WikiJournal Preprints/Working with Bipolar Disorder During the COVID-19 Pandemic: Both Crisis and Opportunity
Authors: Eric A. Youngstrom[a] , Stephen P. Hinshaw[b], Alberto Stefana[c] , Jun Chen[d], Kurt Michael[e] , Anna Van Meter[f] , Victoria Maxwell[g], Erin E. Michalak[h] , Emma G. Choplin[i], Logan T. Smith[j] , Caroline Vincent[k], Avery Loeb[l], Eduard Vieta[m]
Youngstrom, E; Hinshaw, S; Stefana, A; Chen, J; Michael, K; Van Meter, A; Maxwell, V; Michalak, E et al..
Impact of the Pandemic and Public Health Responses
The ongoing COVID-19 pandemic has to date infected more than 6.6 million people and led to more than 388 thousand deaths globally (map here) (projections of peak and incidence curve here). These numbers will undoubtedly go up before they recede. Thus, many governments have implemented regional or national stay-at-home orders in an effort to slow its rapid spread (map of the USA). In this global health emergency, special attention should be paid to the potential impact of the measures taken to combat the pandemic on patients with mental health problems, especially those with bipolar disorders (BDs).
Shelter-in-place and quarantine are key public health tools, yet they have high psychological and economic costs. They require sacrificing daily routines and public/personal social encounters that enhance health and quality of life and provide emotional support. Even in the general population, the time length of social isolation and the constrained physical space in which isolation takes place can be associated with a wide range of adverse psychological effects, including depression, malaise, lowered self-esteem, alienation, helplessness, panic, compulsive buying disorder behaviors, and panic-buying. Anger, clinical anxiety, and posttraumatic stress disorder can persist years after the end of isolation, as indicated by literature on quarantine. Vulnerable populations like people of low income, racial and ethnic minorities, and those who struggle with managing their mental health, are also at an increased risk of contracting coronavirus because of lack of access to physical distancing measures due to access to safe mobility (having to use subways/busing/metros), the inability to work at home due to unpaid time off and type of jobs ( low-wage essential workers like grocers, sanitation workers, home health aides, delivery drivers, and fast food servers), We cite all of this not to undermine the importance of physical and social distancing measures in the COVID era but rather to underscore the potential consequences for vulnerable and marginalized populations.
Effects on People with Bipolar Disorders
There are multiple ways that the pandemic is affecting people with bipolar disorders.
Disruption of Medical and Mental Health Services
The impact of measures to combat COVID-19 could be particularly severe and long-lasting in persons with BD. The present emergency is disrupting both public and private mental health services. Indeed, most patients cannot access outpatient care. More specifically, during the current COVID-19 emergency, the current state of mental health services in different countries worldwide, including China, Italy, and Spain is as follows. Psychiatric outpatient facilities have suspended all programmed and routine clinical activities as well as case management, even though they have guaranteed interventions in urgent cases (e.g., exacerbation of symptoms; appearance of adverse effects reported by the patient or family members), clinical demands (e.g., administration of depot antipsychotic medication), and legal authority prescriptions. Home visits have been limited to urgent cases and to ones that cannot be postponed when patients are unable to reach the service. In all other cases, therapeutic continuity can be achieved via telephone or online sessions, to monitor the patient’s clinical progress. Semi-residential facilities (psychiatric day-care facilities) have been closed, but even in these cases continuity of care has been achieved through phone contact. In residential facilities, individual clinical practices continue to be regularly carried out, as well as some group activities. In these settings, patient passes have been suspended and in many cases outings are allowed exclusively in the presence of an operator -- both of which curtail freedom of movement. The entry of outside visitors has been forbidden, so that the staff are the only potential contagious carriers, thus again increasing social isolation. Entry of new patients is allowed in cases that cannot be delayed (e.g., patients coming from the hospital for a post-relapse period). Even psychiatric inpatient units have limited, as much as possible, hospitalizations to urgent cases and those that cannot be postponed. Patients presenting both active psychiatric disorders needing hospitalization and Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) symptoms are normally placed in psychiatric wards, and when possible, in COVID-dedicated areas or rooms. Under threat are treatment continuity, patient-clinician alliance, treatment adherence, and patient-driven recovery progress – while the pandemic simultaneously escalates stress levels.
