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Disclosures: Johns and McIntyre report no relevant financial disclosures.
April 16, 2020
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Identifying and managing chronic stressors in the era of COVID-19

Source/Disclosures
Disclosures: Johns and McIntyre report no relevant financial disclosures.
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Roger McIntyre
 
Shelley A. Johns

The ongoing COVID-19 pandemic and related personal, financial and health effects likely have resulted in chronic stress throughout numerous populations, according to two experts.

Many studies have shown links between chronic stress and a range of adverse effects, including compromised heart health, weakened immune response and increased risk for depression and dementia. These stress-related outcomes underscore the importance of mitigating significant stressors during the pandemic, according to Roger McIntyre, MD, FRCP(C), professor of psychiatry and pharmacology at University of Toronto, and Shelley A. Johns, PsyD, HSPP, ABPP, assistant professor of medicine and clinical health psychologist at Indiana University School of Medicine and research scientist at Regenstrief Institute’s Center for Health Services Research.

Financial stress adds ‘emotional weight’ to pandemic

The sudden shock to national and global economic systems has left many individuals reeling.

“Almost overnight, people came face to face with employment insecurity,” McIntyre said. “The associated financial hardship of that, along with quarantine, is a combustible mix with respect to stress.”

Researchers gained much insight regarding the mental health effects of unemployment by observing trends during the Great Recession of 2007 to 2009, McIntyre said. For every 1% increase in unemployment in the United States, researchers observed an approximate 1% increase in suicide, and the approximate 4% increase in unemployment during that time was commensurate with a 4% increase in suicide.

During economic downturns, many of the adverse outcomes, such as suicide, are likely compounded by stress as it relates to paying bills and attempting to maintain some semblance of financial security, McIntyre noted.

“We not only have to adjust to changes in the overall social system and sheltering in place, but we also have to adjust to the uncertainty of what’s going to happen to all of us financially, as well as to those around us,” Johns said. “It adds so much more emotional weight to everything that's going on right now if someone is concerned about their finances.”

Chronic stress impacts immune system, overall physical health

Because the pandemic and its far-reaching effects seem likely to last for an extended period, the current environment can be viewed as a macroscopic chronic stressor, according to Johns.

“Chronic stress can cause a cascade of negative health effects,” Johns said. “It can weaken the immune system, which needs to be functioning optimally during the COVID-19 pandemic. Stress can also inhibit healthy functioning of our digestive system, and it can lead to negative effects to the circulatory system through increased heart rate, increased blood pressure and even increased risk for heart disease over time.”

Many individuals with chronic medical conditions are particularly at risk for negative outcomes of elevated stress. For instance, those with diabetes may experience difficulty controlling their glucose levels, Johns said. Further, among individuals with cancer who are immunocompromised, stress has been linked to more rapid tumor growth.

“We need to be mindfully aware of the potential negative health effects of untreated chronic stress,” Johns said.

Chronic diseases also affect certain subgroups more than others. For example, diabetes, heart disease and obesity disproportionately affect people with mental illnesses and members of certain racial/ethnic groups, such as African Americans, compared with the general population, according to McIntyre.

“These chronic, noncommunicable conditions are not only causing inflammation, but they may be a consequence of it,” McIntyre said. “A testable hypothesis has been put forward that perhaps one of the reasons why we’re seeing greater complications among African Americans, people of lower socioeconomic status and those with mental illness in response to COVID-19 is because these individuals already have an immune-dysregulated condition. Being mentally ill or having diabetes, for example, and then being confronted with the stress related to fear of the virus, of job loss or of financial insecurity only further dampens down the immune system, leaving these individuals at greater susceptibility to not only viral complications if they get it, but also complications from their medical conditions.”

Managing stress in the era of COVID-19

Clinicians play an important role in mitigating the impact of pandemic-related stress among their patients, according to Johns.

“I advise clinicians to be as proactive as possible in reaching out to patients who may be particularly vulnerable right now, especially those who live alone,” Johns said. “In speaking with patients, clinicians can explore what worked for these patients in the past when they’ve been under high levels of stress.”

Further, clinicians can ask patients questions such as: What are some stress management tools that were effective for you in the past? Are you using those tools now during the pandemic? If not, would you be willing to consider reengaging them, or perhaps adding some new ones to your coping toolbox?

In Johns’ experience, mindfulness meditation strategies are among the most effective strategies for managing the “unwanted emotional enormity” of the pandemic, and much research supports their use as effective stress management tools. Simple initiatives, such as taking a walk outside, listening to music from a joyful period in one’s life or watching a funny movie also can help mitigate stress, Johns added.

“Another strategy that I offer to health care providers and patients who are experiencing stress is to set an intention to embody values, traits or characteristics by which they want to be known during this difficult and frightening time,” Johns said. “Bringing mindful attention to these elements during our phone-based or virtual interactions may help enhance relationships while we adjust to sheltering in place and physical distancing.”

Particularly for frontline clinicians battling the virus, keeping a “gratitude list” of the things they see day-to-day that inspire or uplift them can help alleviate stress, Johns said.

According to McIntyre, the best way to alleviate stress, as well as to boost the immune system, is to get a good night’s sleep. It is also important to engage in behavioral activation, he said.

“Behavioral activation means a couple of things — first, structure your day,” McIntyre said. “Because many people no longer get in the car to go to work in the morning, there's a slippery slope of having a more unstructured day. Also, people should wake up and go to sleep at the same time as they normally would. Further, getting outside and engaging in activities that are positive and healthy is a behavioral activation shown to mitigate depression.”

Maintaining a healthy diet, avoiding substance abuse and engaging in altruistic behavior, such as dropping off groceries to a friend or neighbor, are additional stress-mitigation strategies, McIntyre said.

“Altruistic behavior, as well as interpersonal contact generally, has been shown to be beneficial for overall health, boosts resiliency, is good for your well-being and probably also decreases immune dysregulation,” McIntyre said. – by Joe Gramigna

Disclosures: Johns and McIntyre report no relevant financial disclosures.