919803

letter2020
JAPXXX10.1177/1078390320919803Journal of the American Psychiatric Nurses AssociationChoi et al.

Letter to the Editor

Journal of the American Psychiatric

A Second Pandemic: Mental

Nurses Association
1­–4
© The Author(s) 2020
Health Spillover From the Novel Article reuse guidelines:
sagepub.com/journals-permissions

Coronavirus (COVID-19) DOI: 10.1177/1078390320919803

https://doi.org/10.1177/1078390320919803
journals.sagepub.com/home/jap

Kristen R. Choi1 , MarySue V. Heilemann2, Alex Fauer3,

and Meredith Mead4

Abstract
The novel coronavirus (COVID-19) pandemic has created an unprecedented global health challenge. There is risk
that the outbreak will create a “second pandemic” of mental health crises in health systems and communities. Thus,
a comprehensive public health response to the pandemic must include (a) attention to the psychological aspects of
hospitalization for patients, families, and staff affected by COVID-19; (b) planning for emergency and acute psychiatric
patient care if hospitals become overwhelmed with COVID-19 patients; and (c) innovations for providing mental
health care in communities while social distancing is required and health system resources are strained. Nurses
and nurse leaders must anticipate these mental health challenges, assist with preparedness in health systems and
communities, and advocate for a coordinated response to promote mental wellness and resilience.

Keywords
nursing, coronavirus, COVID-19, mental health, psychiatry, pandemic

On March 11, 2020, the World Health Organization (WHO) The public health challenges facing our communities
declared a pandemic due to the rapid, global spread of a as a result of COVID-19 are unprecedented. However, as
novel coronavirus (SARS-CoV-2, known as COVID-19; we address the physical health and epidemiological
WHO, 2020a). Spreading from Wuhan, China, in December aspects of COVID-19, it is critical that we also consider
of 2019, this newly identified virus belongs to the coronavi- the mental health impact of the pandemic. Currently, one
rus family, which also includes Severe Acute Respiratory in five American adults have a mental illness (McCance-
Syndrome (SARS) and Middle East Respiratory Syndrome Katz, 2019). Suicide rates have risen dramatically in
(MERS; Zhu et al., 2020). Individuals who contract recent years (30% increase since 1999), and there is a
COVID-19 generally experience a mild illness course, but long-standing, critical shortage of mental health care pro-
much more severe cases can occur, necessitating hospital- viders and resources in the United States (CDC, 2018;
ization and intensive care for Acute Respiratory Distress Covino, 2019). Though the COVID-19 response to date
Syndrome (ARDS; Huang et al., 2020). has focused primarily on containing spread and prevent-
Globally, there have been hundreds of thousands of ing mortality, the pandemic has potential to create a sec-
COVID-19 cases and thousands of deaths, particu- ondary crisis of psychological distress and mental health
larly among vulnerable populations such as the elderly system spillover. The threat of this second pandemic of
(WHO, 2020b). Hospital and health system capacity is a
major concern in managing the outbreak due to limita- 1
Kristen R. Choi, PhD, MS, RN, University of California, Los Angeles,
tions in hospital beds, personal protective equipment, CA, USA
ventilators, workforce resources, and testing capabilities 2
MarySue V. Heilemann, PhD, RN, FAAN, University of California,
(Chopra et al., 2020). Apprehension about community Los Angeles, CA, USA
3
spread of COVID-19 has led governments and commu- Alex Fauer, BSN, RN, OCN®, University of Michigan, Ann Arbor,
MI, USA
nities to implement drastic social distancing measures 4
Meredith Mead, MSN, PHN, RN, Gateways Hospital and Mental
ranging from orders to shelter in place, to closing local Health Center, Los Angeles, CA, USA
businesses, to cancelling major concerts and sporting
Corresponding Author:
events, to closing schools and universities (Centers for Kristen R. Choi, School of Nursing, UCLA, 700 Tiverton Dr., Room
Disease Control and Prevention [CDC], 2020; State of 3-238, Los Angeles, CA 90095, USA.
California, 2020). Email: krchoi@ucla.edu
2 Journal of the American Psychiatric Nurses Association 00(0)

