Opinion

Mental Health Disorders Related to COVID-19–Related Deaths

Naomi M. Simon, MD, Since February 2020, the coronavirus disease 2019 with the deceased, emotional pain, loneliness, diffi-
MSc (COVID-19) pandemic has led to at least 200 000 deaths culty reengaging in life, avoidance, feeling life is mean-
Anxiety and in the US and 1 million deaths worldwide. These num- ingless, and increased suicide risk. Once established,
Complicated Grief
bers probably underestimate COVID-19 deaths by 50%, these conditions can become chronic with additional
Program, Department
of Psychiatry, NYU with excess cardiovascular, metabolic, and dementia- comorbidities such as substance use disorders. Pro-
Grossman School of related deaths likely misclassified COVID-19 deaths.1 In longed grief affects approximately 10% of bereaved
Medicine, New York, this issue of JAMA, Woolf and colleagues1 update their individuals,4 but this is likely an underestimate for grief
New York.
previous estimate, suggesting that the number of ex- related to deaths from COVID-19. 5 Further, each
cess deaths between February and August 2020 attrib- COVID-19 death leaves an estimated 9 family members
Glenn N. Saxe, MD
Department of Child utable to COVID-19 is estimated to be about 225 000. bereaved,6 which projects to an estimated 2 million be-
and Adolescent This devastating pandemic has affected nearly ev- reaved individuals in the US. Thus, the effect of COVID-19
Psychiatry, NYU ery aspect of daily life. While nations struggle to man- deaths on mental health will be profound. Moreover, the
Grossman School of
Medicine, New York, age the initial waves of the death and disruption asso- stress and social disruption caused by the pandemic has
New York. ciated with the pandemic, accumulating evidence heightened depression and anxiety globally, and is ad-
indicates another “second wave” is building: rising rates versely affecting many individuals with preexisting psy-
Charles R. Marmar, of mental health and substance use disorders. This im- chiatric disorders and substance use disorders.
MD
minent mental health surge will bring further chal- How will the US manage this imminent mental
Center for Alcohol Use
Disorders and PTSD, lenges for individuals, families, and communities includ- health wave? The US faces monumental challenges. At
Department of ing increased deaths from suicide and drug overdoses. present, the mental health system is greatly strained, and
Psychiatry, NYU As with the first COVID-19 wave, the mental health wave even a needed infusion of funds would comprise only a
Grossman School of
Medicine, New York,
will disproportionately affect Black and Hispanic indi- partial solution. A possible approach, as depicted in the
New York. viduals, older adults, lower socioeconomic groups of all eFigure in the Supplement, involves 3 distinct and in-
races and ethnicities, and health care workers. terrelated strategies based on graduated levels of risk.
This magnitude of death over a short period of time The strategies include screening, mental health risk as-
is an international tragedy on a historic scale. Focusing sessment, and treatment for those at highest risk for pro-
Viewpoint and on the US, the number of deaths currently attributable longed grief and posttraumatic stress. At the beginning
Editorial to COVID-19 is nearly 4 times the number killed during of the process are the high numbers of adults and chil-
the Vietnam War. This interpersonal loss at a massive dren whose family and friends have died from COVID-
Related article scale is compounded by societal disruption. The neces- 19. In usual circumstances, bereavement would result in
sary social distancing and quarantine measures imple- mental health conditions for only a minority of this group.
Supplemental mented as mitigation strategies have significantly am- Accordingly, a public health approach is needed that
content plified emotional turmoil by substantially changing the seeks to restore usual social and community support-
social fabric by which individuals, families, communi- ive processes for the bereaved and to establish wide-
ties, and nations cope with tragedy. The effect is multi- spread screening protocols in primary care.
dimensional disruption of employment, finances, edu- A public health/community strategy is critical to pro-
cation, health care, food security, transportation, tect the health care system from becoming overwhelmed.
recreation, cultural and religious practices, and the abil- Such a strategy is founded on the knowledge that recov-
ity of personal support networks and communities to ery from loss is greatly facilitated by social support and the
come together and grieve. maintenanceofindividual,family,community,andnational
A June 2020 survey from the Centers for Disease cultural and religious traditions regarding death and griev-
Control and Prevention of 5412 US adults found that ing.Socialdistancingincreasesisolationanddisruptsthese
40.9% of respondents reported “at least one adverse practices, including a chance to say goodbye to the de-
mental or behavioral health condition,” including de- ceased. Similar processes affect children and adolescents
pression, anxiety, posttraumatic stress, and substance who experience sudden losses of a parent or a grandpar-
abuse, with rates that were 3 to 4 times the rates 1 year ent to COVID-19. The child’s sense of the world as safe and
earlier.2 Remarkably, 10.7% of respondents reported se- predictable, and caretakers as a “protective shield,” may
riously considering suicide in the last 30 days.2 The sud- bedisturbed.Caregiversmaybeoverwhelmedandunable
Corresponding den interpersonal loss associated with COVID-19, along tomodulatetheirchildren’sfearsandsadness.Insuchcon-
Author: Charles R. with severe social disruption, can easily overwhelm the texts of crisis, it is easy to lose sight of the emotional dis-
Marmar, MD,
Psychiatry
ways individuals and families cope with bereavement. tress experienced by the grieving child. Clinicians can help
Department, NYU Of central concern is the transformation of normal bereaved families find creative ways to safely honor tra-
Langone Medical grief and distress into prolonged grief and major depres- ditions,memorializethedeceased,andimprovesocialsup-
Center, 1 Park Ave, 8th
sive disorder and symptoms of posttraumatic stress dis- port.Clinicianscanalsosupportthebereavedthroughedu-
Floor, New York, NY
10016 (charles.marmar order. Prolonged grief disorder3 is characterized by at cation about grief and its variable course and by creating
@nyumc.org). least 6 months of intense longing, preoccupation, or both an empathic space for bereaved patients to share their

