The American Foundation for Suicide Prevention’s Chief Medical Officer, Dr. Christine Moutier, was a guest last night on a CNN special, A CNN Global Town Hall: Coronavirus Facts and Fears. Co-hosted by CNN’s Anderson Cooper and Dr. Sanjay Gupta, Dr. Moutier’s segment focused on a discussion on managing your mental health in light of recent news around the virus.

https://afsp.org/story/dr-christine-moutier-discusses-managing-your-mental-health-on-cnn-town-hall

by Doreen Marshall, Ph.D.
Vice President of Mission Engagement, AFSP

Many of us are grieving right now. We are grieving people we have lost, in many instances not having had the opportunity to say goodbye or to be with them in their final moments. We are grieving not being able to have our in-person presence to support one another right now. We are grieving our rituals, our routines and the familiarity of our day-to-day assumptions. For those of us who have a history with grief (especially the unexpected kind), we may be having grief of those former losses stirred and awakened. This week alone, I had two separate dreams connected to previous losses (a death and a miscarriage). I had to remind myself when I woke that it was not those events reoccurring, but another, entirely distinct set of losses that I was currently experiencing.

Grief can be messy. It’s not linear, as in, “when I get through this particular feeling, I’m done with that.”  It is cyclical and lingers around important events, words not said, certain songs, and moments captured like photographs in our minds. It is a place we can choose to visit or ignore, though it resides in the background as if waiting for us to notice.

If you are experiencing grief right now, here are some things you might remind yourself:

1. There are different ways to say goodbye. Unexpected endings tend to bring strong emotions, often anchored in both the present and the past, when we may have felt abandoned or left behind. There are different ways to say goodbye. Write a letter to your loved one, even if you end up being the only one who sees it. If your loved one has died or is in a place you can’t visit, hold an intention for them in your mind, and say it aloud as you think of them throughout the day. One of my favorites is, “May you feel my love for you and be surrounded by peace.” 
2. “The last sentence of the book doesn’t rewrite the entire story.” Years ago, following the loss of someone dear to me, a wise person shared these words with me. It reminded me that even though I was unable to be with my loved one when he died, I had a book full of lines to draw upon that were the story of our life together and of our relationship. Many of those lines were expressions of our love, moments we shared together, conversations and memories. Remembering these feelings and these moments is how we get a sense of who the individual was; who we were with them; and what the relationship was—all of which surpasses their final moments. Right now is a good time to reflect on those earlier, better memories as best as you can, to remind yourself of the full picture of their lives and your connection.
3. Connections can deepen over time, even after loss. My father died 14 years ago this week. In the early days and weeks following his death, all I could remember was the image of him sick, and the trauma I associated with that. As time passed, my memories of him unexpectedly became richer and more accessible than they were in those early days. The images of him being sick began to fade away. I can now more easily remember his laugh and his jokes, and recognize the similarity between my daughter’s eyes and his. I also feel more connected to how he must have felt as a parent, now that I am one, myself. These are newer, deeper connections to my father, ones I couldn’t have anticipated at the time he died.
4. You are not alone in your grief. Know that others are also experiencing grief right now, and that there is support available. Online grief support, and grief support provided by mental health professionals, hospice centers and faith groups are all accessible to you, many via telehealth and other virtual platforms. You can learn about options for grief support by connecting to your local mental health providers, faith organizations or hospice, or through one of the following national resources: National Suicide Prevention Lifeline: 1800 273-TALK (8255); Crisis Text Line: text TALK to 741741. If you are struggling with the loss of a loved one to suicide, even one that occurred prior to COVID-19, AFSP has our Healing Conversations program, which provides peer-to-peer phone or video contact and resources for those struggling with suicide loss.

Please know, at this time, that others who have traveled the roads of grief are here for you and can serve as guides. Look to them for hope, healing and comfort during this difficult time, and know that days are ahead of you in which the intensity of your grief will be lessened, and replaced by loving memories.

Uncertain prognoses, looming severe shortages of resources for testing and treatment and for protecting responders and health care providers from infection, imposition of unfamiliar public health measures that infringe on personal freedoms, large and growing financial losses, and conflicting messages from authorities are among the major stressors that undoubtedly will contribute to widespread emotional distress and increased risk for psychiatric illness associated with Covid-19. Health care providers have an important role in addressing these emotional outcomes as part of the pandemic response.

