Parallel pandemic: psychological facilitation in medical assistance

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Parallel pandemic: psychological facilitation in medical assistance

O.V. Volkova, P.A. Shesternya

^a V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 1, Partizan Zheleznyak Str., Krasnoyarsk, 660022, Russian Federation

Analysis of current studies in Russia and other countries allows to make a conclusion about the growing pace, developing so-called parallel pandemic, which is formed at the level of psychological health. This situation reveals the urgency to analyze the situation of the COVID-19 pandemic from both clinical psychology and general medical practice points of view. This article attempts to highlight the potentially possible, negative consequences of the pandemic, which affect the psychological state of different categories of the population. In particular the special attention is paid to the difficulties faced by health-care staff at the core of the fight against COVID-19. A comparative analysis of the current situation allowed the authors of this article to draw parallels between the state in which most of the population is now living and the state of the learned helplessness. A scheme for the medical and psychological assistance in the post-pandemic period has been proposed.

Keywords: mental health; somatic health; psychological facilitation; parallel pandemic; postpandemic period; COVID-19; medical assistance; learned helplessness.

Параллельнаяпандемия: психологическая помощь в медицинской сфере

Introduction

The situation facing the world community during the COVID-19 pandemic seems to us only somewhat foreseeable. Fixing the facts of destructive and maladaptive types of response in conditions of psychoemotional tension and specific deprivation caused by conditions of self-isolation will inevitably lead to completely new consequences, in terms of global trends.

“The indirect effects of COVID-19 may be greater than the number of deaths due to the virus itself,” - was an opening remark of Dr Tedros Adhanom Ghebreyesus, World Health Organization Director-General on the media briefing on COVID-19 at the 12^th of June 2020 [1]

In reality, none of the existing states, either socially, economically or in terms of the readiness of health-care systems and psychological assistance to the population, has been left out of the elements named COVID-19. An unprecedented social “experiment” cannot be compared to any historical experience of developed states. There are still global economic and political shifts ahead in the world, behind-the-scenes processes in the fight for a “zero” patient, and the search for a way out of the situation with the least losses. However, already now specialists of assisting professions of the “man-to-man” professional sphere for ethical and moral reasons, based on the requirements for missions “doctor” and“psychologist” face realities in which it is necessary to attempt specific actions to reduce the destructive effect of the new coronavirus infection of the SARS-Cov-2, which spreads rapidly throughout the territory of the Russian Federation.

The negative consequences and potential risks currently found in the various types of psychological responses to current events by different segments of the population have an understandable basis from the clinical psychology point of view [2-4].

“We need more high-quality studies to make any final conclusions about a link between mental symptoms and COVID-19. However, ... there are derived effects of the pandemic on the mental health among both healthcare professionals and the population. Given that the previous SARS epidemic was also associated with mental symptoms, we believe that research in this area is extremely important, as knowledge is a prerequisite for dealing with any mental consequences of COVID-19,” - says Nina Vindegaard Sorensen (Department of Immunology and Microbiology at the University of Copenhagen and the Mental Health Centre) [5].

Problem statement

The way of life of modern human in the pre-pandemic period had a number of specific features, among which we can define the prevalence of external locus of control, external determination and conditional stability of reality. The changes, which were previously classified as sudden, spontaneous and uncontrolled, are not in any comparison with the circumstances with which a person has been forced to face COVID-19, both at the level of somatic and psychological, mental health. And, if we take into account that traditional ways to overcome a stressful situation of this kind in a person, as a self-organizing system, representing biopsychosocial unity, does not exist, and the problem has a global level, the scale of the tragedy simply cannot be overestimated.

Stress is a special condition that, despite its negative perception of the stress phenomenon, contributes to the adaptation of a living organism to new conditions of reality, and therefore to adaptation at a completely new level, therefore contributes to the process of development. However, this scheme works only under the conditions of eustress, a useful stress that creates the necessary difficulties to overcome, replenished deficits, which result in the transition of man as a system to a new level of development. At this stage, COVID-19 is another type of stress - its destructive form - a distress, the collision with which leads to the destruction or death of a person. The only hope is the possibility of a reasonable, rational, systemic, technological approach to the pandemic problem, in which joint efforts of specialists of different professional fields will be able to change the polarity of coronavirus infection SARS-Cov-2 effects from “-” into “+” Not baseless optimism, but the persistent search for a solution to a new problem in a new reality rapidly developing under the influence of a new coronavirus infection SARS-Cov-2 should become a priority in the collegiate activities of psychologists and doctors.

