With respect to the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three key themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care, and iii) the impact on providers.
High demand for mental health care
Worsening mental health
There was overwhelming agreement within all focus groups that patients’ mental health worsened during the COVID-19 pandemic. All focus groups discussed in depth the impact that the COVID-19 pandemic had on their patients:
As time went on, people really declined…I have noticed a really big decline in mental health. I’m seeing more patients with mental health concerns, and those patients that were previously doing quite well are starting to decompensate. (FG7, Nurse Practitioner)
All focus groups described seeing more patients struggling with anxiety during the pandemic: “I’ve seen a lot more anxiety symptoms” (FG4, Social Worker). Although not all patients were seeking care specifically for mental health, all focus groups noticed that the pandemic was broadly affecting people’s mental health. “I think anecdotally it’s impacting a lot of people…I think it’s having an impact on them, and I see it indirectly” (FG3, Family Physician). Focus groups discussed the need to adapt some patients’ treatment. For example, patients who previously, “didn’t need medication before, now are maybe needing medication… [As well,] there are some newly presenting patients” (FG7, Nurse Practitioner). In addition, some patients with past-histories of mental health difficulties were struggling: “More people just need psychotherapy…because of the additional stress of COVID…. I’m getting a lot of people…they’re being referred back…just with all the extra stress of what’s going on right now…so then they’re coming back to see our psychiatrists” (FG7, Psychiatry Intake Clerk).
Increased crises
All focus groups overwhelmingly agreed that they were seeing an increase in mental health crises among their patients. A social worker in one focus group noted that they were “
seeing…relatively stable clients suddenly go into crisis” (FG10, Social worker). Most focus groups described an increase in suicidality during the COVID-19 pandemic, “
Last night in fact, I was on call, and I had an encounter with a patient and sent her to the hospital because she was suicidal” (FG7, Family Physician). Another focus group discussed the impact that a recent suicide had on the team:
We just had a suicide of a patient a couple weeks ago. His work was impacted by COVID…and then unfortunately he took his own life…His primary care provider had had him throughout his entire practice and came down to my office and was just in shock…. And then yesterday there was a call come through. Another person concerned about their spouse who was suicidal… So we’re seeing sort of this suicidal increase. (FG9, Executive Director)
In addition, most focus groups – particularly those held in rural communities – noted an increase in crisis related to substance use amongst their patients. “We’ve always had issues with addictions in our community, but now… it’s more obvious …the hospital is having more people being admitted for overdosing …We’re used to hearing about people overdosing, but now we’re actually knowing that this is happening” (FG8, Program Manager). Similarly, another focus group in a rural community noted, “We’ve seen a number of overdose deaths…we’ve certainly seen the number of overdoses increase” (FG9, Social Worker).
Isolation, exhaustion, and fear
The conditions of the pandemic perpetuated isolation, exhaustion, and fear amongst patients. This sub-theme resonated with all focus groups. “
I’ve seen a lot more anxiety for sure, and a lot of isolation, and loneliness. And people…having to learn different coping skills because the coping skills they used to use, they’re not able to because of the restrictions” (FG2, Social Worker). In another focus group, a family physician elaborated on how challenging it is for providers and patients not being able to rely on previous methods of coping or stress relief:
We can fiddle with medications and such from the physician end of things, and we can have supportive chats…but that only goes so far... Patients who are more vulnerable, it is harder to come up with solutions that would help them. I would say there’s been more than a few times where I’m with a patient, and I’m struggling to figure out, ‘well, okay, what are we going to do here?’.... I’m feeling a little bit discouraged. (FG6, Family Physician)
All focus groups described seeing patients exhausted, and noted that this became more evident to them as the pandemic persisted. “The longer [the pandemic has] gone on, the more trying it’s been for people, and the more exhausted they feel, and the more they’ve…exhausted their strategies and their resources (FG7, Social Worker). Further, another focus group expressed concerns with patients’ stress levels, “Patients…are more stressed than ever!” (FG6, Program Manager).
