COVID-19 and Mental Health

Written by: Evelyn Huang, MD (NUEM ‘24) Edited by: Julian Richardson (NUEM ‘21)
Expert Commentary by: Tyler Black, MD, FRCPC

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COVID-19 has been difficult for everyone. Deaths, isolation, loss of work, and countless other hardships abound. With this, comes the concern for mental health crises. In a survey from June 2020, 11% of adults reported thoughts of suicide in the past 30 days [1]. It can be hypothesized that the pandemic has increased suicide rates. However, does this bear out in the literature? As frontline workers, and oftentimes the only interaction that patients have with the healthcare system, it is particularly important that we identify the impact of COVID-19 on the mental health of the patients that we see every day.

In Japan, researcher used a cross-sectional study to analyze national suicide rates during the COVID-19 pandemic. They found that suicide rates in 2020 were increased in October and November for men and in July through November for women when compared to 2016-2019. Increases in suicide rates were more pronounced with men and women that are younger than 30 [2]. This supports the idea that suicide rates increased as a result of the pandemic, especially with the younger population.

However, the trends in the United States are different. A study conducted in the US looked at suicide rates in Massachusetts from March to May 2020. Excluding data from pending death investigations, they found that the incident rate for suicide death was 0.67 per 100,000 person-months for the pandemic period as compared to 0.80 in the corresponding period in 2019. The researchers point to a sense of shared purpose, connections via video platforms, anticipated government aid, and mental health awareness campaigns as possible explanations for the stable rate of suicide deaths [3]. Another study looked at United States suicide related searches during the beginning of the pandemic. Researchers found that internet searches for suicide decreased during the early stages of the COVID pandemic (March to July 2020). While this may be surprising, there is literature that shows that catastrophic events can be associated with increased social support and reduce suicidal outcomes [4]. However, as the pandemic lengthens, more research is needed to see the trends in the data.

The next question is whether the same trend of decreased suicidality also applies to the pediatric population. A pediatric emergency department in Texas looked at the resulted of their routine suicide risk screenings for patients aged 11-21. They found a significantly higher rate of suicidal ideation in March and July 2020 and a higher rate of suicide attempts in February, March, April, and July 2020 when compared to the same months in 2019 [5]. It has also been cited that prior to the pandemic, suicide was the 10th leading cause of death in the United States, but the 2nd leading cause of death among people aged 12-17 [1]. This makes our interactions with the pediatric population even more important and argues for suicide risk screening for every patient.

Looking historically, there are differing trends for different global catastrophes. One researcher found that World War I did not influence United States suicide rates, whereas the great Influenza Epidemic increased suicide rates [6]. Another study looked at suicide rates in Hong Kong during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. They found an increase in older adult suicide in April 2003 when compared to 2002. These researchers cited loneliness and disconnectedness in the older community as a possible explanation [7]. While there are many different factors that go into increased suicidality, trends seen in the past can help guide policy and actions today.

Research is still needed to look at the current trends of suicide rates. The question is whether suicide rates will change as the pandemic continues to lengthen and the sense of shared purpose wanes and social isolation continues. The mental health of our patients is likely to be impacted long after the pandemic ends.

A study conducted in California found that emergency department patients presenting with deliberate self-harm or suicidal ideation had an increased risk of suicide or other mortality during the first year after their initial presentation in the emergency department [8]. This is a troubling trend, but also presents an opportunity for improvement. As emergency physicians, it is also important that we keep vigilant and take the time to talk about mental health. A common fear is that asking about suicide will prompt suicidal ideation, but research has shown that this is not the case [9]. There are several suicide screening tools that can be used in the ED, such as the Suicide Assessment 5‐step Evaluation and Triage (SAFE‐T) and American College of Emergency Physicians ICAR2E [9]. What is important is to ask, because patients will often reveal things to us that they do not mention to their loved ones. Build suicide screenings into your general practice, watch out for risk factors, and support those that are seek help.

References

1. Panchal, Nirmita, et al. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation, 10 Feb. 2021, www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.

2. Sakamoto H, Ishikane M, Ghaznavi C, Ueda P. Assessment of Suicide in Japan During the COVID-19 Pandemic vs Previous Years. JAMA Netw Open. 2021;4(2):e2037378. doi:10.1001/jamanetworkopen.2020.37378

3. Faust JS, Shah SB, Du C, Li S, Lin Z, Krumholz HM. Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021;4(1):e2034273. doi:10.1001/jamanetworkopen.2020.34273

4. Ayers JW, Poliak A, Johnson DC, et al. Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic in the US. JAMA Netw Open. 2021;4(1):e2034261. doi:10.1001/jamanetworkopen.2020.34261

5. Hill RM, Rufino K, Kurian S, Saxena J, Saxena K, Williams L. Suicide ideation and attempts in a pediatric emergency department before and during COVID-19. Pediatrics. 2020; doi: 10.1542/peds.2020-029280

6. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920. Suicide Life Threat Behav. 1992 Summer;22(2):240-54. PMID: 1626335.

