At no other time in modern history have the effects of stress and anxiety on medical and behavioral health been so clearly realized and documented as they are now during the COVID-19 pandemic. Every human being on the planet is having to face a new and formidable enemy that has upturned their lifestyle and their sense of security. Healthcare professionals face the additional burden of crisis-level priorities as they strive to deliver optimal patient care; it is BSN impossible for them to think beyond the triage-level urgency and decision-making that is now their new norm.
It is clear from polling statistics reported by the Kaiser Family Foundation (KFF) that a large percentage of the U.S. population is experiencing new mental and physical challenges related to the pandemic. KFF polling from March 2020 found that 32% of adults reported that their health was negatively impacted by stress and worry over the coronavirus compared to 53% by mid-July, 2020. Many also reported a negative impact on their mental health as manifested by difficulty sleeping (36%) or eating (32%), increases in alcohol consumption or substance use (12%), and worsening chronic conditions (12%), due to worry and stress over the coronavirus. In considering this data, one can see the inseparable connection between mental and physical health, and therefore the need to address both mental and physical components to be successful in whole person advocacy in the process of case management.
As case managers today, we face the challenge of working within this new pressure-cooker environment. Our primary goals of ensuring that patients are admitted and transitioned to the appropriate level of care, that they have an effective plan of care and are receiving the prescribed treatment in a timely and effective manner, and that they have an advocate for services and plans needed during and after their stay, are met with obstacles at almost every turn. It is increasingly more difficult to not only have the time to identify and anticipate our clients’ needs during and after a healthcare encounter, but also to create an executable plan and to procure the services necessary to arm our clients with what they need to foster optimal physical and mental health. Add to this the often-defeating reality that persons who are under stress and experiencing anxiety are often notably impaired in their ability to focus, retain, and attend to what they are taught.
For us to be successful at care planning in these trying times, it is imperative that we have a clear understanding of how the pandemic affects our present reality. For us as case managers, our reality is now one where our familiar referral resources are overwhelmed and overextended—if they exist at all—and our clients most likely have new personal challenges and changes in their support system stability due to the pandemic. Fear and anxiety about this virus and what could happen can be overwhelming and cause strong emotions. Public health actions, such as social distancing and quarantine, can make people feel isolated and lonely and can increase stress and anxiety. Fear of being infected also has people delaying seeking much-needed care. In light of these factors, a broader and more in-depth case management assessment is imperative. Quality case management has always involved the consideration of the whole person including their perceptions, their challenges, and their current place on the health and wellness continuum, but now this takes on a new complexity and imperative.
The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being,” therefore promoting the concept of whole-person advocacy and acknowledging the strong relationship between physical, social, and mental health conditions. The cause-and-effect relationship between mental and physical health is circular, where each causes—and is caused and/or exacerbated by—the other.
The term “mental illness” covers a wide range of problems, from those that affect mood (e.g., depression and anxiety disorders) to those that affect thinking or behavior (e.g., schizophrenia or addictive behaviors), reinforcing the need for careful assessment and the elimination of bias and stigma related to the assessment and the rendering of care. The fact that pre-COVID data shows that one in five adults live with a mental illness in any given year magnifies the concern that these existing cases are now exacerbated and that many more are now dealing with this challenge in pandemic-stricken 2020. It is more imperative than ever that case managers understand how mental illness can manifest in the clients they encounter. Common signs and symptoms can vary, depending on the disorder, circumstances, and other factors, and can affect emotions, thoughts, and behaviors.
Examples of some common signs and symptoms include:
Feeling sad or down
Confusion and impaired concentration
Feelings of guilt, fear, and worry
Withdrawal from friends and activities
Exhaustion, low energy, or problems sleeping
Delusions, paranoia, or hallucinations
Stress and inability to cope with daily problems
Impaired ability to understand and relate to situations or people
Increased substance use
Changes in eating habits
Feelings of hostility and anger
Sometimes symptoms of a mental health disorder appear as otherwise unexplainable physical complaints, such as stomach pain, back pain, headaches, or other aches and pains that do not have an identifiable physical cause. On the other hand, people with chronic physical illnesses or chronic pain are twice as likely to suffer from anxiety or depression as their physically healthy counterparts. Depression can be long-lasting or recurrent, substantially impairing the ability to function and to cope. Our clients depend on us to be able to accurately identify cause and effect and to formulate solutions to address them utilizing our professional skills and resources.