At-risk populations
Focus groups identified several types of patients that were at-risk of worsening mental health during the pandemic, including older adults, youth, and individuals living in rural communities. One participant stated, “The people who are struggling more than others, are probably the people who are more vulnerable to being socially isolated, so seniors, the people with young children…and people with previous mental health [concerns], I would say are having a harder time than usual” (FG7, Family Physician). Similarly, another focus group noted, “I have several older clients…loneliness is becoming a major factor and some of them have taken a turn towards darker thoughts” (FG11, Mental Health Therapist). A social worker noted, “One thing I definitely noticed is a higher incidence of referrals for youth and senior population” (FG1, Social Worker).
Many focus groups spoke about some of the mental health challenges that youth experienced during the pandemic. “A ton of kids with anxiety. A lot of OCD, a lot of just generalized anxiety around the pandemic” (FG3, Family Physician). Another participant noted a difference in their youth patients during the pandemic as compared to previous years: “Teenagers I was working with…I think there was more…depression” (FG2, Social Worker). Participants also observed an increase in crises among youth during the pandemic. “Youth are suffering a little bit more from overdose and…depression” (FG8, Social Worker).
Focus groups held in rural communities expressed concerns that individuals living in rural communities were particularly isolated during the pandemic, and thus, at increased risk for mental health difficulties. “We’re isolated anyways here, and now this is kind of another layer of isolation” (FG8, Social Worker). Additionally, “because we’re rural…there’s been a lot more depression related to feeling really isolated” (FG9, Executive Director). Some focus groups explained that rural and Northern patient populations experienced COVID-19 related stigma, leading to further isolation. For example, “There seems to be…general stigma for COVID in a rural community than there would be in a more urban one…I’ve heard of some of the transactions in other rural communities where people had gotten COVID, and brought it into their community, and they’re pretty ridiculed” (FG8, Social Worker).
Increased referrals and long wait-lists
All focus groups described the increased demand for mental health services since the onset of the COVID-19 pandemic. For example, “mental health and social work are the two busiest programs right now and our referrals are coming in fast and furious” (FG5, Program Coordinator). Increased referrals resonated with all focus groups: “Our biggest intake for counseling was in August, it was almost tripled in August” (FG9, Nurse Health Promoter). All focus groups agreed that the conditions of the COVID-19 pandemic led to increased demands for mental health services, “We’ve been seeing more referrals – and not just from people who have pre-existing anxiety or depression, but new referrals coming in that are people that are specifically having a hard time with COVID” (FG7, Social Worker).
As demand for mental health services increased, most focus groups agreed that waitlists became problematic. “The need is definitely increasing. We’ve gotten a lot of referrals in the last month, so – we haven’t had a waitlist up to this point, but going forward we’re definitely going to, just because of the demand” (FG3, Social Worker). Participants explained that the waitlists for mental health services also grew because of decreased access to community mental health resources during the pandemic. “It’s getting more difficult now to bridge people or to connect them with community resources…because [community resources] have cut back their services” (FG3, Family Physician).
All focus groups spoke at length about having rapidly implemented virtual care – telephone and video appointments – at the onset of the pandemic. “Our team did a great job of pivoting to provide virtual mental health care pretty much over a weekend, and went to phone based calls sessions…for individual sessions” (FG5, Mental Health Therapist). Another participant explained, “It’s all being done by phone so even their…therapy sessions, it’s over phone” (FG10, Program Coordinator). Across most focus groups, telephone appointments were the most frequently used modality for mental health appointments during the COVID-19 pandemic. “I would say 90% want telephone” (FG8, Social Worker). One of the reasons why some patients prefer telephone appointments is that: “It’s easier for them to find privacy on a phone call than then on a video call” (FG10, Social Worker). On the other hand, some focus groups mentioned using video appointments on occasionally. For example, “As a physician, I do have access to video calls…if I know it’s a specific mental health appointment…I’ll do a video visit so I can actually have a face-to-face conversation with them” (FG3, Family Physician).