7. Cheung YT, Chau PH, Yip PS. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry. 2008 Dec;23(12):1231-8. doi: 10.1002/gps.2056. PMID: 18500689.

8. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Association of Suicide and Other Mortality With Emergency Department Presentation. JAMA Netw Open. 2019;2(12):e1917571. doi:10.1001/jamanetworkopen.2019.17571

9. Brenner, J. M., Marco, C. A., Kluesner, N. H., Schears, R. M., & Martin, D. R. (2020). Assessing psychiatric safety in suicidal emergency department patients. Journal of the American College of Emergency Physicians Open, 1(1), 30-37.

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Expert Commentary

This review is a comprehensive summary of the challenges and nuances of suicide epidemiology. Though it goes against the narrative many hold, in the United States we have preliminary but reliable data for suicides two years into the pandemic, we have not seen an increase in suicide rate in any age group (Figure 1) [1,2]. This reassuring news is tempered by the knowledge that prior to the pandemic, a decade-long trend of increasing suicide rates has maintained, and children, adults, and older adults are much more likely to die of suicide now in America than they were in 2010 [3].

Figure 1. Odds ratio for suicide, by age groups (A = under 18 years; B = 18 to 64 years; C = above 64 years). Years are grouped to match with the onset of the pandemic (March 2020), such that each data point represents April of that year to the following March (instead of the typical January to December presentation). The comparator for each year’s odds of suicide is a sum of the odds between April 2017 and March 2020. The shaded vertical lines represent the 95% confidence interval for odds ratio, and they are hidden behind the markers for the adult group due to the small confidence interval. 

Whenever considering suicide risk, it is crucial to remember that there are not direct links between suicidal thinking, suicide attempts or visits to the emergency department, and deaths by suicide. Up to 60% of people die of suicide on their first attempt, and the vast majority (95%) of people who attempt suicide do not die of suicide, so while it is important to see the danger in suicidal presentations to emergency department, it is crucial to be aware of the challenges in predicting who will live and who will die by suicide and focus on a person-centered approach to understanding an individual’s risk and protective factors[4, 5].

I applaud the authors for encouraging all clinicians to consider suicide risk in all patients and to become comfortable with routine screening. This may never demonstrate a reduction in suicide rates in rigorous research, but we have ample evidence that having open, genuine discussions about psychological, social, and health problems regarding suicide risk is beneficial to the patients we care for [6].

References

1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/ucd-icd10.html on Dec 1, 2022.

2. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Provisional Mortality on CDC WONDER Online Database. Data are from the final Multiple Cause of Death Files, 2018-2020, and from provisional data for years 2021-2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-provisional.html on Dec 1, 2022

3. Centers for Disease Control and Prevention. (2022, June 28). Suicide data and statistics. Centers for Disease Control and Prevention. Retrieved December 1, 2022, from https://www.cdc.gov/suicide/suicide-data-statistics.html

4. Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100.

5. Hawton, K., Lascelles, K., Pitman, A., Gilbert, S., & Silverman, M. (2022). Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management. The Lancet Psychiatry.

6. Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?. Psychological medicine, 44(16), 3361-3363.

Tyler Black, MD, FRCPC

Assistant Clinical Professor

Department of Psychiatry

The University of British Columbia

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Huang, E. Richardson, J. (2023, Jan 2). COVID-19 and Mental Health. [NUEM Blog. Expert Commentary by Black, T]. Retrieved from http://www.nuemblog.com/blog/covid-mental-health

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Debriefing in the ED

Written by: Diana Halloran (NUEM ‘24) & Andrew Long (NUEM ‘25) Edited by: Nick Wleklinski (NUEM ‘22)
Expert Commentary by: John Bailitz, MD

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Introduction

The Emergency Department is a challenging work environment for a variety of reasons. It is not surprising that unpredictable work hours mixed with frequent interactions with patients undergoing physical and emotional trauma can cause spillover into the personal lives of ED staff. However, in the recent years there has been an increasing body of literature that highlights the challenges that we face as ED personnel. 

The American Heart Association even recommends a “hot” debrief for every cardiac arrest attended by a healthcare professional. We know debriefing has concrete and tangible advantages. Previous studies have shown that debriefing immediately after an event can improve individual and team performance by 20-25%, issues can be identified for interventions, and mental health and emotional trauma can be addressed. It is well-documented that ED physicians have historically high rates of burnout compared to other specialties as well as a high incidence of post-traumatic stress disorder (PTSD) compared to the general population. PTSD is 2 times more prevalent in physicians (14.8%), with EM resident physicians falling in the range from 11.9%-21.5%.

As a field, we are now starting to design and implement interventions to preserve our own mental wellbeing. In fact, debriefing has been shown to be one method for managing PTSD. One article described an initiative that implemented an immediate (also known as “hot”) debrief protocol immediately following all cardiac arrests during which 90% of participants felt they benefited psychologically, and 100% felt it improved their clinical practice. In this post, we will give a brief overview of a landmark study in the ED debrief literature, which advocates for a “hot” debrief model in resuscitation cases using the STOP5 model.

