“My partner doesn’t want me to come back home now that I’ve come to the hospital. He is worried I’ll come back and infect him and his parents. I have nowhere to go”. Fear and guilt were palpable in the young woman sitting before me. She had decided to follow the recommendation of the psychiatric crisis response team and come to the Emergency Room for worsening thoughts of suicide.
This dilemma wasn’t new. It was a reflection of numerous patients coming to the ER here in Queens, NY – the epicenter of the COVID-19 pandemic. It was increasingly clear that the socio-economically disenfranchised are most impacted by this pandemic, especially if they have mental illness.
As an Army Reservist called to help in the pandemic response, I often find myself feeling utterly helpless in the face of the devastation this virus is causing. Particularly here in Queens, which is a melting pot of Americans, many of whom are underserved and under-resourced to begin with.
COVID-19 has worsened anxiety and paranoid thoughts in the mentally ill. Several patients have been brought to the Emergency Room from various New York City airports and bus terminals as they attempted to leave the city– without tickets. Fears have amplified for family members of the mentally ill as well; many elderly parents have distanced themselves, leading to further diminished supports for the patients.
Patients are also faced with loss and grief. Several patients in the psychiatric emergency room have loved ones in the intensive care unit. At other times, family members have decided to stay home even when they were sick and infected with the coronavirus. Many people have died in the crowded, multifamily homes where they lived. Now, along with pre-existing psychiatric illness, patients have to navigate grief, bereavement, funeral arrangements, and the financial implications of all this.
It is not surprising that empirically emergency rooms are discovering that suicide rates are on the rise in Queens, NY. Many people have lost their jobs and the ability to provide for their families. One population particularly affected in my experience is cab drivers. Rates for depression and suicidal ideation have increased for them. This was a population that was already affected by the advent of Uber and Lyft. Now, this was compounded by not being able to drive if diagnosed with the COVID-19 infection. Their helplessness worsened by the impending impoverished state and further complicated by cultural beliefs and stigma around seeking mental health treatment.
And where do we refer these patients to? Several clinics are closed, as are intensive outpatient programs. Patients have found that their established therapists, nurse practitioners, and physicians have switched in-person appointments to telephone calls or video calls.
“It is not the same.” I have heard this so many times now. As helpful as telehealth has been in this pandemic, physical isolation is hurting people. The therapist or psychiatrist may be the only real people in the lives of our patients, and they miss them. Perhaps their anger and helplessness about the situation manifest in not being willing or able to make an effort to maintain contact over the phone. The result regardless, is the same: missed appointments, lost to follow up, and deterioration of mental health leading to emergency room visits. The reasons have varied from not having a charged phone, not being able to pay for a phone, phone being cut off or stolen, or some other reason. However, for so many of our chronically mentally ill, they simply do not have the internal resources to be able to organize their lives without support to make this happen. It is difficult to do this, especially when they are homeless, cold, hungry, and on their own.
Many of these patients have also tested positive for the COVID-19 virus. Hence, the added burden of social distancing and taking precautionary measures not to infect others. Yet we find some patients are so severely ill that they cannot manage to do this, or their circumstances will not allow it. In simple words, it is a luxury they cannot afford. This pandemic has resulted in a culmination of odds stacked up against people who neither have the internal reserve nor the external supports to take care of themselves. The result has been increased emergency room visits as a last resort that turns into a revolving door for many patients – not for the lack of trying on the part of the overwhelmed healthcare staff, who have courageously risen to respond this crisis, but due to the external supports that were little to begin with and have diminished further.
We can only hope that what we have observed and experienced now will guide us to address these gaps in case of the resurgence of this virus or for pandemics in the future. It will be too late if we wait for the next time we face a similar situation. There is much to be learned here, and if we don’t enact changes, we will find ourselves overwhelmed, yet again, and unable to meet the needs of our patients who are already suffering and depend on us to be their voice the most.
Image credit: Shutterstock.com