Mental Health of Patients and Clinicians Before and During the COVID-19 Pandemic

Mental Health of Patients and Clinicians, US and International, Pre- and during COVID

We continue to witness the impact of the COVID-19 pandemic on patients and family medicine clinicians. This issue includes articles presenting data from before and during the pandemic and from the US and Mexico.

Prepandemic data from the Medical Expenditure Panel Survey (MEPS) provides rich data on Americans’ psychotherapy and psychiatry visits and mental health medication use by age and diagnosis.¹ Mental health visits to psychiatrists or psychologists and prescription medication use varied by age and gender. As these surveys and specific questions are only completed intermittently, this article provides data with current implications and potentially as a pre-COVID-19 baseline for future comparison.

Given the differences between Mexican and American health care, reported mental health issues by family medicine clinicians in 2 different countries are informative – what part of the stressors for clinicians can be attributed to the provision of patient care versus the system in which that care is provided? Guízar-Sánchez et al² report on mental health of family physicians and family medicine residents in Mexico, from late 2019 to May 2020, essentially prepandemic. In fall 2021, Samuel Ofei-Dodoo and coauthors³ repeated a survey of family physicians from earlier in the pandemic, identifying the effect of the ongoing nature of the pandemic and implying future impacts. Can the field of family medicine and individual family physicians thrive as waves of the pandemic continue to occur? And how do we support the drive to “thrive?”

In addition, the dramatic changes caused by the pandemic led many US family physician educators to reconsider the place of work in their lives, questioning what they did and did not like about their work and potentially changing their career future in 2021.⁴ More than 2-thirds of these physicians were satisfied in their jobs and a (perhaps) surprising number were aspiring leaders. Being treated fairly was particularly important to work satisfaction.

Britz et al⁵ surveyed US primary care clinicians in the first year of the pandemic. Clinicians reported high levels of patient stress, increased patient substance use, and provision of higher than usual amount of mental health care for patients. The report also includes information on the use of telemedicine and variability in visit type by patient insurance status. It is worth considering the potential implications of the findings for future care.

Walking as a coping strategy may have risen to prominence in the “silly little walk” meme, but Bennell et al⁶ show that – for adults with multiple chronic conditions – their average amount of walking decreased during the pandemic. The finding is especially disheartening because those walks were connected to improved mental health.

Opioid abuse has been particularly problematic across Appalachia. In 1 state, family physicians and specialists provide reflections on the multiple issues inherent in pain control and opioids, including the problems created by the state’s changing rules and patient expectations.⁷

Video visits could decrease stigma associated with therapies requiring direct observation in this study from Turkey.⁸ Perhaps clinicians should consider whether video-observed therapy for other types of conditions could also improve patient outcomes. Even 1 observation of a patient trying to take their multiple medications could be informative (maybe even transformative).

Patients with uncontrolled hypertension often spontaneously mentioned the impact of gun violence in their community.⁹ Perhaps gun violence should be a discussion in similar clinical encounters. Further, the question remains: how much does that exposure or fear impact their blood pressure?

The warmth and importance of not only the doctor-patient relationship but the interaction with the whole practice is evidenced in this issue’s reflection.¹⁰

Race and Diversity

Based on an analysis of family physicians’ ‘other’ responses to a question on racial and ethnicity identity, Eden et al¹¹ provide recommendations for changes in the response options for questions on personal race identification. This is a must read for researchers. Adetoye and Gold¹² provide data on race and gender disparities in chairs of departments of family medicine. Although this level of diversity of the chairs seems to be more representative of the American public than in the past, we are only part-way through a journey to equity. In another study, female physicians had less access to documentation support, which could infer more time personally required for record completion.¹³

Improving Primary Care Practice

The EvidenceNOW Initiative Cooperatives (funded by the Agency for Health care Research and Quality) provided external support to improve quality for 4 different expected primary care interventions for adult preventive care in multiple small- to medium- size primary care practices cooperatives. The overall improvements from 7 regional cooperatives are reported by Balasubramanian et al.¹⁴ Although modest, such changes could lead to population-level improvements in health outcomes. Nichols et al¹⁵ provide additional specifics on how the EvidenceNow interventions were undertaken in the Virginia Collaborative and its specific results. These projects are a reminder of the effort required to implement wide-spread practice change.

Ludden et al¹⁶ report on increased Hepatitis C testing after an education intervention, then again after an added electronic medical record automated reminder. Their results can assist those considering how to influence clinician care.

Do you order mammograms for women for breast pain (mastalgia)? Diffuse or localized pain? For what age-group? Komenaka et al report¹⁷ that almost a third of women obtaining mammograms at their site had ‘breast pain’. The authors further analyze the rate at which cancer was discovered in those with breast pain by age-group and report the characteristics in those with breast cancer.

Green et al¹⁸ conducted complex computer simulations to estimate the potential impact of continuing telehealth after the pandemic to increase the number of patient visits per physician and to decrease wasted physician time. Thus far, the greatly increased telehealth visits during the pandemic has not been associated with an overall increase in volume for family physicians. The duration of a telehealth visit, including before and after work, compared with an in-office visit is key.

Potpourri

Clinician loan repayment programs that require service in underserved communities are popular and potentially assist the clinicians, the practice sites, and the communities. Pathman et al¹⁹ report the views and data on the outcomes from practice administrators in 14 states.