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story.5 Prevention also depends on what is done prior to death. Every bereavement-related conditions, especially for those patients whose
effort must be made to support end-of-life care decision-making with clinical course is complex, risky, and disabling.
familymembers,educateaboutCOVID-19tolessenself-blameandsur- Of particular concern are psychological risks for health care work-
vivor guilt, facilitate the process of saying goodbye to the deceased, ers and other essential workers who are providing care for patients
and find creative ways to build social support. Technology could be lev- with COVID-19. Health care workers must make challenging deci-
eragedtoconnectgrievingchildrenandadultswiththeirextendedfam- sions such as how to distribute limited resources that may directly
ily and community. Families and communities must make special ef- affect patient survival, may experience concerns about acquiring in-
forttoreachouttogrievingindividuals,particularlythosewholivealone. fection with severe acute respiratory syndrome coronavirus 2, and
Public health campaigns and public policy initiatives could be created may experience anxiety, insomnia, and symptoms of traumatic stress,
to support the implementation of these preventive strategies. as well as moral injury, guilt, and shame. Systems must work to sup-
After a death occurs, primary care clinicians can use validated port health care workers, including acknowledging these severe chal-
screeningtools,suchasthePTSDChecklistforposttraumaticstressdis- lenges; supporting coping with clear and frequent communica-
order symptoms, the Patient Health Questionnaire 9 for depression tions from leaders, sufficient rest, peer support, and evidence-
symptoms,andtheProlongedGrief12questionnaireforprolongedgrief based mental health resources; and screening and treatment for
symptoms, to proactively identify family members or friends of the de- those who develop mental health disorders.7 Supporting the men-
ceased person who are at highest risk of developing mental health con- tal health of these and other essential workforce is critical to readi-
ditions. For individuals identified at risk for or who have recently ac- ness for managing recurrent waves of the pandemic.
quired mental health disorders, such as prolonged grief disorder, the In summary, a second wave of devastation is imminent, attrib-
goal is to deliver evidence-based interventions to return pathological utable to mental health consequences of COVID-19. The magni-
manifestations of bereavement to their normal grief trajectories. Ide- tude of this second wave is likely to overwhelm the already frayed
ally, evidence-guided interventions could be implemented within pri- mental health system, leading to access problems, particularly for
marycareorcommunitysettings,butanadditionalroleforprimarycare the most vulnerable persons. The solution will require increased
is to identify individuals with highest risk and complexity who are best funding for mental health; widespread screening to identify indi-
managed by specialty mental health care such as those with suicidal viduals at highest risk including suicide risk; availability of primary
and violent impulses and high levels of dysfunction. care clinicians and mental health professionals trained to treat those
This strategy can only be successful if training is offered to pri- with prolonged grief, depression, traumatic stress, and substance
mary care clinicians and community mental health practitioners abuse; and a diligent focus on families and communities to cre-
about grief and traumatic distress and their variable course. Such atively restore the approaches by which they have managed trag-
training should include the implementation of evidence-based psy- edy and loss over generations. History has shown that societies re-
chosocial interventions and the judicious use of psychiatric medi- cover from such devastation when leaders and members are joined
cations for those developing mental disorders. Such training should by a shared purpose, acting in a unified way to facilitate recovery.
also include the use of assessment tools to identify persons who need In such societies, there is a shared understanding that its members
specialty mental health care. Further, many mental health clini- must care for one another because the loss of one is a loss for all.
cians will need training in the treatment of prolonged grief and other Above all, this shared understanding must be restored.

ARTICLE INFORMATION reported receiving support from the National 2020. https://icd.who.int/browse11/l-m/en#/http://
Published Online: October 12, 2020. Institute on Alcohol Abuse and Alcoholism, the id.who.int/icd/entity/1183832314
doi:10.1001/jama.2020.19632 NIMH, Department of Defense, US Army 4. Lundorff M, Holmgren H, Zachariae R,
Congressionally Directed Medical Research Farver-Vestergaard I, O’Connor M. Prevalence of
Conflict of Interest Disclosures: Dr Simon Program, the Steven and Alexandra Cohen
reported receiving research grants from the prolonged grief disorder in adult bereavement.
Foundation, Cohen Veterans Bioscience, Cohen J Affect Disord. 2017;212:138-149. doi:10.1016/j.jad.
American Foundation for Suicide Prevention, Veterans Network, the Home Depot Foundation,
Department of Defense, Patient-Centered 2017.01.030
the McCormick Foundation, the Robin Hood
Outcomes Research Institute, the Highland Street Foundation, and New York City. He serves on the 5. American Psychiatric Association.
Foundation, the National Institute of Mental Health scientific advisory board and owns equity in Considerations for family and other personal losses
(NIMH), the National Center for Complementary Receptor Life Sciences and on the PTSD advisory due to COVID-19–related death. Accessed
and Integrative Health, and the Cohen Veterans board for Otsuka Pharmaceutical. September 8, 2020. https://www.psychiatry.org/
Network; personal fees from Vanda File%20Library/Psychiatrists/APA-Guidance-Death-
Pharmaceuticals Inc, MGH Psychiatry Academy, REFERENCES Dying-Personal-Bereavement.pdf
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