developing procedures and protocols that minimized the risk of patients becoming infected on the unit while at the same time allowing effective treatment to occur. Table 1 shows measures typically put into place on inpatient units.

Some institutions, including UCLA and Johns Hopkins, created psychiatric units specifically designated for the care of COVID-positive patients. Practice on these units included procedures for donning and doffing PPE by all staff and for handling behavioral emergencies that might require hands-on intervention.

The pandemic made discharge planning for psychiatric inpatients even more difficult than usual, particularly for those hospitalized for behavioral complications of dementia and/or requiring residential aftercare. The early experience of aggressive spread and high mortality from COVID-19 infection in long-term care led facilities to limit admissions and adopt policies that left residents largely isolated and on their own. This helped slow disease spread but deprived residents of the stimulation and family contact critical to the well-being of people with dementia. Many nursing facilities responded with measures to support the efforts of staff thrust into the role of de facto family members. Simple innovations such as picture-bearing name tags helped increase the warmth and intimacy of interactions between residents and their masked caregivers.

A variety of inventions developed for Veterans Administration (VA) LTC facilities are summarized in Table 2.

4. COVID challenged us to find more effective ways to protect and support health care workers.

Some of the most vivid images from the height of the pandemic were photos of beleaguered health care staff, exhausted from long hours caring for patients with a deadly disease to which they themselves were vulnerable. Frontline workers experienced “moral distress” as they found themselves unable to meet their internal expectations for preventing death and were forced to make heartbreaking decisions about who would—and who wouldn’t—be given access to scarce lifesaving resources. While health care workers were recognized publicly as heroes for their selfless labor, they clearly needed more than expressions of gratitude and praise. A top priority was making adequate supplies of PPE available, an obvious requirement that many health care institutions struggled to meet. Other acute priorities included ensuring that staff had safe housing arrangements (some staff feared carrying infection home to loved ones), access to food (many restaurants near hospitals closed), and help with child care (an urgent need created by school closures). Health care facilities responded by creating alternative housing arrangements in dormitories or local hotels, partnering with local businesses for food delivery, and developing or expanding low-cost child care programs.

We quickly came to appreciate the importance of “emotional PPE” for staff. To allay anxiety, it was essential to make information readily available to staff. Frequent town hall meetings, leadership rounds on inpatient units, and regularly updated online resources were among the approaches utilized for information-sharing. Institutions introduced a variety of new emotional support measures, including 24/7 support lines, daily mindfulness sessions conducted over Zoom, and specialized mental health services for staff needing urgent psychiatric care. At Mount Sinai Hospital in New York City, the Department of Rehabilitation collaborated with outside vendors to create a “Recharge Room” for staff to provide a special setting for self-care. The VA developed a publicly available digital application, COVID Coach, to help staff and others manage their COVID-related emotional distress. Institutions also recognized the need to help allay secondary sources of stress for staff, developing informational programs to provide guidance about educating children at home and about finding eldercare solutions.

Emerging from the pandemic were insights about the importance of taking a proactive, rather than a purely reactive, approach to staff support and of including a robust mental health component in pandemic response programs at every level.

5. COVID was found to be associated with myriad mental health manifestations with different underlying mechanisms.

While symptomatic COVID-19 usually presents with respiratory and/or gastrointestinal manifestations, neurological and psychiatric symptoms have been recognized as part of the clinical picture from the beginning of the pandemic. Hypoactive and hyperactive delirium, exacerbation of comorbid dementing illnesses, and new onset or exacerbations of comorbid psychosis and mood disorders have all been reported. It has been speculated that these neuropsychiatric symptoms may be a result of brain infection by the virus, inflammatory responses to infection in the brain or elsewhere, hypercoagulable states leading to strokes, and other mechanisms, including drug side effects (for instance, mood instability due to treatment with high doses of corticosteroids). Since these symptoms can be the most conspicuous features of the initial presentation of COVID-19, sometimes overshadowing other medical manifestations, diagnosis and treatment of patients can be delayed. It is especially important to recognize that delirium may often be the presenting sign of COVID-19 infection in older adults without other signs of the illness.

Other psychiatric consequences of the illness are less closely linked to the biology of infection. Posttraumatic stress disorder (PTSD) has been described as a sequela of the experience of treatment in intensive care units, and it is likely that PTSD will emerge in the aftermath of treatment for severe COVID in some survivors.

