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
2020, Vol. 26(4) 340­–343
© 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)
declared a pandemic due to the rapid, global spread of a
novel coronavirus (SARS-CoV-2, known as COVID-19;
WHO, 2020a). Spreading from Wuhan, China, in December
of 2019, this newly identified virus belongs to the coronavi-
rus family, which also includes Severe Acute Respiratory
Syndrome (SARS) and Middle East Respiratory Syndrome
(MERS; Zhu et al., 2020). Individuals who contract
COVID-19 generally experience a mild illness course, but
much more severe cases can occur, necessitating hospital-
ization and intensive care for Acute Respiratory Distress
Syndrome (ARDS; Huang et al., 2020).
Globally, there have been hundreds of thousands of
COVID-19 cases and thousands of deaths, particu-
larly among vulnerable populations such as the elderly
(WHO, 2020b). Hospital and health system capacity is a
major concern in managing the outbreak due to limita-
tions in hospital beds, personal protective equipment,
ventilators, workforce resources, and testing capabilities
(Chopra et al., 2020). Apprehension about community
spread of COVID-19 has led governments and commu-
nities to implement drastic social distancing measures
ranging from orders to shelter in place, to closing local
businesses, to cancelling major concerts and sporting
events, to closing schools and universities (Centers for
Disease Control and Prevention [CDC], 2020; State of
California, 2020).
The public health challenges facing our communities
as a result of COVID-19 are unprecedented. However, as
we address the physical health and epidemiological
aspects of COVID-19, it is critical that we also consider
the mental health impact of the pandemic. Currently, one
in five American adults have a mental illness (McCance-
Katz, 2019). Suicide rates have risen dramatically in
recent years (30% increase since 1999), and there is a
long-standing, critical shortage of mental health care pro-
viders and resources in the United States (CDC, 2018;
Covino, 2019). Though the COVID-19 response to date
has focused primarily on containing spread and prevent-
ing mortality, the pandemic has potential to create a sec-
ondary crisis of psychological distress and mental health
system spillover. The threat of this second pandemic of
1
Kristen R. Choi, PhD, MS, RN, University of California, Los Angeles,
CA, USA
2
MarySue V. Heilemann, PhD, RN, FAAN, University of California,
Los Angeles, CA, USA
3
Alex Fauer, BSN, RN, OCN®, University of Michigan, Ann Arbor,
MI, USA
4
Meredith Mead, MSN, PHN, RN, Gateways Hospital and Mental
Health Center, Los Angeles, CA, USA
Corresponding Author:
Kristen R. Choi, School of Nursing, UCLA, 700 Tiverton Dr., Room
3-238, Los Angeles, CA 90095, USA.
Email: krchoi@ucla.edu
Choi et al. 341
mental health crises must be addressed as part of a com-
prehensive public health response to COVID-19 (Xiang
et al., 2020). Anticipating where mental health spillover
may occur will help buffer the short- and long-term psy-
chological harm of the outbreak and prepare us to build
population resilience.
There are serious psychological aspects to hospitaliza-
tion for patients, staff, and family members who are
directly affected by COVID-19. Prolonged exposure to
stressful environments, invasive procedures, and the per-
ception of threats in an intensive care unit (ICU) can be
experienced as traumatic, leading to long-term psycho-
logical harm (Righy et al., 2019). Evidence suggests that
survivors of ICU treatment are at elevated risk for post-
traumatic stress disorder, depression, sleep disturbance,
poor quality of life, and cognitive dysfunction (Righy
et al., 2019; Wang et al., 2019). Family members may
experience distress, fear, or anxiety about the hospitaliza-
tion of a loved one, particularly when infection control
measures restrict visitation (Ying et al., 2020). The trau-
matic and stressful aspects of involvement in a pandemic
also risks psychological harm to clinicians (Kang et al.,
2020; Lima et al., 2020). Nurses and physicians involved
in global outbreaks such as SARS, MERS, and Ebola
experienced increased burnout, compassion fatigue,
lower job satisfaction, lower morale, and job stress (Kim
& Choi, 2016; Maunder et al., 2006; M. W. Smith et al.,
2017). The traumatic and stressful aspects of involvement
in a pandemic create mental health risks for both patients
and staff. Health systems should anticipate mental health
needs of patients, staff, and families and prepare support-
ive resources.
