Frontline Workers Need New Approaches to Treat COVID-19-Related Mental Health Issues

Robert Cuyler, PhD, Chief Clinical Officer at FreespiraWe’ve long known that the coronavirus pandemic would dramatically impact the mental health of health care professionals and the general population. But just how many of us have been impacted is stunning.

Fully 41% of Americans reported at least one adverse mental or behavioral health condition associated with Covid-19, according to the Centers for Disease Control and Prevention. Essential workers had the highest reported rates of adverse mental health outcomes compared to all other employment groups surveyed by the CDC. More than 38% of essential workers reported having a COVID-19-related trauma- and stressor-related disorder. Comparatively, about 25% of nonessential workers reported the same.

Frontline healthcare workers are particularly at risk. The prevalence of post-traumatic stress disorder (PTSD) related to Covid-19 can be as high as 35% among this group, with nurses and those who have experienced symptoms of the disease being most at risk, according to a review of numerous studies. 

Little wonder. Healthcare workers have been faced with unprecedented demands as they struggle to manage a highly infectious disease with personal risk, limited treatments, high mortality rates and, until recently, no vaccine. They must function professionally and personally under conditions of uncertainty, exhaustion, and often intense fear for themselves and their loved ones.  Repeated exposure to Covid-19 related trauma and health anxiety sets the stage for development of PTSD and panic in at-risk individuals.

Unfortunately, current treatments for PTSD, as well as for the closely-related panic attacks that affect some 27 million Americans, are often ineffective or unavailable for many people. Psychotherapy is useful for some patients with panic attacks and PTSD, but the long duration of treatment can pose obstacles for access, affordability, and adherence over time. High dropout rates are reported for talk therapy, particularly the exposure-based therapies commonly used to address PTSD as well as panic. Commonly used medications, particularly antidepressants, often produce unwelcome side effects that lead to adherence problems and high dropout rates. Benzodiazepines are not recommended for PTSD or for extended use, and carry risk for abuse and dependence. 

Most people are familiar with the symptoms of a panic attack, even if their own panic is as short lived as an onstage walk to a microphone. Symptoms include shortness of breath, racing heart, chest tightness, dizziness, and lightheadedness. In extreme cases the panic is recurring and accompanied by intense fear of impending death and feelings of losing control or ‘going crazy. These symptoms can be misinterpreted as a medical emergency, only to be later ruled out as a cardiac or neurological event. Patients are often told their symptoms are ‘all in your head,’ or are referred out to a primary care or medical specialist for testing or follow up. 

Faced with increasing rates of PTSD and recurrent panic attacks, health systems and health plans need new approaches to help their employees and members with treatments that are safe, effective, and produce minimal side effects. Amid pandemic limits on in-person care, they also need treatments that can be delivered remotely.

Fortunately, new treatment approaches now exist, based on multiple published studies addressing an important underlying physiological factor in panic attacks and PTSD. Surprisingly, this emerging science reveals an unexpected contributor to panic attacks and PTSD – hypersensitivity to carbon dioxide (CO2). In experimental lab settings, most panic and PTSD sufferers react with pronounced fear and physiological distress when exposed to a single breath of air with high CO2 concentration. Subsequent research has shown that treatments aimed at normalizing respiratory rates are effective in minimizing or eliminating symptoms, and they are now available in clinical practice. 

Highmark Health, the nation’s fourth-largest Blue Cross Blue Shield plan, has made one such treatment available to its 5.6 million members in Pennsylvania, Delaware and Virginia. The FDA-cleared non-medication digital therapeutic targets the symptoms of both PTSD and panic disorder. During twice-a-day 17-minute sessions that are conducted at home, the patient inhales and exhales in sync with rising and falling audio tones and adjusts their respiratory volume to keep their exhaled CO2 in the normal zone, guided by a graphical display on a tablet. Weekly telehealth coaching provides support, encouragement and guidance to help patients achieve their breathing targets. 

Several peer-reviewed studies have confirmed the regimen can reduce or eliminate symptoms of panic disorder and PTSD in just 28 days. The most recent study, which was funded by Highmark Health and conducted at Alleghany Health Network in Pittsburgh, found that 68% of treated patients were in remission one-year post-treatment and 91% had significant symptom reduction as long as one-year after treatment.  Research on PTSD at the VA Palo Alto Health Care System measured significant improvement in over 80% of participants who used the regimen, and remission in 50% of participants. 

Coincidentally, the Highmark study also found the treatment significantly lowered health care costs. Following a claims analysis that documented sharply higher medical costs for individuals with panic disorder compared to matched controls, the study found a 35% reduction in any-reason medical costs for the year after treatment with the device. Pharmaceutical costs were slashed by 68%, and Emergency Department costs fell by 65%.

Until we have brought Covid-19 completely under control, it is good to know that health care organizations have options for helping their employees, members, and patients deal with the most acute mental health impacts of the pandemic. Just as transmission of the virus can be prevented by the adoption of new habits like mask-wearing, we are learning that the acute symptoms of panic attacks and PTSD can be prevented with new self-management skills. 

All we needed was to take a fresh look at the problem. 

About Robert Cuyler, PhD

Robert N. Cuyler, PhD, is the Chief Clinical Officer of Freespira, Inc., which offers Freespira, an innovative intervention for the treatment of panic disorder, panic attack and PTSD. He is the President of Clinical Psychology Consultants, LLP, his Houston, TX practice.With more than 15 years activity in behavioral health telemedicine, he previously served as Chief Executive Officer of JSA Health Telepsychiatry as well as Clinical Advisor to MDLive/Breakthrough Behavioral and BrainCheck. His telemedicine activities have included implementation, reimbursement policy, practitioner training, technology choice, and business development. He is an author and presenter on telemedicine and technological innovations in behavioral health. He has co-authored one book and four book chapters on psychiatric telemedicine. 

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