Psychiatric Issues Encountered in Home Healthcare in the age of COVID-19

Abstract

The COVID-19 pandemic has caused physical and mental harm to home healthcare clinicians as well as the patients we serve. As home healthcare professionals, we became acutely aware of our patients' suffering while simultaneously dealing with our own personal and professional challenges. It is critical that those who provide healthcare learn how to manage the deleterious effects of this frightening virus. This article focuses on the effects of the COVID-19 pandemic on patients and healthcare providers and suggests ways of developing resilience. Home healthcare providers must be able to manage their own psychological needs before they can assess and intervene with the multiple mental health consequences of anxiety and depression in their patients that can result from COVID-19.

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Although mental health issues have always existed, the onslaught unleashed by the COVID-19 pandemic has traumatized the population, complicated the provision of care to home care patients, and has forced us, as caregivers, to find new ways to safeguard ourselves. The impacts of COVID-19, both physical and mental, have caused undue pain to patients as well as healthcare clinicians. As home healthcare professionals, we became acutely aware of our patients' suffering while simultaneously dealing with our own personal and professional challenges. The effects of COVID-19 destabilized our sense of safety, social support, and economic wellbeing. COVID-19 anxiety has negatively impacted not only the general health of many, but also the ability to cope. Mental health issues such as anxiety, depression, stress, and sleep disorders have become problems worldwide (^{Yildirim et al., 2022}). The need for us, as professional caregivers, to deal appropriately with these emotional responses, is critical.

Anxiety

Anxiety, that vague feeling of apprehension we all experience in our lives, results from a perceived threat to our safety and wellbeing. Anxiety disorders, which include panic attacks, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder, affect roughly 40 million American adults each year (^{Collier, 2021}). Anxiety is most often manifested by restlessness, feelings of uneasiness, sleep issues including insomnia or hypersomnia, trembling, shortness of breath, cold or sweaty hands or feet, numbness of hands or feet, and/or chest pain (^{Mayo Clinic, 2023}). Healthcare professionals have suffered increased rates of depression and anxiety, resulting in high levels of burnout (^{Sawyer & Bailey, 2022}). Burnout is a psychological syndrome characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment. In a study with 58,408 healthcare provider respondents, high childcare stress was associated with 80% greater odds of burnout, 91% greater odds of intent to reduce work hours, and 28% greater odds of intent to leave their professional role (^{Harry et al., 2022}).

^{Arnetz et al. (2020)} analyzed qualitative responses from 455 nurses about the most stressful situations they encountered during the pandemic. The participants identified seven stress-inducing situations directly linked to COVID-19. These situations include: 1.) fear of self-exposure and passing the virus on to others; 2.) illness and deaths of patients, co-workers, and loved ones; 3.) workplace relationships and inadequate supplies and training; 4.) dealing with unknowns (e.g., changing viral symptoms, financial security); 5.) politics and polarization related to disinformation; 6.) social restrictions (such as distancing and isolation); and 7.) feelings of inadequacy and helplessness related to patients' conditions and treatments.

^{Elliott et al. (2023)} interviewed 13 home care clinicians who worked during the COVID-19 pandemic. The participants described uncertainty, guilt, fear, and anxiety as they attempted to provide care with inadequate PPE, rapidly changing guidelines, societal polarization, and misinformation. They recommended weekly team meetings to reduce isolation and anxiety, open, transparent communication from leadership, and attention to self-care.

Unfortunately, depression and anxiety among healthcare workers tend to be taboo subjects. According to the Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative, 18% of nurses exhibit symptoms of depression, double the rate within the general population (^{Ferguson, 2016}). As long as the stigma associated with mental health persists, nurses and other healthcare clinicians will continue to avoid seeking the mental health support they need. Healthcare leaders and healthcare facilities need to prioritize the mental health and well-being of their front-line staff, creating spaces for nurses and other clinicians that encourage self-care over silent suffering.

Depression

Depression can manifest itself in both physical and mental pain. According to the ^{World Health Organization (2021)}, depression affects approximately 5% of adults and is the leading cause of disability worldwide. It is characterized by persistent sadness, lack of interest or pleasure in doing previously enjoyable activities, and sleep and appetite disturbances. The pandemic negatively impacted sleep, and increased depression and alcohol use in caregivers and noncaregivers. The severity of insomnia increased, sleep quality decreased, and depressive symptoms increased for both caregivers and noncaregivers during the pandemic (^{Herpen, 2022}). Depression can be related to genetics (first-degree relatives of a person with depression have two to three times greater chance of also having depression). Untreated depression can lead to heart disease with a 64% greater risk of adults with depressive disease or symptoms of developing coronary artery disease. Depression can mask or be confused with dementia and is also considered a risk factor for dementia (^{Seladi-Schulman, 2022}).