Alarming news reports about the economic and human costs add heightened stress, while social distancing measures simultaneously reduce opportunities for exercise, sunlight exposure, and participation in meaningful activities and social engagement. Job loss and financial uncertainty add additional strain, potentially triggering anxiety as well as mood symptoms—again, in a population already vulnerable. At the time of writing, there are now more than 22 million Americans out of work. Over 10 million Americans have applied for unemployment benefits and more are anticipated to apply. The surge is causing unemployment offices to fall behind. Many large corporations and small businesses are having to lay off workers and are experiencing great financial hardship. The U.S. federal government appropriated funds for small businesses, but businesses are still in need of aid while waiting for the funds to be disbursed. Many shuttered businesses may not reopen, causing the unemployment rates to remain low even when regions relax restrictions on movement and work.
Disrupted Routines and Sleep
The regular rhythm of a healthy life becomes hard to maintain as sheltering-in-place eliminates much of the existing structure from an individual’s day and interferes with the positive influence of other zeitgebers (e.g., getting exposure to sunlight, eating meals, engaging in social activities, going to the gym) that help to keep sleep and activity regular. Sleep and schedule regularity are key components of mood maintenance for people with BD who typically have less social rhythm regularity under normal circumstances. Thus, when work-at-home policies are implemented and classes are cancelled or moved on-line, there are fewer external forces to help people with BD to adhere to a routine.
Many people with BD have an evening chronotype, preferring to stay up late and sleep through the morning. Work or school obligations can help to keep an individual’s circadian rhythm more or less entrained with the environment. Yet for many people, COVID-19 has led to job loss or cessation of regular classes (e.g., replacement of instruction with independent work or online instructional videos that can be viewed at any time). More than a third of the global workforce was employed in sectors now experiencing a severe reduction in productivity with high risk of furlough, job loss, or bankruptcy.
Additionally, many other activities in which people have engaged for social and/or health benefits (e.g., sports teams, clubs) are on pause. Guidelines during shelter-in-place – stay at home as much as possible, leaving only to engage in essential activities – reinforce behaviors that clinicians often try hard to discourage. Although it is possible to impose structure on one’s day during shelter-in-place, doing so requires motivation and self-control. For many people with BD, acting against what feels best (i.e., resisting the tendency to stay up late) may be quite difficult to enforce. Other people can help to impose structure through shared meals and other activities, but this also becomes a challenge. That is, people with BD are less likely to be partnered than other adults and, as a result, may find themselves isolated. For those who do live with others, although the social interaction patterns may be beneficial, other stressors related to being confined can introduce interpersonal challenges, with associated mood consequences.
Medical risk factors and comorbidity
Higher risk of infection and poor outcome
People with BD are likely to be especially susceptible to infection because BD shows high comorbidity with obesity, diabetes mellitus, coronary heart disease, and obstructive pulmonary disease, as well as smoking and substance use. These factors and related physical illnesses compromise immune functioning and heighten risk for severe acute respiratory syndrome (COVID-19 if one is infected with the coronavirus). Smoking and cardio-pulmonary disease are also common comorbidities observed among those who perish from COVID-19.
Managing complex treatments
Current treatment protocols for COVID-19 are rapidly evolving, incurring risk for drug interactions, especially in patients being managed with complex regimens. Of course, BD itself frequently involves polypharmacy. Because no specific antiviral treatment has been developed, current treatment options include off-label use of azithromycin, lopinavir–ritonavir, chloroquine/hydroxychloroquine, tocilizumab, remdesivir, atazanavir, favipiravir, and other agents. Yet using these medications for patients with BD requires careful attention because of interactions between azithromycin/lopinavir–ritonavir and the commonly recommended medications for BD. For example, atazanavir and liponavir/ritonavir may substantially increase quetiapine, lurasidone, ziprasidone and pimozide levels, as well as levels of benzodiazepines, such as midazolam and triazolam. Of real concern, the possible adverse psychiatric effects of chloroquine/hydroxychloroquine include psychosis, mood change, mania, and suicidal ideation. Chloroquine may exacerbate BD and might increase phenothiazine levels. Corticosteroids are being used in some COVID-19 patients with severe respiratory distress, and effects of steroids in terms of triggering manic episodes in bipolar patients are well-known. Finally, carbamazepine may significantly decrease the blood levels of many of the drugs medications for COVID-19, thus reducing the effectiveness of such treatment. In short, the management of dual treatments for COVID-19 and BD requires substantial monitoring.
Social stigma flares when societies are under stress, with a malign eye falling on people associated with or belonging to high-risk groups, on those considered contagious, as well as on anyone considered “different.”
