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The COVID-19 pandemic has had widespread effects across the country and state.

Since it began, experts have warned of a secondary health crisis — a mental health crisis.

As the reality that the virus had reached Missouri set in, people had fears, said Angeline Stanislaus, medical director for the state Department of Mental Health. They were afraid of the virus but also of the unknown and what would happen in the future.

Paul Thomlinson, a psychologist and the executive director of the Compass Health Research Institute, said organizations have been collecting information about the COVID-19 pandemic and its effects from its onset.

People feel anxiety, he said.

"Human beings are not good at dealing with unpredictability and uncertainty. We have unprecedented levels of it right now," Thomlinson said. "We're afraid folks will start to unravel a little bit. Even people who have held their emotional health together will feel periods of anxiety."

Data from recent studies going through May show people of widespread walks of life are affected by the pandemic, but it's had a particularly heavy toll on parents, he said.

Parents are concerned about a number of things — family members getting COVID-19, receiving services, jobs, schools and other stressors.

The American Psychological Association, at apa.org, has a series of reports on the pandemic, Thomlinson said. Across the board, people are stressed about it.

And people of color are more likely to report higher stress related to COVID-19, he said.

"It's a quantifiable new level of stress for a lot of people," Thomlinson said.

Anxiety about the pandemic strongly affected DMH's pre-existing patients, Stanislaus said. And anxiety causes surges in substance misuse and subsequent treatment programs, such as methadone clinics or opioid abuse treatment programs.

But the Ryan Haight Online Pharmacy Consumer Protection Act required medical evaluations to be done in person before a provider may write prescriptions.

"That had been a huge barrier for several years because (patients and mental health care providers) had to meet face to face before they could get medication, such as Suboxone or methadone," Stanislaus said.

And there was a lack of personal protective equipment for providers, she said, which was crucial for providers to be able to sit face to face with patients and engage in conversations.

"Knowing there was a virus around, and not enough PPE, was a significant challenge," she said.

There was a "little lag" from the time the initial positive COVID-19 tests occurred (in early March) until regulations allowing use of telemedicine or telephonic medicine were loosened, Stanislaus said. Community mental health agencies were quick to get on board when restrictions eased.

And there was a lot of anxiety about working from home, she said, because of the pandemic and safety concerns.

Working from home posed challenges for families.

A lot of workers were furloughed or lost their jobs entirely.

Studies show people surveyed have common concerns, Thomlinson said.

"Seven in 10 say the government response to the coronavirus has been a significant source of stress," Thomlinson said. "Everything from the pandemic to the government's response has caused folks to feel they've been set adrift a little bit."

A report this month on the American Psychological Association website, psycnet.apa.org, which looked at residents of New Zealand, showed strong leadership is essential for helping communities cope with widespread challenges posed by pandemics.

The study found during a "strong and cohesive national response" to a shared threat (such as a pandemic) and national lockdown, if there is a strong and cohesive national response, people are likely to lean on and trust politicians, scientists, police and communities. Participants in the research displayed resilience except for an increase in mental distress relative to controls, the report found.

"Coming together in the face of adversity is necessary, especially when the threat can only be defeated through a collective response," the report states. "But even as people work to protect their communities (and stay home to save lives), they may pay a cost in mental well-being."

Although his executive statewide stay-at-home order ended, Missouri Gov. Mike Parson extended most waivers to align with the federal Coronavirus Aid, Relief and Economic Security (CARES) Act (for things like interstate compacts that allow physicians to operate across state lines, easing restrictions on telemedicine, etc.) granted early during the pandemic through Dec. 30, according to Dave Dillon, Missouri Hospital Association vice president of public and media relations. That allows the state flexibility throughout the rest of 2020, Dillon said.

Federal funding through the CARES Act and state funding have helped Compass Health and other organizations provide mental health services to folks at their homes, Thomlinson said.

Health care workers are also experiencing severe COVID-19-related stress.

The American Psychiatric Nurses Association just released a report that looks at the effects the pandemic is having on health care providers. "The impact of COVID-19 Extreme Stress and Trauma on America Health Care Providers" warns that health care workers are susceptible to stress that may cause them to develop disorders that create emotional and physical symptoms.

"Persistent levels of extreme stress or exposure to traumatic events can have a negative impact on the mental health of our most important asset during an epidemic like COVID-19 — our health care workers," the report states.

Excessive stress may cause short- or long-term effects to workers' mental health. Some health providers, the report states, may develop acute stress disorder.

Health care workers treating COVID-19 patients oftentimes find themselves in settings with high rates of infection, witness high mortality rates among their patients each day and may fear for their own personal health and safety, the report states.

Among those health care workers are employees from the DMH, dealing with some of the most difficult situations in the state, Parson said during last Thursday's COVID-19 briefing. During the briefing, DMH Director Mark Stringer expressed his condolences to families who had lost loved ones to COVID-19 and reported two members of his department had died from the disease over the past week.

"It has not only stressed our systems and businesses, it has stressed our citizens," Stringer said.

To help overcome the stresses, the Federal Emergency Management Agency awarded DMH $2.1 million for a Crisis Counseling Program called Show Me Hope.

"It's a grant that will help us better address the statewide emotional distress caused by the pandemic," Stringer said.

Missouri supplemented the FEMA grant with $100,000 from CARES Act funding to assist in the state's hardest-hit area — St. Louis.

The program will provide information, education and training on coping skills and problem-solving, and connections to community resources, Stringer said.

Every Missourian can access the program at no charge, Stringer said, by calling the Show Me Hope line at 800-985-5990 or texting "talkwithus" to 66746.

One of the things that has come up in response to the pandemic is dealing with the layers of causes of stress Missourians may be facing, Stanislaus said. So, in late March and early April, the administration created fusion cells to look at every angle of an issue possible, she said. Working teams from the state's departments have conversations every day, she said.

"If there's an economic crisis, DMH comes in and asks what is the mental health part," Stanislaus said. "One of the things that has come from that is the social impact of COVID-19."

Along those lines, DMH is working with the state Department of Elementary and Secondary Education to see what it might put in place before children return to schools to identify mental health issues and intervene, she said.

That may be more training for staff at schools and colleges. It means empowering staff to identify issues as they arise and make resources available for students, Stanislaus said.

A lot is still unknown about how things will look in two months, she said, when students are scheduled to return to schools.

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