Public health emergencies may affect the health, safety, and well-being of both individuals (causing, for example, insecurity, confusion, emotional isolation, and stigma) and communities (owing to economic loss, work and school closures, inadequate resources for medical response, and deficient distribution of necessities). These effects may translate into a range of emotional reactions (such as distress or psychiatric conditions), unhealthy behaviors (such as excessive substance use), and noncompliance with public health directives (such as home confinement and vaccination) in people who contract the disease and in the general population. Extensive research in disaster mental health has established that emotional distress is ubiquitous in affected populations — a finding certain to be echoed in populations affected by the Covid-19 pandemic.

After disasters, most people are resilient and do not succumb to psychopathology. Indeed, some people find new strengths. Nevertheless, in “conventional” natural disasters, technological accidents, and intentional acts of mass destruction, a primary concern is post-traumatic stress disorder (PTSD) arising from exposure to trauma. Medical conditions from natural causes such as life-threatening viral infection do not meet the current criteria for trauma required for a diagnosis of PTSD,¹ but other psychopathology, such as depressive and anxiety disorders, may ensue.

Some groups may be more vulnerable than others to the psychosocial effects of pandemics. In particular, people who contract the disease, those at heightened risk for it (including the elderly, people with compromised immune function, and those living or receiving care in congregate settings), and people with preexisting medical, psychiatric, or substance use problems are at increased risk for adverse psychosocial outcomes. Health care providers are also particularly vulnerable to emotional distress in the current pandemic, given their risk of exposure to the virus, concern about infecting and caring for their loved ones, shortages of personal protective equipment (PPE), longer work hours, and involvement in emotionally and ethically fraught resource-allocation decisions. Prevention efforts such as screening for mental health problems, psychoeducation, and psychosocial support should focus on these and other groups at risk for adverse psychosocial outcomes.

Beyond stresses inherent in the illness itself, mass home-confinement directives (including stay-at-home orders, quarantine, and isolation) are new to Americans and raise concern about how people will react individually and collectively. A recent review of psychological sequelae in samples of quarantined people and of health care providers may be instructive; it revealed numerous emotional outcomes, including stress, depression, irritability, insomnia, fear, confusion, anger, frustration, boredom, and stigma associated with quarantine, some of which persisted after the quarantine was lifted. Specific stressors included greater duration of confinement, having inadequate supplies, difficulty securing medical care and medications, and resulting financial losses.² In the current pandemic, the home confinement of large swaths of the population for indefinite periods, differences among the stay-at-home orders issued by various jurisdictions, and conflicting messages from government and public health authorities will most likely intensify distress. A study conducted in communities affected by severe acute respiratory syndrome (SARS) in the early 2000s revealed that although community members, affected individuals, and health care workers were motivated to comply with quarantine to reduce the risk of infecting others and to protect the community’s health, emotional distress tempted some to consider violating their orders.³

Opportunities to monitor psychosocial needs and deliver support during direct patient encounters in clinical practice are greatly curtailed in this crisis by large-scale home confinement. Psychosocial services, which are increasingly delivered in primary care settings, are being offered by means of telemedicine. In the context of Covid-19, psychosocial assessment and monitoring should include queries about Covid-19–related stressors (such as exposures to infected sources, infected family members, loss of loved ones, and physical distancing), secondary adversities (economic loss, for example), psychosocial effects (such as depression, anxiety, psychosomatic preoccupations, insomnia, increased substance use, and domestic violence), and indicators of vulnerability (such as preexisting physical or psychological conditions). Some patients will need referral for formal mental health evaluation and care, while others may benefit from supportive interventions designed to promote wellness and enhance coping (such as psychoeducation or cognitive behavioral techniques). In light of the widening economic crisis and numerous uncertainties surrounding this pandemic, suicidal ideation may emerge and necessitate immediate consultation with a mental health professional or referral for possible emergency psychiatric hospitalization.

On the milder end of the psychosocial spectrum, many of the experiences of patients, family members, and the public can be appropriately normalized by providing information about usual reactions to this kind of stress and by pointing out that people can and do manage even in the midst of dire circumstances. Health care providers can offer suggestions for stress management and coping (such as structuring activities and maintaining routines), link patients to social and mental health services, and counsel patients to seek professional mental health assistance when needed. Since media reports can be emotionally disturbing, contact with pandemic-related news should be monitored and limited. Because parents commonly underestimate their children’s distress, open discussions should be encouraged to address children’s reactions and concerns.