Suicidal ideation often occurs concomitantly when a person is feeling overwhelmed or suffering from depression. Physicians and nurses already represent the highest risk groups of suicide among the general population, making suicide an occupational hazard in the healthcare industry. The incidence of suicide among healthcare workers has increased as workload, burnout and fatigue, unprecedented challenges of female healthcare workers, and substance abuse during COVID-19 have all increased (^{Awan et al., 2022}). In a study by ^{Firth (2022)}, 1 in 10 nurses reported experiencing suicidal thoughts as a result of the COVID-19 pandemic, with the majority reporting feelings of burnout (75%), compassion fatigue (66%), depression (64%), declines in their physical health (64%), and extreme feelings of trauma, extreme stress, and/or PTSD (50%). However, nearly 60% of respondents said they were either “very unlikely” or “somewhat unlikely” to share their suicidal thoughts or mental health issues with a manager or colleague at their facility due to concerns about confidentiality (72%), concerns about job security (69%), anticipation that employers wouldn't address the issue (64%), or fears it would impact their nursing license (44%).

Managing the Effects of Anxiety and Depression

The key to managing the deleterious effects of anxiety and depression is to develop resilience. Resilient nurses and those who perceived higher organization and social support were more likely to report lower anxiety related to COVID-19 (^{Labrague & De Los Santos, 2020}). They were able to implement coping mechanisms to aid in resilience. Three other themes of resilience include insight, self-compassion, and empowerment (^{Sawyer & Bailey, 2022}). In another study, nurses who had more years of experience and felt supported by their peers and employers demonstrated more resilience. Their foundation of resilience served to promote their capacity to thrive and adapt during the pandemic, motivating them to persevere in the face of adversity from the virus (^{Fredericks et al., 2022}).

^{Algorani and Gupta (2022)} define coping as the thoughts and behaviors mobilized to manage internal and external stressful situations. Coping involves the conscious and voluntary mobilization of acts as differentiated from “defense mechanisms,” which are subconscious or unconscious responses aimed to reduce or tolerate stress. They categorized coping in four major categories:

• Problem-focused that addresses the problem causing the distress and uses active coping and planning.
• Emotion-focused that aims to reduce the negative emotions associated with the problem including positive reframing, turning to religion, and humor.
• Meaning-focused that concentrates on cognitive strategies to derive and manage the meaning of the situation.
• Socialcoping in which an individual seeks emotional or community support to reduce stress.

Additional techniques that can aid in lessening the effects of anxiety include:

• Being aware of the anxiety and/or depression
• Being aware of the need to care for oneself by eating regular and healthy meals
• Getting adequate sleep and exercise that are essential to wellbeing
• Practicing mindfulness
• Implementing relaxation techniques such as slow, deep breathing, progressive
• muscle relaxation, and meditation (^{Fredericks et al., 2022}).

Agency administration must also support nurses and other healthcare providers by providing support systems, encouraging self-care, and providing access to behavioral health resources (^{Labrague & De Los Santos, 2020}).

Techniques that help manage depression include:

• Aerobic exercise that can exert a significant antidepressant effect due to increased endorphins in the brain that increase feelings of wellbeing
• Social interactions and confiding in others help to decrease isolation
• Diet, especially a Mediterranean diet (fruits, vegetables, whole grains), Vitamin B12, and folate and Omega 3 fatty foods (salmon, tuna, fatty fish), which can help reduce depression
• Volunteering that can be helpful because it focuses on helping others rather than focusing on oneself
• Prayer, music, and meditation that can help calm the mind and encourage the body to relax
• Outdoor activities that can reduce the isolation, increase circulation to the brain, and expose one to sunshine
• Limiting alcohol (which is a depressant)
• Replacing negative thoughts with positive ones
• Journaling which can provide an outlet for sad feelings
• Identifying triggers to depressed thoughts and removing or altering them can reduce their influence
• Counseling that provides insight and aid in developing coping strategies
• Medications that may help to alleviate depressive thoughts and feelings (^{Gordon, 2021; Murphy, 2021}).

The Role of Home Care Clinicians with Patients who Experience Anxiety and/or Depression

Home healthcare professionals work with patients in the community to ensure the multiple needs of each patient are addressed. The needs of patients who home healthcare clinicians traditionally encounter may be physical, emotional, social, financial, and/or safety-related. Since COVID-19, however, there have been significant changes in the responsibilities of nurses and other in-home healthcare providers. Before home healthcare clinicians can assess and intervene with patients with mental health issues in the home, they must be aware of, and deal with, their own issues of anxiety and depression. Now clinicians may need to look both at their patients' needs as well as their own needs, to determine if treatment for COVID-19 anxiety and depression are a necessary part of a viable treatment plan.