mental health crises must be addressed as part of a com- health in communities (Lima et al., 2020). Social distanc-
prehensive public health response to COVID-19 (Xiang ing measures, while necessary to stop the spread of the
et al., 2020). Anticipating where mental health spillover virus, increase risks for loneliness, isolation, and anxiety
may occur will help buffer the short- and long-term psy- (Long, in press). There is high potential for individuals
chological harm of the outbreak and prepare us to build with preexisting mental illness to experience symptom
population resilience. exacerbations or impairment in functional status due to
There are serious psychological aspects to hospitaliza- increased stress and fear around the outbreak (Jiang et al.,
tion for patients, staff, and family members who are 2020). Furthermore, being isolated at home may increase
directly affected by COVID-19. Prolonged exposure to family or financial pressures as the economic fallout of
stressful environments, invasive procedures, and the per- the outbreak worsens, leading to poor mental health
ception of threats in an intensive care unit (ICU) can be (Brooks et al., 2020). Individuals may face unemploy-
experienced as traumatic, leading to long-term psycho- ment, housing instability, and food insecurity while care-
logical harm (Righy et al., 2019). Evidence suggests that giving responsibilities for children or family members
survivors of ICU treatment are at elevated risk for post- intensify. Those who experience trauma or violence in
traumatic stress disorder, depression, sleep disturbance, their intimate partner and family relationships—includ-
poor quality of life, and cognitive dysfunction (Righy ing psychological trauma—may be at increased risk for
et al., 2019; Wang et al., 2019). Family members may victimization. At the very time individuals affected by
experience distress, fear, or anxiety about the hospitaliza- mental illness are likely to need more support than usual,
tion of a loved one, particularly when infection control mental health systems are at risk for losing capacity due
measures restrict visitation (Ying et al., 2020). The trau- to hospital spillover and clinic closure to promote social
matic and stressful aspects of involvement in a pandemic distancing. Innovative models to deliver mental health
also risks psychological harm to clinicians (Kang et al., support to communities in the midst of a pandemic are
2020; Lima et al., 2020). Nurses and physicians involved needed to prevent a mental health crisis (A. C. Smith
in global outbreaks such as SARS, MERS, and Ebola et al., 2020).
experienced increased burnout, compassion fatigue, There is opportunity for health system planning,
lower job satisfaction, lower morale, and job stress (Kim resource mobilization, and new interventions to address
& Choi, 2016; Maunder et al., 2006; M. W. Smith et al., mental health challenges resulting from the COVID-19
2017). The traumatic and stressful aspects of involvement outbreak. Collaboration among health system leaders
in a pandemic create mental health risks for both patients from hospital and community mental health systems
and staff. Health systems should anticipate mental health must occur to assure safety and continuity of care for
needs of patients, staff, and families and prepare support- individuals experiencing mental health crises during this
ive resources. time. Additionally, health systems must offer support
In additional to psychological distress related to mechanisms for buffering outbreak-related stress. This
COVID-19 hospitalizations, the rapid influx of patients includes interventions for patients and families (e.g.,
seeking COVID-19 treatment has potential to displace providing trauma-informed ICU care, providing mental
mental health beds and treatment capabilities in inpatient health resources and education upon discharge, support-
settings. While hospitals are increasing capacity for ing virtual visits) and for staff (e.g., occupational mental
COVID-19 patients, non-COVID-19 patients—including health resources, support for illness and family leave,
psychiatric patients—may not be able to access usual ensuring adequate staffing, and a safe practice environ-
sources of needed care. We anticipate that hospitals are ment with adequate personal protective equipment;
likely to become increasingly challenged with how to American Psychiatric Association, 2020; Center for the
manage and treat acute psychiatric crises in emergency Study of Traumatic Stress, 2020). In communities, inno-
rooms and how to ensure safety and care continuity for vative models of mental health care should be imple-
currently hospitalized psychiatric inpatients. As hospitals mented so individuals who need support have access to
experience increased COVID-19 admissions, they should professional treatment. Telehealth (including insurance
prepare for losing mental health bed capacity and develop coverage for telehealth), extended medication supplies,
a continuity plan for psychiatric patients, especially those increased provider mental health training, virtual peer
that require essential procedures related to mental health support, and virtual substance use support groups may
(Centers for Medicare & Medicaid Services, 2020). Less help ensure that community mental health needs are met
intensive psychiatric care settings and community psy- (National Alliance on Mental Illness, 2020; A. C. Smith
chiatric hospitals should expect increased patient admis- et al., 2020).
sions and prepare for overflow where possible. Nurses are central to the entire spectrum of responses
Finally, we anticipate that the COVID-19 outbreak to the COVID-19 pandemic including the mental health
will have an increasingly negative impact on mental effects of the outbreak. As the largest health care
Choi et al. 3