Study Analysis

This study published in 2019 designed, tested, and developed the STOP5 model to facilitate safer patient care, team development, and quality improvement within the Emergency Department. The STOP5 model, the first widespread debriefing tool, was designed as a “hot debrief”: “an interactive and structured team dialogue that takes place either immediately or very shortly after a clinical case”. Any team member of the resuscitation may lead the hot debrief.

Figure 1: The STOP5 Model Debriefing Framework (proposed by CA Walker et al 2020)

After an initial check-in the team moves to a group discussion and follows the STOP framework above: Summarize the case, Things that went well, Opportunities to improve, and Points to action and responsibilities. Inclusion criteria for these hot debriefing cases were major traumas, deaths in resuscitation, and any cases upon request by any staff member. No potential resuscitation cases were formally excluded.

After 18 months the ER staff was re-surveyed to ascertain STOP5 rating scores, the number of staff involved in the debriefs, any possible benefits or barriers to team performance, and if staff believed there should be more or less hot debriefing in the ER. In this 18-month review all STOP5 debriefs were rated “good” to “excellent”, suggesting the debriefing was highly valued. 98% of respondents believed that there should continue to be more hot debriefs in the emergency department. In a 12-month review there were 10 process and equipment changes (“hard outcomes”) as a direct result of the STOP5 hot debriefs and 14 additional opportunities for improvement. The hot debrief allowed for concrete actions to be taken about these issues and for a dedicated plan of action for correction. These hard outcomes identified issues such as those listed below which allowed for concrete solutions for all the identified problems.

• Shortage of resuscitation room equipment

• Drug stocking issues

• Drug preparation/infusion regime for vital but rarely used medications difficult for staff to find

• Faulty equipment (doors, machines)

Reported barriers to enacting hot debriefs include time constraints, workload, low staff confidence in leading the debrief, or absence of team members (consultants who might have left the department, change of shift). For these reasons hot debriefing is still not standard practice. However, a hot debrief such as STOP5, with a concrete checklist, is an inexpensive and quick way to enhance team performance, improve patient care, and assist with emotional trauma and mental check-ins for the team. Debriefing is a valuable and important aspect of our medical career. We hope to bring more of a focus to debriefing within our institution by beginning to enact the STOP5 based hot debriefing after clinical events.

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Expert Commentary

Whether working in a community or academic Emergency Department, recurrent extraordinary cases threaten the well-being of the clinical team during that shift and after. Although resources often exist for individual employee assistance after a difficult shift has ended, few interventions have been described to help the team regroup and recover during that particular shift. Furthermore, department level morbidity and mortality conferences or hospital level quality assurance reviews focus more on the technical case details and less on team wellness.

With the primary purpose of quickly restoring team performance and wellness, hot debriefs at NUEM provide the opportunity for our ED teams to have a structured yet brief meeting immediately after an extraordinary case. Using STOP5, team leaders have a step-by-step plan to quickly yet effectively help every clinician on the team properly mentally frame the case, share gratitude, and then identify and assign opportunities for immediate improvement. Building on life support courses and residency training, specific education on the STOP5 framework quickly prepares senior clinicians to lead hot debriefs. Utilizing change management principles to identify and address logistical barriers helps to create a culture that supports immediate debriefing. Successful strategies in our NUEM ED include protocols to pause new inflow and cover existing patient demands, designating meeting spaces, adding positive program reminders to clinical areas and recurring meetings, and tracking and celebrating program success.

References

1.    Get With The Guidelines - Resuscitation Clinical Tools. (2021, August 16). Www.Heart.Org. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-resuscitation/get-with-the-guidelines-resuscitation-clinical-tools

2.    Gilmartin, S., Martin, L., Kenny, S., Callanan, I., & Salter, N. (2020). Promoting hot debriefing in an emergency department. BMJ Open Quality, 9(3), e000913. https://doi.org/10.1136/bmjoq-2020-000913

3.    Tannenbaum, S. I., & Cerasoli, C. P. (2012). Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Human Factors: The Journal of the Human Factors and Ergonomics Society, 55(1), 231–245. https://doi.org/10.1177/0018720812448394

4.    Vanyo, L., Sorge, R., Chen, A., & Lakoff, D. (2017). Posttraumatic Stress Disorder in Emergency Medicine Residents. Annals of Emergency Medicine, 70(6), 898–903. https://doi.org/10.1016/j.annemergmed.2017.07.010

5.    Walker, C. A., McGregor, L., Taylor, C., & Robinson, S. (2020). STOP5: a hot debrief model for resuscitation cases in the emergency department. Clinical and Experimental Emergency Medicine, 7(4), 259–266. https://doi.org/10.15441/ceem.19.086

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Halloran, D. Long, A. Wleklinski, N. (2022, Sept 12). Debriefing in the ED. [NUEM Blog. Expert Commentary by Bailitz, J]. Retrieved from http://www.nuemblog.com/blog/debriefing-ED

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