People who were not infected with the virus experienced a host of pandemic-related psychiatric symptoms. Anxiety about becoming infected was very common, sometimes assuming clinical proportions. Perhaps more significant were the psychological sequelae of measures taken to contain the spread of infection. Staying alone and staying apart were critical to staying safe, but these measures exacted a price. Social isolation and loneliness are as detrimental to general health and mental health as smoking and obesity. Older people were already at risk for these conditions prior to the pandemic. COVID-19 dramatically increased their prevalence, creating a secondary mental health epidemic amplifying the adverse impact of the infection itself. Among older adults, depression, anxiety, and cognitive impairment increased the risk of isolation and its negative health impacts.

Recognition of this secondary epidemic among older adults gave rise to an inspiring variety of outreach efforts. Prominent among these were “digital literacy” programs to assist older adults in the use of technology to communicate with friends, loved ones, and health care professionals. Outreach services focusing on behavioral activation and exercise were offered remotely to older adults. “Virtual senior centers” were created, and programs were developed linking young volunteers with older homebound adults to provide safety-conscious in-person visits and/or regular telephone contact.

Many infectious diseases produce enduring effects, including neuropsychiatric sequelae. So-called “long COVID” has a host of manifestations, many of which are neuropsychiatric. Time will tell which symptoms will persist and for how long.

The impact of the pandemic on suicidality is complex and just coming into focus. While suicide rates increased during past pandemics, the overall suicide rate appears to have dropped in the United States since the onset of the current pandemic. While encouraging at first glance, this statistic obscures the fact that suicide rates rose in certain demographic groups, including most racial and ethnic minority groups. This calls attention yet again to the tragic reality that pandemics may have the most severe impact on those already disadvantaged.

6. The pandemic introduced new complexity into the prescribing of medications.

The pandemic complicated the prescribing of psychotropic medications. Psychiatrists had to become comfortable monitoring for medication side effects such as orthostatic hypotension and parkinsonism without the benefit of in-person assessments. They had to contend with the reluctance of some patients to go to facilities where blood could be drawn for blood chemistries, blood counts, and drug levels. The pandemic also increased the risk of drug toxicity (for example, due to effects of infection or inflammation on the cytochrome P450 system) and drug interactions (for example, between psychotropics affecting QT intervals and new antiviral agents with potential effects on cardiac conduction).

7. Older adults, while more vulnerable to the acute medical impact of COVID-19, may be protected from some of the adverse mental health sequelae of COVID.

Older adults clearly showed a higher risk of mortality from COVID-19 infection. Based on experience from past disasters, we might have expected the elderly to also be at higher risk for adverse mental health outcomes due to factors correlated with aging, such as cognitive impairment, mobility limitations, and dependence on systems of care. In fact, older adults have not in general shown worse mental health outcomes than younger people during the pandemic. Their rates of depression, anxiety, general psychological distress, suicidal thoughts, and substance use appear lower. A Swedish study performed early in the pandemic showed that older adults rated their sense of well-being higher than they had in the previous five years and higher than younger age cohorts. It has been speculated that these relatively favorable outcomes might be due to wisdom and resilience born of life experience. Other contributing factors might be more stable financial circumstances and less responsibility for dependents than younger adults, who were generally at greater risk for stresses such as financial strain due to unemployment and the daunting responsibility of supervising children at home in virtual classrooms.

8. The COVID-19 pandemic highlighted the fault lines in our health care system and illuminated ways forward.

The pandemic again showed us that health inequities persist, even in the nation with the highest per capita spending on health care in the world. The burden of illness still falls disproportionately on racial and ethnic minorities, the poor, and other marginalized groups, including older adults with mental illness. The National Academy of Medicine is clear that high-quality care is safe, effective, efficient, timely, patient-centered, and equitable. Erasing health inequities needs to be at the top of the list of priorities in health care reform.

The pandemic reminded us that we can be slow to adopt new models of care such as telehealth, even when there is strong evidence that these models offer accessible, cost-effective, and patient-centered alternatives to traditional approaches. The good news is that we turned on a dime to adopt new models and make them work. This should inspire us to look for other opportunities to improve our approaches to care delivery. Payers should support, not constrain, our efforts to find more and better ways to provide care.

Conclusion

We had been warned that a worldwide pandemic was likely to occur. The pandemic showed us that our health care infrastructure was not built to accommodate an arguably predictable surge in demand. We can use this experience to make sure we have the facilities and materials we need for future surges. We also need to build and support the health care workforce. And we need to ensure that mental health care resources are built into the public health and workforce-support plans. Let’s leverage these and other lessons from the pandemic to improve our health care system and prepare it to meet the challenges of the future. ■

^{Author Disclosure Statement}

^{Robert P. Roca, M.D., M.P.H., M.B.A., receives revenue from APA Publishing and has no other financial conflicts to disclose. Micheline Dugue, M.D., and Maria D. Llorente, M.D., have no conflicts to disclose.}