Discussing the mental health care measures in response to COVID-19 Korean specialists response: “Despite the elapsed time since this outbreak (Middle East respiratory syndrome coronavirus (MERS-nCoV) infection), a high risk of posttraumatic stress disorder symptoms were reported by healthcare workers who treated the MERS-nCoV infected patients and by hemodialysis patients in quarantine. Additionally, the negative emotion and stress experienced by the healthcare workers who treated the MERS-nCoV infected patients were characterized by trigger events categorized into mistake, missing, delay due to communication failure, and others. Moreover, among the exposed individuals in quarantine not diagnosed with the MERS-nCoV infection, 7.6% and 16.6% presented anxiety and feelings of anger symptoms, respectively, during the quarantine period” [6].

Psychological problems met by representatives of all countries and cultures are as follows: difficulties of self-organization, low level of self-control, total lack of psychological self-support skills, lack of competence in the field of time management, which has led to tragic but quite logical consequences in the form of lifestyle stagnation, mental health disorders, increase in the amount of suicides, escapism in destructive forms of psychoemotional tension reduction, including alcohol abuse (according to the latest data, demand for alcoholic products in trading networks increased by 30%) [7].

Methodological background

Our observations reveal that in a state that can be noted as the general psy- choemotional background of the population, there are clear signs of a psychological phenomenon, which was defined as a state of learned helplessness by American psychotherapist, founder of the New Positive Psychology Martin Seligman in 1970s [8, 9].

Learned helplessness arises from long-term out-of-control events that cannot be overcome by any effort. Such a force, insurmountable and beyond the control, proved to be COVID-19 for a human at the global level. It is important to mention that the state of learned rather than objective helplessness is characterized by a deficit in four personal spheres:

- emotional (the population of all countries experiences dysphoric emotional states, the red line of which combines panic, anxiety, aggression, despair, frustration, uncertainty);

- motivational (in current conditions the motivational sphere has changed, there has been a shift in the focus of dominant motivation from classical life values, including the importance of self-realization, self-actualization, professional and personal formation to motivation to maintain non-adaptive forms of “preservation” of life, for example, uncontrolled and non-rational purchase of basic necessities in stores, etc.);

- will-power (the level of self-control as a manifestation of the will of the population has significantly decreased, which has been manifested in the violation of the regime of the day, lack of reliance on elementary rules of time management, lack of necessary discipline in maintaining the foundations of a healthy lifestyle, violation of the regime of self-isolation with full awareness of the consequences by the mass media, etc.);

- cognitive (there is an acute problem of selectivity in terms of information absorption, which contributes to an endless flow of fake news about the situation with a new coronavirus infection SARS-Cov-2, reduction of the criticality of thinking, inability to change the usual (rigid) methods of response, replacing them with new, flexible, more adaptive within the current situation).

Discussion

In addition to the evidence of negative consequences of a general nature, it is necessary to refer to the age criterion in the analysis of the impact of the pandemic on the mental and somatic health of the population.

Children of pre-school age who are not at direct risk of COVID-19 disease face special conditions of deprivation: observance of the regime of self-isolation contributes to restriction of physical activity, conditions of stay in home deprive children of natural development of the leading age activity - games, the most effective mastering of which is possible in the process of communication with peers. Deficits concerning the educational process are being formed, based, inter alia, on the fact that modern parents are not ready to take on the educational function, as well as on the lack of formation of the relevant pedagogical skills and competences. Limited space, physical and psychological activity, closed circle of environmental communication, suppressed psychoemotional condition of adult environment members are all conditions that contribute to negative consequences in the sphere of psychological and physical health of children.

A group of school-age children, including junior schoolchildren, middle- level schoolchildren, school graduates, is a special risk group. While junior and middle-level students have the potential to compensate for the deficits created by self-isolation, distance learning, in the post-pandemic period, the situation in 9th and 11th grades is close to tragic. The absence of systematic training in the graduate class on the threshold of passing the Final State Certification Procedure creates the highest level of anxiety and uncertainty. The illusory joy associated with the cancellation of passing the exams creates a deficit in knowledge within certain disciplines, which will reduce the level of education in the future. Formalization of the homework assessment (on the principle of “sent/not sent”) negatively influences the will-power sphere of teenagers which is at the peak of formation.

The situation is really critical in groups of 11^th grades students. If graduates of 9 grades have a chance to compensate the lack of knowledge in high schools, 11-graders stand on the threshold of entering the university. Uncertainty of the situation, uncertainty about the forthcoming conditions and circumstances of the period of passing the finals and entering the university, shifting of the final certification conditions, imbalance of the system of preparation for the final examinations at school, inability to adapt to the university within the system of pre-university training in the walls of the potential Alma Mater - all these factors have an extremely negative, destructive impact on the psychological condition of students of the graduate classes.