profession with nearly four million nurses in the United local COVID-19 transmission. https://www.cdc.gov/
States and more than 20 million nurses globally, nurses coronavirus/2019-ncov/downloads/community-mitigation-
are already addressing the physical and mental health strategy.pdf
aspects of the pandemic directly through hospital and Centers for Medicare & Medicaid Services. (2020). CMS
adult elective surgery and procedures recommendations:
community patient care. Whether they are working with
Limit all non-essential planned surgeries and procedures,
hospitalized COVID-19 patients, in psychiatric settings,
including dental, until further notice. https://www.cms.
or in communities, nurses have a responsibility to care gov/files/document/31820-cms-adult-elective-surgery-
for the psychological needs of their patients. Health sys- and-procedures-recommendations.pdf
tem and nursing leaders must ensure that their clinical Center for the Study of Traumatic Stress. (2020). Taking care
nursing staff are protected and supported so that they of patients during the coronavirus outbreak: A guide for
can provide this crucial dimension of COVID-19 care. psychiatrists. Uniformed Services University. https://
Nurses must also advocate for a comprehensive public www.cstsonline.org/assets/media/documents/CSTS_
health response to COVID-19 that includes attention to FS_Taking_Care_of_Patients_During_Coronavirus_
mental health spillover. By acting now to prepare for a Outbreak_A_Guide_for_Psychiatrists_03_03_2020.pdf
second pandemic of mental distress related to COVID- Chopra, V., Toner, E., Waldhorn, R., & Washer, L. (2020, March
11). How should U.S. hospitals prepare for coronavirus
19, nurses can promote resilience in our mental health
disease 2019 (COVID-19)? Annals of Internal Medicine.
systems and communities.
Advance online publication. https://doi.org/10.7326/M20-
0907
Author Roles Covino, N. A. (2019). Developing the behavioral health work-
KRC and MM developed key article concepts. KRC led the writ- force: Lessons from the states. Administration and Policy in
ing of the manuscript. MM, AF, and MVH assisted with writing Mental Health and Mental Health Services Research, 46(6),
areas of the manuscript related to their expertise and revised the 689-695. https://doi.org/10.1007/s10488-019-00963-w
manuscript for intellectual content. All authors reviewed the Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., Zhang,
final manuscript before submitting for publication. L., Fan, G., Xu, J., Gu, X., Cheng, Z., Yu, T., Xia, J., Wei,
Y., Wu, W., Xie, X., Yin, W., Li, H., Liu, M., Xiao, Y.,
Declaration of Conflicting Interests . . . Cao, B. (2020). Clinical features of patients infected
with 2019 novel coronavirus in Wuhan, China. Lancet,
The author(s) declared no potential conflicts of interest with 395(10223), 497-506. https://doi.org/10.1016/S0140-6736
respect to the research, authorship, and/or publication of this (20)30183-5
article. Jiang, X., Deng, L., Zhu, Y., Ji, H., Tao, L., Liu, L., Yanga, D.,
& Ji, W. (2020). Psychological crisis intervention during
Funding the outbreak period of new coronavirus pneumonia from
The author(s) received no financial support for the research, experience in Shanghai. Psychiatry Research, 286, 112903.
authorship, and/or publication of this article. https://doi.org/10.1016/j.psychres.2020.112903
Kang, L., Li, Y., Hu, S., Chen, M., Yang, C., Yang, B. X.,
ORCID iD Wang, Y., Hu, J., Lai, J., Ma, X., Chen, J., Guan, L., Wang,
G., Ma, H., & Liu, Z. (2020). The mental health of medi-
Kristen R. Choi https://orcid.org/0000-0001-5453-1091
cal workers in Wuhan, China dealing with the 2019 novel
coronavirus. Lancet Psychiatry, 7(3), e14. https://doi.
References org/10.1016/S2215-0366(20)30047-X
American Psychiatric Association. (2020). Coronavirus and Kim, J. S., & Choi, J. S. (2016). Factors influencing emer-
mental health: Taking care of ourselves during infectious gency nurses’ burnout during an outbreak of Middle East
disease outbreaks. https://www.psychiatry.org/news-room/ respiratory syndrome coronavirus in Korea. Asian Nursing
apa-blogs/apa-blog/2020/02/coronavirus-and-mental- Research, 10(4), 295-299. https://doi.org/10.1016/j.anr
health-taking-care-of-ourselves-during-infectious-disease- .2016.10.002
outbreaks Lima, C. K. T., de Medeiros Carvalho, P. M., Lima, I. D. A.
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., S., de Oliveira Nunes, J. V. A., Saraiva, J. S., de Souza, R.
Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The I., da Silva, C. G. L., & Neto, M. L. R. (2020). The emo-
psychological impact of quarantine and how to reduce it: tional impact of coronavirus 2019-Ncov (new coronavirus
Rapid review of the evidence. Lancet, 395(10227), 912- disease). Psychiatry Research, 287, 112915. https://doi.
920. https://doi.org/10.1016/S0140-6736(20)30460-8 org/10.1016/j.psychres.2020.112915
Centers for Disease Control and Prevention. (2018). CDC vital Long, N. J. (in press). From social distancing to social contain-
signs: Suicide rising across the US. https://www.cdc.gov/ ment: Reimagining sociality for the coronavirus pandemic.
vitalsigns/pdf/vs-0618-suicide-H.pdf Medicine Anthropology Theory.
Centers for Disease Control and Prevention. (2020). Imple- Maunder, R. G., Lancee, W. J., Balderson, K. E., Bennett, J.
mentation of mitigation strategies for communities with P., Borgundvaag, B., Evans, S., Fernandes, C. M. B.,
4 Journal of the American Psychiatric Nurses Association 00(0)