In additional to psychological distress related to
COVID-19 hospitalizations, the rapid influx of patients
seeking COVID-19 treatment has potential to displace
mental health beds and treatment capabilities in inpatient
settings. While hospitals are increasing capacity for
COVID-19 patients, non-COVID-19 patients—including
psychiatric patients—may not be able to access usual
sources of needed care. We anticipate that hospitals are
likely to become increasingly challenged with how to
manage and treat acute psychiatric crises in emergency
rooms and how to ensure safety and care continuity for
currently hospitalized psychiatric inpatients. As hospitals
experience increased COVID-19 admissions, they should
prepare for losing mental health bed capacity and develop
a continuity plan for psychiatric patients, especially those
that require essential procedures related to mental health
(Centers for Medicare & Medicaid Services, 2020). Less
intensive psychiatric care settings and community psy-
chiatric hospitals should expect increased patient admis-
sions and prepare for overflow where possible.
Finally, we anticipate that the COVID-19 outbreak
will have an increasingly negative impact on mental
health in communities (Lima et al., 2020). Social distanc-
ing measures, while necessary to stop the spread of the
virus, increase risks for loneliness, isolation, and anxiety
(Long, in press). There is high potential for individuals
with preexisting mental illness to experience symptom
exacerbations or impairment in functional status due to
increased stress and fear around the outbreak (Jiang et al.,
2020). Furthermore, being isolated at home may increase
family or financial pressures as the economic fallout of
the outbreak worsens, leading to poor mental health
(Brooks et al., 2020). Individuals may face unemploy-
ment, housing instability, and food insecurity while care-
giving responsibilities for children or family members
intensify. Those who experience trauma or violence in
their intimate partner and family relationships—includ-
ing psychological trauma—may be at increased risk for
victimization. At the very time individuals affected by
mental illness are likely to need more support than usual,
mental health systems are at risk for losing capacity due
to hospital spillover and clinic closure to promote social
distancing. Innovative models to deliver mental health
support to communities in the midst of a pandemic are
needed to prevent a mental health crisis (A. C. Smith
et al., 2020).
There is opportunity for health system planning,
resource mobilization, and new interventions to address
mental health challenges resulting from the COVID-19
outbreak. Collaboration among health system leaders
from hospital and community mental health systems
must occur to assure safety and continuity of care for
individuals experiencing mental health crises during this
time. Additionally, health systems must offer support
mechanisms for buffering outbreak-related stress. This
includes interventions for patients and families (e.g.,
providing trauma-informed ICU care, providing mental
health resources and education upon discharge, support-
ing virtual visits) and for staff (e.g., occupational mental
health resources, support for illness and family leave,
ensuring adequate staffing, and a safe practice environ-
ment with adequate personal protective equipment;
American Psychiatric Association, 2020; Center for the
Study of Traumatic Stress, 2020). In communities, inno-
vative models of mental health care should be imple-
mented so individuals who need support have access to
professional treatment. Telehealth (including insurance
coverage for telehealth), extended medication supplies,
increased provider mental health training, virtual peer
support, and virtual substance use support groups may
help ensure that community mental health needs are met
(National Alliance on Mental Illness, 2020; A. C. Smith
et al., 2020).
Nurses are central to the entire spectrum of responses
to the COVID-19 pandemic including the mental health
effects of the outbreak. As the largest health care
342 Journal of the American Psychiatric Nurses Association 26(4)
profession with nearly four million nurses in the United
States and more than 20 million nurses globally, nurses
are already addressing the physical and mental health
aspects of the pandemic directly through hospital and
community patient care. Whether they are working with
hospitalized COVID-19 patients, in psychiatric settings,
or in communities, nurses have a responsibility to care
for the psychological needs of their patients. Health sys-
tem and nursing leaders must ensure that their clinical
nursing staff are protected and supported so that they
can provide this crucial dimension of COVID-19 care.
Nurses must also advocate for a comprehensive public
health response to COVID-19 that includes attention to
mental health spillover. By acting now to prepare for a
second pandemic of mental distress related to COVID-
19, nurses can promote resilience in our mental health
systems and communities.
Author Roles
KRC and MM developed key article concepts. KRC led the writ-
ing of the manuscript. MM, AF, and MVH assisted with writing
areas of the manuscript related to their expertise and revised the
manuscript for intellectual content. All authors reviewed the
final manuscript before submitting for publication.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Kristen R. Choi https://orcid.org/0000-0001-5453-1091
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