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COVID-19 survivors may experience cognitive and mental health symptoms during the acute illness or as sequelae.1,2 This may include exacerbations of pre-existing conditions or new illness. One report from the UK identified COVID-19 patients with depression, personality change, catatonia, and mania.2 Some patients with prolonged ICU stays will likely also suffer from PTSD. The full spectrum of behavioral health issues related to COVID infection will become more clear as the pandemic progresses.
Behavioral health issues are also a concern for workers who have not contracted COVID-19. With the pandemic have come a host of economic and other stressors which have negatively affected the mental health of American workers. Some recommended preventive actions for COVID-19, such as isolation, quarantine, and social distancing, have compromised the web of social and professional interactions which are foundational to many of our coping mechanisms for managing behavioral health problems. Mental health disorders such as depression, anxiety, PTSD, and behavioral health issues, including eating disorders, substance use disorders, and related issues such as domestic abuse, were highly prevalent before the pandemic. For persons with pre-existing behavioral health issues, the pandemic may interfere with access to usual care. Enforced time at home may increase risk of domestic violence, and relapse in persons in recovery from
substance use disorders or eating disorders.
The Center for Health Statistics (NCHS) “Household Pulse” survey showed that for the period of January – June 2020 over 30% of Americans without behavioral diagnoses experienced symptoms of anxiety and/or depression. This is up sharply from 11% noted in a similar survey done in 2019.3 Persons experiencing COVID-19 related symptoms or illness have additional stressors, and the frequency of mental health symptoms is greater among them.
To safely return employees to work, following CDC advice from an infection prevention standpoint is necessary, but not sufficient. Employers and health care providers participating in the return to work process must consider residual behavioral health symptoms. Some will be apparent, but to detect those which are not, available screening instruments for depression, anxiety, substance use disorders, domestic violence and cognitive impairment should be used routinely by those appropriately trained in administration, interpretation, of these instruments. As with other medical records, confidentiality must be maintained. Employers will need to reach out to health care providers, and Employee Assistance providers to manage this process. Occupational physicians are ideally qualified to serve in this role.
THE EMPLOYER AND OCCUPATIONAL PHYSICIAN’S ROLE IN RETURN TO WORK
Patients with significant cognitive or emotional symptoms require careful assessment. Where a mismatch between job requirements and capacity is suspected, or if, in some cases, where a workplace accommodation is requested, a fitness-for duty evaluation may be helpful. Depending on the circumstances, formal neuropsychiatric evaluation, substance use evaluation, and/or a psychiatric or psychological fitness for duty evaluation may be required. The employer should enlist the aid of an occupational physician, or EAP professional to coordinate this process. For safety sensitive employment, in particular, a fitness for duty evaluation performed as an independent medical evaluation, may be a more reliable basis for decision-making than using the opinion of the patient’s treating provider exclusively. Training for managers in assessment of reduced capacity in co-workers, and procedures for initiating referrals for evaluation is advisable.4,5,6
CREATING AND MAINTAINING A PSYCHOLOGICALLY SAFE WORKPLACE
To put it simply, “Employers need to prioritize mental health as part of their “new normal.”7 The specific actions required will be determined in part by regional differences in pandemic severity, whether or not a workplace is essential, and the likelihood of employee exposure to the virus in the work setting. Employees should be involved in this effort; asking them what they need help with is a useful first step. Free flow of information is also fundamental to building a supportive environment. Providing information about pandemic decision-making which is timely, direct, inclusive, and transparent builds trust. Finally, specific programs teaching coping-strategies, building employee resilience, and reducing the stigma associated with behavioral health issues in the workplace will be helpful. Employers large and small will also need to address the access and payment barriers inherent in our mental health treatment system in general and our worker’s compensation systems specifically.
Mental health services are normally provided as part of an employee assistance program (EAP), or healthcare plan. How did this work for your employees before the pandemic? Does it still work now? The ability of patients to receive mental health care through telehealth visits is particularly important. A May 2020 survey by the American Psychiatric Association showed that prior to the public health emergency a majority of psychiatrists did no visits by tele-health. By mid-May, 86% percent of providers were seeing 75% or more of their patient load via telehealth.8 Make sure your programs provide payment for virtual visits. Similarly, for patients who rely on 12 step programs, such as Alcoholics Anonymous, there has been an explosion of virtual meetings. Employees should be made aware of available opportunities for self-care. CDC has provided resources and guidance to cope with stress during the pandemic13. ACOEM has touched on mental health issues in its statement on safely returning America to work.9 There is an evolving list of mental health resources for employers and employees on the ACOEM COVID-19 resource center page.10 The American Psychiatric Association Foundation has produced an entire program for employers which can be downloaded free of charge.11 To assist employers in making workplaces more supportive of those dealing with substance abuse, the state of New Hampshire has developed a “Recovery Friendly Workplace” program.12