From this point of view the social layer of students is seemingly in more secure situation. However, remote form of educational process contributes to the development of procrastination (“putting tasks on the back-burner”), limits the sphere of social communication, restricts direct adoption of practical experience by future specialists.

Medical universities in current circumstances were, however, in special conditions, which can be traced on the example of Krasnoyarsk State Medical University named after Prof. V.F. Voyno-Yasenetsky. On the one hand, the situation of self-isolation in the context of the pandemic complicated the educational process, on the other hand, played a role of litmus paper and showed all vulnerabilities, difficulties and deficient aspects of the remote form of education, which allowed to eliminate problems in real time as they were detected, and thus created conditions for improving the remote format of the educational process. Moreover, the acquisition of practical skills by senior students and residents within the framework of the Headquarters for the Prevention of New Coronavirus Infection Spread has acquired the format of a specific socio-educational experiment (a kind of a “crash test”), which would simply not be possible in other conditions, and has made it possible to obtain data, results and conclusions which are necessary to analyze in details and take into account in the future.

One of the supporting arguments voting for this question is opinion of Massachusetts Medical Society members about educational system in post-pandemic period: “While initially considered one of the functions we had the most experience with, we quickly learned that traditional methods we have relied on to disseminate information to clinical teams are of limited value in a situation where information frequently changes and key messages need to be delivered to large audiences. A total transformation of both the methods and the format used to communicate occurred in our system in a short period of time, challenging our past assumptions of whether messages get across even under normal circumstances. The work of this group redefined how we communicate with our clinical teams and has created a new standard that will likely be continued after the Covid-19 crisis” [10].

The middle-aged population filters all the negative effects of the new coronavirus infection pandemic SARS-Cov-2: threat or fact of unemployment, transition to form of remote work, social deprivation, need to learn new competences, anxiety for family members of younger and older generations, exacerbation of conflicts in the family (if previously family members spent a certain limited time in collaboration, now the communication has entered the 24/7 mode, the results of which we can already find in data reflecting the increase in the number of divorces since the abolition of the self-isolation regime in China). In addition, modern representatives of the working layer of the population have met with the phenomenon, which in western psychology and management is called the term “overlap” - when the boundaries between professional activity and the home environment are blurred, the working space and professional tasks are moved to the territory, which is intended for rest, recuperation, intimate and personal relations, etc. All the above-mentioned conditions contribute to the highest level of psychological tension and increase susceptibility to stress effects, which are abundant in the modern information environment [11-13].

Representatives of the third age group are also in special conditions. Above all, older population are among the main risk groups for COVID-19. And this, apparently, purely physical factor, promotes formation of the psychological vulnerability which is shown in feeling of anxiety, concern, feeling of isolation and loneliness, lack of psychological flexibility in development of new forms of life organization, communication implementation, receiving services. Psychological vulnerability, supported by the weakness of somatic health associated with age-related changes in the body, is formed by the so-called “closed circle mechanism”, which contributes to the reduction of immunity and increases the risk of infection due to increasing stress factor.

The situation among medical personnel requires special attention [14]. This is a classic rock and roll scenario - health workers are desperately needed, but they represent one of the most vulnerable groups in the population. The obvious factors that have a negative impact on the emotional background of health workers, who are on the front lines in the fight against COVID-19, are the higher risk of infection and potential spread of infection, excessive load, work under conditions of mandatory use of personal protective equipment, isolation from the family and society during the period of work and subsequent quarantine [15]. Widespread media coverage and inadequate feelings of support can contribute to mental difficulties and professional burnout due to excessive stress in an increasingly burdened health care system [7].

As experience the suggestion of Korean scientific society reflected in a leaflet of the National Center for Disaster Trauma can be used as promoting mental health care “against the distress caused by infectious disease outbreaks. According to this leaflet, somatic symptoms, insomnia, anxiety, anger, rumination, decreased concentration, low mood, and loss of energy are listed as the warning symptoms that should be evaluated and managed by mental health professionals” [6].

The US Health care professionals compare the traumatic effects of COVID-19 pandemic by following words: “Like the volunteers who flooded into Manhattan after the World Trade Center attacks, the health care providers working on the front lines of the Covid-19 pandemic will be remembered by history as heroes. These courageous people are risking their lives, threatened not only by exposure to the virus but also by pervasive and deleterious effects on their mental health. Tragically, we are already seeing reports of clinicians dying by suicide amid the pandemic, including the highly publicized death of a prominent emergency medicine physician in Manhattan, the epicenter of the U.S. Covid-19 outbreak. Before the virus struck, the U.S. clinical workforce was already experiencing a crisis of burnout. We are now facing a surge of physical and emotional harm that amounts to a parallel pandemic” [16].

