The Next Wave: Anticipating the Mental Health Fallout from COVID-19

The human experience related to the novel Coronavirus (COVID-19) has created a challenging human experience as authorities impose shelter-in-place restrictions and limit access to non-essential services.

For some, the pandemic poses a catastrophic risk to life and livelihood. Mexico has one of the populations with the greatest economic disparity in the world. More than 48 percent of Mexicans live in poverty. In Baja California Sur (BCS), many people live without financial reserves and therefore rely on daily or weekly wages to afford basic necessities. In addition, the incidence of diabetes, heart disease and obesity are especially high among this group – conditions that correlate with higher mortality from the virus even among young individuals. Anxiety over financial and health risk combined with the disruption of daily routines and stressful confinement within the home have created powder keg circumstances for individuals and families. 

As the medical director of the Padrino Children’s Foundation (PCF), a U.S. 501(c)3 non-profit organization based in Todos Santos, BCS, Dr. Alejandra Peña Salguero focused initial efforts on preparing for the arrival of COVID-19, hoping to spare her communities the horrors experienced elsewhere in the world. Initially, the Foundation raised funds for, procured, and distributed medical-grade personal protective equipment, disinfectants and cleaning supplies for the local health center and first responders.

The PCF Clinic, closed in compliance with government orders, was converted to a critical supply depot for the community. Then, as the weeks wore on and families felt the strain of prolonged lack of income, PCF assisted local food banking efforts and supplemented the aid with baby formula, diapers, and other necessities. Yet, as she worked around the clock with community leaders to slow the spread of the virus and ease the suffering of the community, the less obvious consequences of social distancing measures weighed on her mind. She began to anticipate a second wave of clinical impact in which the mental health effects of the pandemic will present in millions of people worldwide.

Preparing for the Second Wave

According to Sandro Galea, MD, of the Boston University School of Public Health and chief author of an article published online in the April 10th issue of the Journal of the American Medical Association (JAMA), “These consequences are of sufficient importance that immediate efforts focused on prevention and direct intervention are needed to address the impact of the outbreak on individual and population-level mental health.”

The authors note that large scale disasters are generally marked by “increases in depression, post-traumatic stress disorder, substance use disorder, a broad range of other mental and behavioral disorders, domestic violence, and child abuse.” Specific to the COVID-19 pandemic, the closure of activities including schools greatly increases the risk of family violence and child abuse. Indeed, the toll on mental health has already begun and will persist over a long period of time. The article offers three steps, that if taken sooner than later, can help to proactively prepare for the inevitable increase in COVID-19 related mental health conditions.

    •    Plan ways to intervene in the loneliness that comes from physical and social isolation. 

    •    Establish mechanisms for surveillance, reporting, and intervention for high-risk situations including suicide, domestic violence, and child abuse.

    •    Bolster our mental health system in preparation for the second wave.

Dr. Galea and colleagues suggest that scaling up treatment in the midst of crisis will take creative thinking—especially in small communities with already limited mental health resources. The authors recommend, “Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support. Even small signs that someone cares could make a difference in the early stages of social isolation.”

A proactive plan for early intervention

Dr. Peña Salguero, could not agree more with the JAMA article, acknowledging that a second wave of mental health consequences is a certainty for the community. PCF provides psychiatric care and psychotherapy to nearly 80 children and their families from financially challenged homes in the region. These individuals are especially vulnerable to the stresses brought on by the current circumstances. Along with the PCF clinical psychologist, Israel Navarro Maldonado, Dr. Peña Salguero designed an intervention plan to proactively address this second wave in a timely manner. They began by creating a list of the more than 750 local children whom PCF treated in the past 4 years and then prioritized the list by financial vulnerability. Indeed, the foundation’s patient population represents a large portion of the poverty-stricken families in the region, including residents of migrant camps and children from the distant ranches.

Using an inquiry tool, each member of the PCF team makes brief phone calls to 10 or more families weekly. In each call, information on COVID-19 is provided and recommendations are made for the prevention and promotion of health. Questions are designed to screen for family violence, risk of depression and suicide, as well as any urgent medical or psychological care required. Additionally, each caller evaluates the family’s supply of food, baby formula, diapers and products for hygiene and cleaning.

Carefully structured, the inquiry tool gently reveals individuals and families at risk. The PCF caller offers tips for promoting mental health such as:

    •    Make a healthy daily routine including good nutrition, exercise, study, work and rest schedules.