Stigma around COVID-19
Social stigma has particularly manifested toward several high-risk groups since the beginning of the COVID-19 outbreak. Aside from those who are ostracized because of their diagnosis, healthcare workers treating COVID-19 patients and people of Asian race/ethnicity have been subject to increased maltreatment in countries around the world. In India, news outlets report that stigma towards healthcare workers is on the rise and has resulted even in physical violence. In the United States, there are higher rates of infection and death in African Americans. There have also been reports of Asian Americans who fear racially motivated violence due to COVID-19. Government officials and the media's use of improper language to describe COVID-19 has created friction between racial groups and incited others to weaponize it against Asians across the globe. Increase of fear and anxiety surrounding the Coronavirus outbreak has breed racially-motivated hate crimes against Asians as a form of scapegoating. The rise of coronavirus hate crimes towards people of Asian descent has taken the form physical assault such as acid attacks, verbal abuse and harassment such as yelling racial slurs and blaming for "spreading the virus". Survivors of hate crimes are more likely to experience psychological distress than survivors of violent crimes. Victims of hate crimes suffer from psychological trauma like internalizing the messages associated with perpetrators' motivation to engage in the attacks which leads to low self-esteem, posttraumatic stress reactions, and a fear and distrust of others and social institutions. Another consequence of the use of racist language and influx of hate crimes against the Asian community is the fracturing of unity in society which makes preserving the sustenance of the global economy harder to achieve.
Stigma around bipolar disorder and other serious mental illnesses
BD is already prone to high levels of stigmatization and will undoubtedly take a second hit when people with BD also contract COVID-19 (Article about ostracism and violence against doctors and people with disease – several news reports). Even more, it is well documented that when people with mental disorders also develop a physical condition, the “medical” disorders are likely to be discounted and undertreated. If a person with BD contracts SARS-CoV-2 and develops COVID-19, there is clear risk that stigma could change treatment decisions and threaten therapeutic rapport. The double stigma of having two burdens may not just aggravate a sense of isolation but provoke hostility instead of support—and deprive the individual of needed treatments.
Still, crises are also times of opportunity. We can learn from examples of resilience and rethink and adapt our ways of working. At a global level, the pandemic and response to it are accelerating social and economic changes, as well as transforming daily life and use of technology for shopping, communicating, and engaging with community in ways likely to persist.
Learning from unexpected resilience
Within a few months after the start of China’s COVID-19 lockdown, Chinese mental health clinicians are seeing that if patients move from situations with insecure housing to more secure housing, they report more daily regulation and mood stability or improvement. These positive trends occur in patients returning to live with their families, as well as in hospital settings. Similarly, people with lived experience of BD who are engaged with the Collaborative RESearch Team in Bipolar Disorder (CREST.BD) network report silver linings. Indeed, during the TalkBD Online Meetup: Staying Mentally Well During COVID-19 (March 20, 2020) forum, investigators found that being proactive about protecting routine and doubling down on wellness tools prevented social distancing from triggering deterioration.
Opportunities to transform service delivery
The COVID-19 pandemic forces a rethinking of how best to improve access to and implementation of enhanced psychological and psychiatric intervention services specific for the treatment of BD. These should include--but not be limited to--home visits with physical distancing measures in place, as well as telepsychiatry and telepsychology (including both therapy and assessment; e.g., Effective Child Therapy's online assessment center). Online prescription and medicine express delivery, telepsychology management interventions, telepsychotherapy, online psycho-education programs, online mindfulness-based interventions, online sleep hygiene resources and apps, and facilitating access to existing phone and online support lines staffed by mental health professionals trained in treating BD are all salient and important. The emerging number of apps and m-health resources may play a crucial positive role. Reddit, Quora, and Wikiversity provide mechanisms for rapid, interactive information exchange and education, with Reddit and Quora providing models for expert-community exchange (e.g., “Ask Me Anything” (AMA) threads, such as CREST-BD). Wikiversity offers a potential “train the trainer” platform for rapidly changing areas, such as telepsychology. A great need exists to train and support clinicians to go to people’s online presence.
There are a number of low or no-cost crisis support resources for patients experiencing acute distress during and after the pandemic. For example, in the USA, the Suicide Prevention Lifeline (800-273-8255) is available 24/7. The Suicide Prevention Lifeline is also available in Spanish (Nacional de Prevencion del Suicido; 888-628-9454), and for the Deaf and Hard of Hearing (800-799-4889). For those who are more comfortable texting, Crisis Text Line (CTL) is accessible and available around the clock (Text HOME to 741741). Disaster distress helplines like SAMHSA are now offering counseling and support to those experiencing emotional distress related to the Coronavirus pandemic for free 24/7 by phone (1-800-985-5990), by texting "TalkWithUs" to 66746, or by visiting DisasterDistress.samhsa.gov. Since 2013, CTL volunteer crisis workers have engaged in over 140,000,000 crisis conversations with individuals across the U.S. On average, ~25% of crisis conversations include support requests by people experiencing suicidal thoughts. Among support options, CTL in particular is accessed at higher rates during population-wide stressors, such as exposure to fictional suicides (e.g., 13 Reasons Why), media coverage of suicide deaths of celebrities (e.g., Anthony Bourdain), and climate-related disasters. For example, changes in CTL crisis text volume in North and South Carolina, USA, was examined before and after Hurricane Florence in 2018. Results showed an immediate and sustained increase in crisis texts for stress/anxiety and suicidal thoughts in the six weeks following a weather-related disaster. Taken together, these data provide some promise in offering feasible, acceptable, and accessible resources for those in distress in short order.