In performing an intake assessment and client history review, case managers should be on the lookout for medical conditions that cause inflammation in the brain, which has been associated with depression, as possible causes of mental disorders. An example would be the inflammation caused by abnormal levels of neurotransmitters and hormones, such as with Parkinson’s disease, which involves abnormalities in the dopamine system. Chronic pain has been associated with imbalances of GABA, serotonin, dopamine, and norepinephrine, which can alter normal brain chemistry and function.
If the case management assessment reveals that a client has a history of chronic stress, they may be more likely to develop mental health conditions. A study from the University of California at Berkeley found that people under chronic stress can experience an imbalance in the ratio of gray matter (fewer neurons generated) to white matter (more myelin-producing cells generated) in the brain. This adversely affects the hippocampus, which regulates emotions, so manifestations of emotional disturbances might be seen.
Case managers should also consider medications that are known to have potential mental health effects. These include beta-blockers (e.g., metoprolol, propranolol, and atenolol), statins (which lower cholesterol, which is needed in the brain to aid the release of neurotransmitters), opioids (which may initially cause euphoria but can contribute to depression over time due to their effects on dopamine and GABA), stimulants (e.g., Ritalin which alters dopamine levels), and corticosteroids (affects serotonin levels) to name a few common examples. Anxiety is also a possible side effect of many medications. Steroids, stimulants, and blood pressure medications may cause anxiety and depression.
Case management assessments should always include a thorough evaluation of the psychosocial aspects of the client’s situation to identify stress factors. This can include lack of support at home, challenges with staying in contact with family and friends, and work and financial challenges, which are even more common now due to the pandemic. There should also be a focus on assessing for possible abuse (mental and physical) that might be occurring, particularly in the context of stay-at-home orders mandating forced close and constant contact. Case managers need to be aware of psychosocial resources that are available for referrals and whether they are operating “business-as-usual” during the pandemic. Planning and brokering of referral services must start with the first contact to avoid excessive delays related to a probably overtaxed provider network.
Case managers also need to be aware of treatment modalities available for the client before seeking their inclusion in a plan of care. Some considerations would be the availability, financial impact, and insurance (if any) approval, as well as the appropriateness for the client’s situation and level of engagement. Treatment for mild to moderate mental illness may involve the treating physician changing or adding medications as well as possibly the use of Cognitive Behavioral Therapy (CBT), psychotherapy, or other talk therapies, pending physician agreement. Stress reduction and management techniques may also be helpful and might be available through referral to a social worker, therapist, or psychiatrist, depending, again, on availability. Some straightforward lifestyle modifications such as eating a healthy diet, exercising, and getting adequate sleep, sunlight, and fresh air could also be encouraged as appropriate, as these all play an important role in overall wellness.
Even during the best of times, case managers, healthcare providers, and clients need to realize that unaddressed mental health issues can lead to serious physical concerns such as heart disease, high blood pressure, a weakened immune system, asthma, obesity, gastronomical problems, and even premature death as well as that many medical conditions can cause or worsen mental health issues. A whole-person approach must be taken to be successful in meeting the needs of the client now and going forward. It is much harder to maintain the energy and motivation necessary to work on improving a physical illness when there is also depression, anxiety, fear, or other mental health challenges in the mix. By addressing both mental and physical aspects of all health conditions, healthcare providers can greatly improve a client’s quality of life.
Susan Curtin McDonnell, RN, BSN, is a certified medical and user experience (UX) copywriter with 29 years as a registered nurse. Susan has extensive experience as a director of hospital and health plan case management. You can reach her at[email protected].