    •    Choose a reliable source of information and limit the time you watch, read or listen to the news.

    •    Question the credibility of social media and avoid sharing information from untrusted sources to avoid further confusion and concern.

    •    Schedule consistent school hours from Monday to Friday for 3 hours daily.

    •    Distribute household chores to all family members regardless of gender to keep the home clean.

    •    Do family activities at least 30-60 minutes per day (games, cooking together, watching movies, etc.)

    •    Stay connected by phone or video call with loved ones.

    •    Promote the importance of asking for help.

Often, in discussing these tips, the family member confides concerns about circumstances within the home. Dr. Peña Salguero noted, “Each call takes less than 20 minutes but already we have identified some critical situations including two teenage girls and one mother contemplating suicide. We were able to intervene with immediate psychiatric support and subsequent psychotherapy sessions via the telephone.”

In fact, within the first three weeks of initiating the call program, the team had completed 166 calls. As a result, 25 families were referred for psychotherapy, including nine which reported family violence. Eight children were referred for medical treatment including two in urgent need. All needs detected during the calls were triaged to the PCF social worker, medical professional, or psychologist for immediate follow-up. The team is also identifying food instability which can then be mitigated in collaboration with one of several community food banking efforts now in effect. 

Long-term treatment

This pandemic has, and will continue to have, immense implications for individual and collective health and wellbeing. Being a reference point for pediatric health in the region, PCF is exploring near term and long term resources to prepare for the expansion of its Mental and Social Health Program in response to the second wave. The PCF vision includes a creative combination of expert human resources and technology to monitor the psychosocial needs of families and address concerns.

PCF clinical psychologist, Israel Navarro, uses an approach with families called narrative. He described, “With narrative, we establish a respectful and non-blaming relationship to do therapy and work within the community. We assume that the individual is an expert in his or her own life and we view the problem as a separate entity from the person. We highlight that people have many skills, competencies, convictions, values, commitments, and capacities that will help them to reduce the negative influence of the problem over their lives.” Solution-Focused Brief Therapy (SFBT) and Purpose-oriented Systemic Therapy are two methods employed with patients of the PCF Mental and Social Health program. “Systemic therapy seeks to identify patterns of behavior within the family, and address those patterns directly, irrespective of cause, so that more healthy patterns develop,” said Navarro.

Secondly, Dr. Peña Salguero points to the role that technology may play at the Foundation in the future. “Telemedicine therapies and group sessions will be important components of our Mental and Social Health program development. If there is a silver lining to our COVID-19 experience, it is that an investment in telemedicine could give the Foundation long-term access to medical specialties of all types that are not available to us locally,” said Peña Salguero.

Dr. Peña Salguero reminds us that obtaining the coveted N95 masks was a simple task in comparison to the challenges we could face in the months to come. “There are likely some dark days ahead, our community will feel the impact, financial stresses will mount, we will grow weary of isolation, and until a vaccine is widely available, the risk of an outbreak happening in our community remains a possibility. Our preventative community outreach efforts will help to identify individuals and families at high risk for violence and mental health issues so that we can carefully monitor their wellbeing and provide the necessary support. It is a critical part of our strategy to provide integrated healthcare to our patients throughout this crisis and beyond. We are ready.”

If you wish to support the efforts of the Padrino Children’s Foundation to help the families of BCS, please donate at www.padrinocf.org/donate/

If you or a loved one needs help for depression, suicidal thoughts, or domestic violence, consider these resources:

Emergencies: 911  Attention for violence:  Centro de Justicia para las Mujeres Ph. 612 688 1236, 612 122 2945 Calle Carabineros S/N, entre Blvd. Luis Donaldo Colosio Murrieta y San Antonio, Col. Ex Base Aérea, La Paz. 8 a.m. - 8 p.m. Monday to Friday, 8 a.m. - 2 p.m. Saturday, On-call Sunday. Psychological support: Línea de la Esperanza: 612 165 4761 Salud mental: 612 121 1444 Facebook: Colegio de psicólogos de BCS (lists psychologists who provide free consultations). Medical attention for information and COVID-19 symptoms:  800-227-26843 (800-COVID-BCS). Families in need in Todos Santos and subdelegations: 145 05 06, 612 137 4397 apena.pcf@gmail.com