COVID-19, Frontline Responders and Mental Health: A Playbook for Delivering Resilient Public Health Systems Post-Pandemic

COVID-19’s effects go beyond physical health, including impacts to behavioral health such as documented increases in loneliness, depression, anxiety, and alcohol misuse. Research on other disaster and mass trauma events suggests that behavioral health impacts may persist for many years after the initial onset of the event and could be compounded with other disasters. These impacts have not, and will not, be distributed evenly across the population. Of note, evidence from early in the pandemic suggests that older adults’ (adults aged 65 and older) behavioral health may not be as adversely affected as expected, given past research on age and disasters.

Prior to the onset of the COVID-19 pandemic, women did nearly three-quarters of the world’s unpaid work. As institutional supports, including in-person school and community-based care for children, the elderly, and the disabled vanished early in the pandemic, many women’s caregiving responsibilities increased. In some cases, opportunities for paid employment disappeared due to layoffs and furloughs, while in others, paid work was no longer possible without access to the missing institutional supports. Either way, access to needed supports – financial, practical, and social – was diminished. The lapse of needed supports also had severe impacts on subgroups of women, including pregnant and post-partum women. A range of considerations – vaccine safety, social interaction and infection risk, disease severity – have posed serious challenges for pregnant and post-partum women. Across the board, women’s need for continuous access to better social, financial, and practical supports at home, in the community, and in the workplace was made even more evident by the COVID-19 pandemic.

The COVID-19 pandemic imposed significant and abrupt lifestyle changes on the pediatric population. Major lifestyle changes that occur during children’s and adolescents’ vital developmental years have the potential to introduce stressors, which have both immediate and long-term effects on physical and mental health. The aspects of the COVID-19 pandemic that impacted pediatric mental health included school closures, quarantine, increases in screen time, changes to Labor & Delivery unit COVID-19 policies, and changes to the delivery of clinical mental health care, including telehealth. In addition, pediatric mental health was deeply impacted by the ongoing challenges to health equity associated with health disparities and racism as a health crisis. Pediatric mental health declined since the start of the pandemic, school closures and quarantine affected rates of food insecurity and physical activity levels, and the COVID-19 pandemic exacerbated pre-existing health disparities and mental health conditions among the pediatric population. Recommendations for building more resilient public health systems are explored.

Rates of anxiety, depression, and suicidality have long been known to be elevated among LGBTQ+ communities and it was expected that the COVID-19 pandemic would deepen systemic injustices and inequities in mental health outcomes. However, it remains difficult to document inequities as surveillance systems do not typically capture LGBTQ+-inclusive data necessary to study the impact of COVID-19 on LGBTQ+ population health. This chapter reports on two studies designed to address this gap. The COVID-19 Impacts Study (CIS) documented the early mental health and social impacts of COVID-19 among sexual and gender minority adults, as well as adults with HIV, during the first round of shut-downs and initial economic disruptions. Subsequently, the Youth and Young Adults COVID-19 Study (YYA) measured the impacts of COVID-19 on the mental health outcomes, testing/vaccination behaviors, and stigmatization experiences of LGBTQ+ and BIPOC (Black, Indigenous, People of Color) young people. Several recommendations are discussed – including mandated collection of data on sexual orientation and gender identity in all surveillance systems, policy solutions to better address access and cost barriers, and deep and meaningful engagement that empowers communities.

People with chronic conditions faced a type of double jeopardy during the COVID-19 pandemic. Their pre-existing health conditions made them more likely to become severely ill – and more likely to be admitted to intensive care, intubated, and die – if infected with SARS-CoV-2, the virus that causes COVID-19. At the same time, access to needed screening, testing, and treatment was often limited due to the cancelation of primary care services by healthcare providers and systems overwhelmed by the need to treat patients with COVID-19. Patients with chronic conditions feared being exposed to COVID-19 while receiving care. The resulting stress, fear, and anxiety made the management of chronic diseases even more difficult. Several subsets of patients with certain medical conditions, including immunodeficiencies and disabilities, were particularly impacted. The COVID-19 pandemic, and the response to it, also impacted support and services available to caregivers and heightened stress, particularly among parents and caregivers.

Long-term care (LTC) homes are highly regulated settings that provide care to people living with complex health conditions who are often at the end of their lives. Mental health and quality of life are important concepts in LTC given the inherent poor health and diminished autonomy of residents living in this setting. The COVID-19 pandemic had the potential to further compound these issues through lockdowns limiting movement within and outside of LTC homes, increased fear of severe COVID-19 infections, staff shortages, and impaired communication through personal protective equipment. However, the evidence describing the effect of the pandemic on mental health and quality of life is mixed, with some studies describing increased rates of mental health concerns and others presenting modest increases or decreases. Creative strategies to mitigate negative mental health consequences of lockdown included technology supported and window or outdoor visits, increased access to volunteers, and supports for families. However, the evidence in this area continues to evolve as subsequent waves of the pandemic progress. Future research may present new evidence about other strategies that became important in different stages of the pandemic.

COVID-19 has had remarkable impacts in rural America. Although the onset of the pandemic was in urban areas, it quickly spread to rural areas and ultimately resulted in higher mortality rates for rural populations. Due to this and other associated impacts, the pandemic has resulted in mental health issues across rural America. In this chapter, the authors first describe the state of rural America pre-pandemic, then detail the overall and mental health impacts of the pandemic on rural people. Following this, the authors report results of a case study on COVID-19 in the rural America West and conclude with recommended steps for addressing the unfolding crisis. Many of the steps the authors can take to improve rural mental health following the pandemic have long-been necessary. However, given the impacts of COVID-19, they are now needed more than ever.