Anti-epidemic interventions are based mainly on early detection of cases, subsequent testing, isolation and quarantine. Such tactics were successfully implemented in the fight against previous epidemics of Severe Acute Respiratory

Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS), when outbreaks of infection were rapidly localized. However, the “Achilles heel” of the current activities is the possibility of transmission SARS-Cov-2 already during the incubation period, as well as from asymptomatic patients. Another key factor in the rapid spread of COVID-19 is the accumulation of SARS-Cov-2 virus in the upper respiratory tract, as opposed to previous coronaviruses “versions” [17].

Coronaviruses are an important family of animal and human viruses in constant circulation on all continents and cause up to 20% of all respiratory infections. Studies show that the number of asymptomatic carriers exceeds the number of patients, and SARS-Cov-2 is no more lethal than other circulating viruses, which are ecosystem infections [18].

The UK professional health care society suggested two types of actions fighting the effect of COVID-19 on risk of anxiety, depression, and other outcomes, such as self-harm and suicide: immediate actions and long-term programs among which: “Improve monitoring and reporting of the rates of anxiety, depression, self-harm, suicide, and other mental health issues; determine the efficacy of mechanistically based digital and non-digital interventions and evaluate optimal model(s) of implementation... Determine the mechanisms (e.g., entrapment and loneliness) that explain the rates of anxiety, depression, self-harm, and suicide; understand the role of psychological factors in buffering the effect of social context on mental health issues; ascertain the longer-term consequences on wellbeing of COVID-19 for the young and older generations (and vulnerable groups)” [19-20].

The Chinese clinicians suggested three important factors in terms of the mental health care response to the COVID-19 outbreak: “1) multidisciplinary mental health teams (psychiatrists, psychiatric nurses, clinical psychologists, and other mental health professionals), 2) clear communication with regular and accurate updates about the COVID-19 outbreak, and 3) establishment of secure services to provide psychological counseling (e.g., electronic devices and applications)” [21].

The difficulty of assessing the emotional impact on health workers is also due to the lack of official data on morbidity among health workers at the forefront of the pandemic, while reports of thousands of sick doctors are replicated in the media and social networks. Growing media noise and hyperbolized fear of the pandemic are real catalysts of much deeper processes taking place in the professional medical community as a whole. COVID-19 gives rise to a lot of uncertainty, and it has resonance with medical workers, far incomplete understanding of pathogenesis, absence of vaccine for preventive measures and rapidly changing recommendations for treatment introduce additional discoordination [20, 21]. It is obvious that more effort is required to optimize the psychological safety of health workers in the current conditions [22, 23].

Project description

The problems identified above, with reference to the analysis of data covered in recent publications by representatives of world science, as well as the synthesis of information of qualitative content received from staff of medical institutions and representatives of the psychological professional society, set us the task of organizing systematic medical and psychological assistance to the population in the context of the pandemic, which include:

- development of an educational projects system aimed at minimizing misinformation, which forms a general dysphoric emotional background,

- organization of a clear and transparent system of informing the population about risk factors as well as algorithms of action in a pandemic situation,

- implementation of an accessible system of communication with specialists of helping professions that create a sense of security in the context of a pandemic,

- creation of psychological counselling channels, including using electronic devices and applications,

- introduction of a preventive measures system aimed at reducing the signs of learned helplessness in order to block the transition of the temporary state into permanent personal feature,

- building a technology of psychological assistance to health-care system specialists aimed at maintaining their psychological well-being, as well as creating psychological resistance to emotional and professional burnout,

- organization of advanced training courses for specialists of psychological service, aimed at the development of non-drug therapy short-term programs, techniques and tools of urgent-assistance to victims of the pandemic, the formation of psychological support techniques through the service of the counselling channels, etc.,

- development and implementation of programs for the psychological rehabilitation of health-care system specialists who were in the center of the fight against COVID-19,

- building systematic educational psychological activity focused on universal human values, aimed at formation and maintenance of psychological immunity of the population through carrying out flash mobs, marathons on-line by means of mass-media and social nets.

Directions for the organization of psychological assistance in the post-pandemic period

Conclusion

Thus, relevant and future post-pandemic periods demand from experts of the mental health care system development of systematized and complex work in respect of the organization of psychological support to the population. It is important to remember that, unfortunately, among the population of our country, the culture of receiving psychological assistance and seeking it has been formed at an extremely low level, and that is why in a pandemic situation specialists of helping professions should make huge effort to create conditions that will allow to form this healthy-saving skill.

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