In addition to promoting such easy-access crisis resources for patients with bipolar disorder, it may become necessary to make home environments safer during prolonged shelter in place orders. Unfortunately, suicidal crises, though often brief, can escalate quickly. In studies involving patients who have made a serious attempt, nearly 50% escalated from experiencing suicidal thoughts to an attempt in under 10 minutes. Thus, for those patients at risk for suicide (i.e., with either a history of attempts or in acute distress), helping families to secure unlocked firearms and reduce access to dangerous medications could help prevent suicide death during the pandemic. For clinicians unfamiliar with these suicide prevention strategies, online trainings for particular types of means safety approaches (e.g., Counseling on Access to Lethal Means; CALM) are publicly available and free here. Other prominent “lethal means safety” approaches are available either for free here or for a modest cost, including the Collaborative Assessment and Management of Suicidality (CAMS) Model.
Telepsychology, including both therapy and assessment, can be especially helpful during shelter-in-place. In addition to providing support during a stressful time, telepsychology can help patients to maintain the lifestyle strategies and skills they have developed and to adapt and cope with changing circumstances. Therapy also provides some interaction and structure during weekdays, which can be valuable for patients with BD. The rapid shift to online services is part of a general trend for the pandemic response to accelerate transition to online services. There are a number of ways to successfully conduct therapy while maintaining social distance. The easiest option is to use the phone, as both patient and therapist should have the necessary equipment and are familiar with its use. Furthermore, phone-based therapy raises fewer HIPAA-related concerns than other modalities. The primary downside of phone therapy is that the therapist and patient cannot see each other during a given session, so that important information can be lost.
If possible, it is often preferable to use a secure video conferencing platform such as doxy.me, Zoom(with needed security features), or thera-LINK. In addition to being able to see one another and interact in a more natural way, video enables the use of worksheets, play, and other activities that help increase engagement and facilitate learning. Video is more technologically difficult to use than a phone, but most people can master it with some instruction. Video also requires that both the patient and the therapist have a camera-enabled device. Assessment--particularly frequent self report of mood, sleep, and activities--can provide insight to both the therapist and patient. Routine assessment enables early identification of clinically significant change in need of intervention; it can also help the patient to better understand him/herself and how choices they make (e.g., sleep habits, exercising or not) can clearly affect mood and later physiology. Assessment can be conducted by emailing of self reports, reading the assessment aloud for patient response, using an online form or survey, or procuring an app. When choosing to engage in telepsychology, it is also important to consider patient symptom severity and risk. Knowing the patient’s address and emergency contact information is important, as is updating the safety plan with the patient to account for current circumstances. Some patients may need more intensive services than can reasonably be offered via telepsychology, finding an appropriate referral is important in these cases.
Despite the dramatic consequences of the COVID-19 pandemic, this emergency situation provides both the opportunity for (a) broader and more in-depth understanding of BD patients’ psychological functioning and (b) development and implementation of mental health policies and services. A prompt and effective response holds the potential to ameliorate the personal and societal risks associated with poor mental health, with the added benefit of saving private and public money. These efforts offer the opportunity to address mental illness stigma and potentially ameliorate internalized stigma by fostering a society where persons with mental disorder are demonstrably valued--with adequate support of their health needs. Indeed, appropriate use of technology can help to maintain human connections despite physical distance.
The COVID-19 crisis is a wave propelling sweeping changes in policy, access, delivery, and attitudes. When it recedes, the landscape for the treatment of BD will have changed. There will be damage and loss, but also opportunities to learn—as well as changes in service delivery that could evolve into significant innovations in service provision and improved outcomes.
We thank Nick Fogg for help gathering candidate links, and Jennifer Youngstrom, PhD, for comments on several early versions of the paper.
Eric A. Youngstrom, PhD, is the co-founder and CEO of Helping Give Away Psychological Science, a 501(c)3 nonprofit charitable educational organization. The other authors have no competing interests to declare.
There are no primary results from human or animal subjects research presented in this paper.
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