The COVID-19 pandemic, and the responses to it that were required from frontline healthcare providers and others working in healthcare settings including environmental, clerical, and security staff, has challenged our healthcare systems in unprecedented ways. The threats to the financial, physical, and psychological well-being of healthcare professionals – many of whom entered the field due at least in part to a deep commitment to caring for and helping others – will have profound and long-lasting personal and professional impacts. Early in the pandemic response, healthcare professionals knew little about the risks they, their patients, and their loved ones faced from COVID-19 as they operated under crisis standards of care and without adequate supplies of personal protective equipment. As the pandemic response progressed, the lack of clear, science-based guidance, and the politicization of the pandemic presented new medical, ethical, and moral dilemmas. New psychological support mechanisms, including crisis counseling and evidence-based interventions, are needed for all workers in healthcare settings, regardless of their job role.

The governmental public health workforce provides essential public health services to communities from public health agencies operations at the local, state, and federal levels of government. The roles and duties of public health workers range from infectious disease tracking and control to healthy eating promotion to checking food service establishments for safety. Unfortunately, most of the time, the general public is unaware of, and unconcerned with, public health’s primary mission of disease prevention. This behind-the-scenes, service-oriented workforce has responded to the COVID-19 pandemic by working long hours, extra days, and ever-changing job roles, all while becoming targets of political attacks and enduring substantially elevated psychological distress and burnout. Though this workforce is not well enumerated, existing studies indicate that public health workers face higher anxiety, depression, post-traumatic stress disorder, and burnout than other frontline healthcare workers during the COVID-19 pandemic response. Several strategies have been suggested to address these vulnerabilities, including increasing the amount and stability of available funding, implementing organizational-level policies and programming to boost resilience, and providing individual-level social support, both instrumental and emotional, to protect against burnout and other psychological distresses.

Little attention has been given to the mental and physical health impacts of COVID-19 on the academic public health workforce. Academic public health is an important support mechanism for public health practice, providing expertise and workforce training, conducting research, disseminating evidence-based scientific information to both public health and lay audiences, and serving as a supplementary workforce when additional resources are needed. These roles become more important during a public health emergency, particularly during a prolonged public health crisis like the COVID-19 pandemic. As a result of the COVID-19 response, the roles of academic public health have expanded to include developing and implementing contact tracing, surveillance, testing, and vaccination programs for universities and their surrounding communities, all while continuing to prepare students and support the public health practice workforce in their ongoing efforts. As in other responder groups, this has resulted in significant mental health effects and burnout among public health academicians. The authors suggest important steps that can be taken to improve the resilience of the academic public health workforce and to support their contributions during prolonged public health emergencies.

The stressors, and subsequent mental health sequelae, associated with being a part of the frontline, patient-facing healthcare response to the COVID-19 pandemic have been clear from the very start of the pandemic. However, a broader group of workers, perhaps typically not considered to be part of the frontlines of a public health emergency response, have also been deemed essential to the response to the COVID-19 pandemic. Protective service workers, including law enforcement and emergency services, those working in food production, processing, and dietetics, maintenance and environmental service workers, and laboratory workers are among those unable to work from home, yet potentially unaccustomed to the stressors of being an essential workers during a public health emergency. Changes to many systems – including health insurance and other benefits, provision of personal protective equipment, and prioritizations for vaccinations and other pharmaceutical and nonpharmaceutical interventions – are needed going forward to retain and protect essential workers during future public health emergencies.

Much of the research on the mental health impacts of the COVID-19 response have been focused on frontline healthcare workers (FHCW). However, other essential workers (OEW) have also faced many mental health challenges due to exposures associated with their employment status, which may be compounded by higher levels of social vulnerability. This chapter describes disparities among FHCW, OEW, and the general public regarding mental health outcomes associated with the pandemic. In addition, it considers the role that structural racism (e.g., historical redlining of neighborhoods and biased lending practices) plays in the higher vulnerability of OEW to the mental health impacts of the COVID-19 pandemic response. Mental health inequities overall, and among essential workers, must be addressed as part of the recovery from COVID-19 to build resilience to future public health emergencies. The model used by New York City to more equitably distribute mental health resources and support services is shared.

The COVID-19 pandemic, and the measures implemented to control it, collided with another public health emergency – the opioid crisis – with dire consequences. In October of 2017, the Secretary of the US Department of Health and Human Services declared the opioid crisis a public health emergency. That declaration has been renewed several times, including during the COVID-19 pandemic, with the latest renewal set to go into effect on July 4, 2022. The overlap of individual, environmental, and social risk factors for substance use disorder (SUD) and COVID-19 present major challenges to those working as part of the response to both pandemics. The severity of the implications of this dual pandemic – an estimated 100,000 people in the United States died from a drug overdose during the first year of the pandemic – make this an area of the pandemic response where lessons learned had to be rapidly implemented to save lives. Identifying ways in which those lessons can be expanded to other populations at risk, including those with other pre-existing mental disorders, will be important to reducing the inequitable impacts of the pandemic on mental health.