As for health care providers themselves, the novel nature of SARS-CoV-2, inadequate testing, limited treatment options, insufficient PPE and other medical supplies, extended workloads, and other emerging concerns are sources of stress and have the potential to overwhelm systems. Self-care for providers, including mental health care providers, involves being informed about the illness and risks, monitoring one’s own stress reactions, and seeking appropriate assistance with personal and professional responsibilities and concerns — including professional mental health intervention if indicated. Health care systems will need to address the stress on individual providers and on general operations by monitoring reactions and performance, altering assignments and schedules, modifying expectations, and creating mechanisms to offer psychosocial support as needed.

Given that most Covid-19 cases will be identified and treated in health care settings by workers with little to no mental health training, it is imperative that assessment and intervention for psychosocial concerns be administered in those settings. Ideally, the integration of mental health considerations into Covid-19 care will be addressed at the organizational level through state and local planning; mechanisms for identifying, referring, and treating severe psychosocial consequences; and ensuring the capacity for consulting with specialists.⁴

Education and training regarding psychosocial issues should be provided to health system leaders, first responders, and health care professionals. The mental health and emergency management communities should work together to identify, develop, and disseminate evidence-based resources related to disaster mental health, mental health triage and referral, needs of special populations, and death notification and bereavement care. Risk-communication efforts should anticipate the complexities of emerging issues such as prevention directives, vaccine availability and acceptability, and needed evidence-based interventions relevant to pandemics and should address a range of psychosocial concerns. Mental health professionals can help craft messages to be delivered by trusted leaders.⁴

The Covid-19 pandemic has alarming implications for individual and collective health and emotional and social functioning. In addition to providing medical care, already stretched health care providers have an important role in monitoring psychosocial needs and delivering psychosocial support to their patients, health care providers, and the public — activities that should be integrated into general pandemic health care.

Paramedic, EMS educator shares his personal experience of COVID-19 symptoms, testing and illness – EMS1

Recently, I was confirmed COVID-19-positive and, as a result, and especially given the fact that I had worked a partial shift before being confirmed positive, my employer rightfully sent out an email to everyone stating a public safety employee had tested positive. They did emphasize that my primary symptom was a mild cough and not a temperature. While I appreciated my employer respecting my privacy, I felt that that by sharing my experience with others, it will give people a little different perspective then what they are hearing every day.

Keep in mind that in our region, for many of my friends and coworkers, I am the first person they know with COVID-19. This will likely change in the upcoming weeks. I decided to share my experience with the entire department. Since being exposed, I have had many people reach out to me to see how I am doing and what symptoms I am experiencing.

What is interesting is that for those that I have talked with, all expected I would be sicker than I actually am. The fact is my biggest problem every day is extreme boredom. I can only speak from my experience, but as I have researched online, and have talked to those that are interviewing suspected or confirmed cases is that my story is not that uncommon. Watching the news, all the preparation planning etc. have been based off the worst-case scenarios. However, I think all of us have this impression that if you get COVID-19 you will have more severe symptoms. I know I did.

Travel history: I had just returned from an 18-day trip from Colombia (amazing country by the way). There has been some speculation that I may have contracted the virus abroad, which as we all know is a strong possibility, but Colombia was not considered a hot spot, but I did return from an international flight and that in itself is worrisome.

The person I traveled with has not shown any symptoms. But to be honest, she was the smart one, she was super paranoid and self-quarantined (and trust me, I have been reminded over and over of this fact of how I am sick and she is not). Of course, after returning from our trip, we needed supplies like food and wine, so I did all the shopping. It’s very possible and probably most probable I contracted COVID-19 here in the U.S. But who really knows.

Onset of symptoms: On Sunday March 22, I developed what I can only describe as a slight dry cough. It felt like a cough from being back in a dry house. I didn’t feel any indications that I was coming down with something at all.

Monday morning (March 23) when I arrived at work, the dry cough felt more like a cold coming on and was a little more active. But very minor, and with no sore throat. I wrote it off to bad timing. I had no other symptoms.