Goldbloom, D. S, Gupta, M., Hunter, J. J., Hall, L. M., State of California. (2020). Executive order N-33-20. https://
Nagle, L. M., Pain, C., Peczeniuk, S. S., Raymond, G., covid19.ca.gov/img/Executive-Order-N-33-20.pdf
Read, N., Rourke, S. B., Steinberg, R. J., Stewart, T. E., Wang, S., Meeker, J. W., Perkins, A. J., Gao, S., Khan, S. H.,
Coke, S. V., . . . Wasylenki, D. A. (2006). Long-term psy- Sigua, N. L., Manchanda, S., Boustani, M. A., & Khan,
chological and occupational effects of providing hospital B. A. (2019, March 20). Psychiatric symptoms and their
healthcare during SARS outbreak. Emerging Infectious association with sleep disturbances in intensive care unit
Diseases, 12(12), 1924-1932. https://doi.org/10.3201/ survivors. International Journal of General Medicine, 12,
eid1212.060584 125-130. https://doi.org/10.2147/IJGM.S193084
McCance-Katz, E. F. (2019). The National Survey on Drug Use World Health Organization. (2020a). WHO Director-General’s
and Health: 2017. Substance Abuse and Mental Health opening remarks at the media briefing on COVID-19—11
Services Administration. https://www.samhsa.gov/data/ March 2020. https://www.who.int/dg/speeches/detail/who-
sites/default/files/nsduh-ppt-09-2018.pdf director-general-s-opening-remarks-at-the-media-briefing-
National Alliance on Mental Illness. (2020). COVID-19 (coro- on-covid-19—11-march-2020
navirus) information and resources. https://www.nami. World Health Organization. (2020b). Coronavirus disease 2019
org/getattachment/About-NAMI/NAMI-News/2020/ (COVID-19): Situation report 63. https://www.who.int/docs/
NAMI-Updates-on-the-Coronavirus/COVID-19-Updated- default-source/coronaviruse/situation-reports/20200323-
Guide-1.pdf sitrep-63-covid-19.pdf?sfvrsn=d97cb6dd_2
Righy, C., Rosa, R. G., da Silva, R. T. A., Kochhann, R., Xiang, Y. T., Yang, Y., Li, W., Zhang, L., Zhang, Q., Cheung,
Migliavaca, C. B., Robinson, C. C., Teche, S. P., Teixeira, T., & Ng, C. H. (2020). Timely mental health care for
C., Bozza, F. A., & Falavigna, M. (2019). Prevalence of the 2019 novel coronavirus outbreak is urgently needed.
post-traumatic stress disorder symptoms in adult critical Lancet Psychiatry, 7(3), 228-229. https://doi.org/10.1016/
care survivors: A systematic review and meta-analysis. S2215-0366(20)30046-8
Critical Care, 23(1), 213. https://doi.org/10.1186/s13054- Ying, Y., Kong, F., Zhu, B., Ji, Y., Lou, Z., & Ruan, L. (2020).
019-2489-3 Mental health status among family members of health care
Smith, A. C., Thomas, E., Snoswell, C. L., Haydon, H., workers in Ningbo, China during the coronavirus disease
Mehrotra, A., Clemensen, J., & Caffery, L. J. (2020). 2019 (COVID-19) outbreak: A cross-sectional study.
Telehealth for global emergencies: Implications for corona- MedRxiv. https://doi.org/10.1101/2020.03.13.20033290
virus disease 2019 (COVID-19). Journal of Telemedicine Zhu, N., Zhang, D., Wang, W., Li, X., Yang, B., Song, J., Zhao,
and Telecare. Advance online publication. https://doi. X., Huang, B., Shi, W., Lu, R., Zhan, F., Ma, X., Wang,
org/10.1177/1357633X20916567 D., Xu, W., Wu, G., Gao, G. F., Tan, W., & China Novel
Smith, M. W., Smith, P. W., Kratochvil, C. J., & Schwedhelm, Coronavirus Investigating and Research Team. (2020). A
S. (2017). The psychosocial challenges of caring for novel coronavirus from patients with pneumonia in China,
patients with Ebola virus disease. Health Security, 15(1), 2019. New England Journal of Medicine, 382(8), 727-733.
104-109. https://doi.org/10.1089/hs.2016.0068 https://doi.org/10.1056/NEJMoa2001017