Home healthcare patients experiencing COVID-19 anxiety often suffer the same fears that plague healthcare staff and include fear of death, fear of transmission, and fear of lingering effects of the disease. However, patients may also experience anxiety caused by other comorbid medical conditions such as cancer, heart disease, diabetes, uncontrollable pain, and/or a terminal diagnosis. It is critical that home healthcare staff explore the source of a patient's anxiety and help the patient develop a plan to manage/cope with the source. One study of Japanese home care nurses noted they made efforts to carefully reach out to address the anxiety of patients/families, attempted to alter the outlook of the situation, and created comfort as ways to alleviate anxiety (^{Yamamoto-Mitani et al., 2016}). Another study validated the value of nurses intervening with patients through cognitive behavioral therapy, teaching coping skills, instruction in relaxation techniques, anger control, crisis intervention, promotion of resilience, and stress reduction (^{Amaral et al., 2022}). Listening to a patient's concerns can be one of the most therapeutic techniques that all home healthcare clinicians can use to reduce anxiety among their patients.

COVID-19 has had a serious impact on the home healthcare community in the last 3 years. At the start of care, home healthcare nurses and therapists are required to screen for depression in patients as part of the Outcome and Assessment Information Set (OASIS). If the PHQ-2 screening tool indicates the patient may be experiencing depression, a social work or psychiatric home care nurse referral is in order. Depression may result from the isolation imposed to prevent exposure to COVID-19, the lack of a support system, and/or it may be the result of preexisting depressive symptomatology. Once again, listening to patients and helping them express their feelings is a good therapeutic technique that can be used by all home care staff. Being nondefensive in posture and encouraging patients to ventilate their angry feelings can open up opportunities for them to feel control over their situation. It is critical that home healthcare clinicians engender hope in patients by helping them develop achievable goals for the future. In Dellosso's article, “Sell Them Happiness,” the following points were made: focus on the positive, remind them of their progress, encourage them often, keep them focused on the end goal, and remind them of their own worth (^{Dellosso, 2021}). Additionally, encouraging interactions with friends and family, exploring sources of spiritual support such as prayer and sharing concerns with a spiritual leader (pastor, priest, rabbi, etc.), encouraging meditation and calming music, and teaching about a healthy diet can aid in management of depression.

Suicide is another area that impacts home healthcare patients. People 85 years and older face one of the highest suicide rates of any group. In 2020, suicde was the 12th leading cause of death. (^{National Institute of Mental Health, 2022}). Major depression among home care patients is twice that of their counterparts receiving only primary care. ^{Raue et al. (2010)} found suicidal ideation among 1,202 community dwelling older adults to be 29% among those with major depression, 11% among those with minor depression, and alarmingly, 7% among those without depression.

A 2016 article on suicide by Salvatore includes the following points: Terminal cancer patients receiving home healthcare who took their lives showed signs of hopelessness, aversion to suffering, social isolation, and a desire to not burden their families. Depressed moods, suicidal ideation, past attempts, alcoholism, chronic pain, poor family relationships, and financial problems have been found among other patients who completed suicide. Limited socialization correlated strongly with suicidal ideation which was also associated with greater depression, medical comorbidity, and poorer perceived social support. Be aware also of passive suicide, when patients don't necessarily express a desire to die but do little to stay alive. They may not eat or ignore necessary medical regimens. This may give way to more overt suicidal behavior (^{Salvatore, 2016}).

Steps that home care staff can take in providing care to someone who demonstrates suicidal behaviors include:

• Asking “are you thinking about hurting/killing yourself”
• Asking if the patient has a plan, and remove or disable any lethal means (Veterans, in particular, often have a firearm in the home)
• Acknowledging and allowing the patient to talk about suicidal feelings
• Helping them to contact the 988 Suicide and Crisis Lifeline (call or test 988) and the Crisis Text Line (text HELLO to 741741)
• Helping them connect with a trusted individual for support
• Following up frequently (^{National Institute of Mental Health, 2022}).

It is also crucial that any overt or covert signs and/or symptoms of suicidal ideation be reported to the patient's primary care provider.

As home healthcare professionals who are battling the negative impact of COVID-19 for 3 long years, it is imperative that we support each other and ensure that our own emotional needs are being met before we attempt to care for others. Having insight into our own stresses and then implementing the appropriate coping strategies to manage our own needs will enable us to better confront the mental health issues of our patients and their caregivers and provide the supportive care that they need.