Later that day, I did develop some GI issues, nothing major and I have certainly had worse. It was at this time, because of recent travel, and now having some GI symptoms, that I went home.

Later that afternoon, I developed other symptoms that I would best describe as my body was trying to fight something off. Primarily these symptoms consisted of chills, some general body aches, and feeling tired. But even these symptoms were mild. A definite contrast from how I started the day off. I had no fever even when I felt my worst.

Since Monday, March 23, these symptoms have remained but in moderation and continue to be mild. And the only way I can describe is a general sense that my body is fighting off an infection. I will also add one other minor symptom, I have an appetite, but nothing really tastes good to me, this may be related to a loss of smell, but all I can say is food just doesn’t taste satisfying.

So why share this? I think we all have this impression that COVID-19 is some nasty stuff and of course we are hearing constantly about all the deaths, and horror stories. And there will be those exceptions of the 35-year-old adult that dies of COVID-19 with no other health issues. Some of you are seeing firsthand these cases. It is undeniable that for a percentage of the population it can be deadly, as we are constantly reminded.

But what is not being reported, at least not in the headlines, is the average healthy person’s response to the virus. The reality is for many healthy adults that contract COVID-19, symptoms may be very mild and, in some cases, non-existent.

Don’t do what I did. I found myself writing it off to something minor. My exact words on Monday were, “I picked a poor time to come down with a cold.”

Do not rely on a temperature as your marker for being infected. I know this is in contrast to what many departments and experts are relying on. When most of us develop a fever, we have other indicators that tell us we need to check our temperature. It is rare that you have a 99.4°F temp and not feel any other symptoms. This is like waiting for the water to be seen on the promenade deck on the Titanic before you abandon ship. That has been my message to everyone. Having a fever, of course, is an absolute “do not even think of coming to work.” But my lesson to you is pay more attention to the minor symptoms like a cough, or sense that you are coming down with something.

If you experience any of these symptoms, it is best to assume you have it. If I would have felt like I did Monday afternoon in the morning, there is no question, given the current situation, I would have stayed home.

Testing: First off, I am very appreciative of the support I have been given by my employer. After some discussion, it was decided that I get tested. Here is how that process went. Essentially, we were given a number to call at a local clinic in case we exhibited possible signs of COVID-19.

I called the number and I was first interviewed by a screener of sorts to see if I met the criteria to talk to a nurse. It was crucial in my case that I tell them that I was a first responder or there was no way I was getting tested. Then I was put on with a nurse who asked me a series of additional questions. After this interview, I was deemed appropriate to be tested.

My appointment time was set to a time between 8 a.m. and 7 p.m. I was instructed to call a number once I arrived in a parking lot for further instruction. Once I called the number, I was instructed to drive up to a tent. I was then called by a physician and asked a series of questions. Then two staff members came out, in full PPE of course, they verified my identity and performed a very brief test that is best described as not a very pleasant experience, but it was quick. I was told to wait for results for 5-7 days. This all transpired with me sitting in my car.

To my amazement, I received a call from a clinic physician the next day with news that I was in fact positive. I then received a call from the Department of Health on Friday morning for further screening and was asked a series of questions. They also sent me a document stating I tested positive that I could present to my employer.

I want to emphasize that this is a serious health crisis and it will have many casualties before it is over. But I feel it is also important to tell the other side, the side that the majority of patients will experience. As the weeks progress, we all will hear firsthand experiences from friends, family and the odds are you may in fact be joining me in your own COVID-19 experience. Hopefully, many of your stories will be like mine. I have apologized to those I potentially exposed when I came to work on Monday. 

Follow up: After I sent out the email to my coworkers, I found many were extremely appreciative of my candor and transparency. What I heard the most is people telling me is that how my story is in stark contrast to what they hear every day in the news, social media, and the many other sources, many of which are painting a very grim picture. My lesson is a simple one, don’t wait to get sick or get a temperature. You must assume that minor symptoms do not prevent you from spreading COVID-19 to others. Take the smallest symptoms as a strong indicator that you may be infected. Follow your local guidelines for screening and testing.

A week after I first showed symptoms, I am still experiencing body aches, some GI issues, and a general feeling that I am fighting off something. My cough has diminished. My biggest complaint today is boredom. I guess I should consider myself lucky. If boredom is the worst that happens to me, I can live with that. Be safe my friends.