New household dynamics abound when people are suddenly forced into atypical routines. In the context of COVID-19, working parents may be forced to balance the demands of their jobs with homeschooling their children. Couples may find themselves arguing more frequently. Adult children may find themselves needing to care for their ill parents. Limited space, a lack of leisure activities, and uncertainty about the future coalesce to increase conflict and stress. Research suggests that how people cope with a stressor is a more reliable determinant of health and well-being than the stressor itself.12
Interventions. Mental health clinicians can offer several recommendations to help patients cope with increased household stress (Table 3). We can encourage patients to have clear communication with their loved ones regarding new expectations, roles, and their feelings. Demarcating specific areas within living spaces to each person in the household can help each member feel a sense of autonomy, regardless of how small their area may be. Clinicians can help patients learn to take the time as a family to work on establishing new household routines. Telepsychiatry offers clinicians a unique window into patients’ lives and family dynamics, and we can use this perspective to deepen our understanding of the patient’s context and household relationships and help them navigate the situation thrust upon them.
Grief
Following a psychiatric hospitalization for an acute exacerbation of psychosis, Ms. S, age 79, is transferred to a rehabilitation facility, where she contracts COVID-19. Because Ms. S did not have a history of chronic medical illness, her family anticipates a full recovery. Early in the course of Ms. S’s admission, the rehabilitation facility restricts visitations, and her family is unable to see her. Ms. S dies in this facility without her family’s presence and without her family having the opportunity to say goodbye. Ms. S’s psychiatrist offers her family a virtual session to provide support. During the virtual session, the psychiatrist notes signs of complicated bereavement among Ms. S’s family members, including nonacceptance of the death, rumination about the circumstances of the death, and describing life as having no purpose.
The COVID-19 pandemic has complicated the natural process of loss and grief across multiple dimensions. Studies have shown that an inability to say goodbye before death, a lack of social support,13 and a lack of preparation for loss14 are associated with complicated bereavement and depression. Many people are experiencing the loss of loved ones without having a chance to appropriately mourn. Forbidding visits to family members who are hospitalized also prevents the practice of religious and spiritual rituals that typically occur at the end of life. This is worsened by truncated or absent funeral services. Support for those who are grieving may be offered from a distance, if at all. When surviving family members have been with the deceased prior to hospitalization, they may be required to self-quarantine, potentially exacerbating their grief and other symptoms associated with loss.
Interventions. Because social support is a protective factor against complicated grief,14 there are several recommendations for survivors as they work through the process of grief (Table 4). These include preparing families for a potential death; discussing desired spiritual and memorial services15; connecting families to resources such as community grief support programs, counseling/therapy, funeral services, video conferencing, and other communication tools; and planning for additional support for surviving family and friends, both immediately after the death and in the long term. It is also important to provide appropriate counseling and support for surviving family members to focus on their own well-being by exercising, eating nutritious meals, getting enough sleep, and abstaining from alcohol and drugs of abuse.16
Continue to: An ongoing challenge