Many focus groups discussed some of the challenges they encountered with the initial transition to virtual care. For example, not all types of treatment were easily adaptable for virtual delivery. “
I used to do an in-person anxiety and depression group… and that’s harder to facilitate…online” (FG7, Social Worker). One of the challenges raised in all focus groups was the lack of education and training in using virtual care modalities:
It would be very useful…training people like myself... in how to perform virtual care, …using the hardware itself or the software itself…But also, training for how to perform counseling in a virtual setting, right? Right now, we are just trying to do what we normally do just over the phone, but maybe that’s better delivered, in a different way. (FG9, Social Worker)
A few focus groups spoke about how they continued to see a small sub-set of patients for in-person care during the pandemic because virtual care was not effective for all patients. For example, “People who have been…hard of hearing where virtual or phone was not really working that well…it’s harder on the phone…It has been better to meet where…we can see each other…We’re trying to be very selective about that though” (FG11, Mental Health Therapist). Participants also noted that they used some in-person mental health appointments during the pandemic if they had concerns about a potential mental health crisis. A family physician explained, “I’m on the phone, and I think somebody’s struggling with a mental health issue…there’s nothing stopping me from actually bringing them in for an in-person assessment” (FG3, Family Physician).
Limited access to technology
One challenge that all focus groups spoke about was providers’ limited access to technology. For example, “The lack of equipment at home…computer and things like that… was a challenge” (FG10, Social Worker). In addition, all focus groups raised concerns that patients without access to technology may be disadvantaged. “It’s challenging to get people information if they don’t have computers [to receive] information or resources” (FG5, Mental Health Therapist). There was concordance across focus groups that virtual care may not be accessible to some disadvantaged populations, “Vulnerable populations [may not] have access to technology, or isn’t comfortable over the phone” (FG7, Social Worker). To address these challenges, one team was considering distributing tablets to patients: “We’re thinking about…sending mobile data tablets to people’s houses for borrowing” (FG11, Mental Health Therapist).
Challenges in rural and remote communities
Rural and remote communities experienced challenges due to the lack of high-speed internet. One focus group explained, “If [they] were able to get better access to high speed internet, that would make a tremendous difference” (FG5, Mental Health Therapist). We even experienced connectivity problems when conducting one focus group, “Like, this [virtual focus group], I disconnected once already and it’s like, I can barely see it because it’s very low-res, and it’s also jittery, so that’s one of the challenges of living in a Northern community…our internet service is pretty horrible here” (FG8, Social Worker). Unreliable reception created significant challenges for telephone appointments: “Phone reception and the lack of reliability…Cellphone reliability in a rural area, there’s so much of a session where I’m like, can you please say that again?…I didn’t get that part” (FG11, Mental Health Therapist).
Impact on quality of care
Across all focus groups, virtual care improved access because it enabled some providers to be more available. “We’re much more efficient at fitting people in…if I have a full day of phone calls…how difficult is it really for me to fit in an extra phone call? It’s not that difficult” (FG3, Family Physician). Virtual care enhanced accessibility because patients did not need to travel for an appointment: “People really appreciate the flexibility of not having to come into the office” (FG10, Social Worker). Virtual care improved some patient’s ability to engage with care: “I would say…moms who have young kids at home or people who…don’t want to drive…really enjoyed the option of phone calls” (FG9, Nurse Health Promoter). All focus groups indicated that virtual care enhanced access for patients with anxiety: “I have had people tell me that they wouldn’t have really access these services unless they were being offered virtually. Those people are people with high levels of anxiety who have anxiety about coming into the office” (FG10, Social Worker). Some focus groups suggested that patients experienced less fear of stigma with virtual care, and that enhanced access for mental health services: “I’ve had a couple of patients say too, that doing it over the phone, they find less stigmatizing…Patients say that they don’t have to worry about running into anyone” (FG2, Social Worker). Additionally, many focus groups noted that virtual care helped enhance continuity of care. “I’m discovering when I talk to them… they’re up at their cottage, or they’ve moved…or temporarily relocated…now I’m able to still remain connected with them through a telephone appointment. And so the continuity of care maybe is a little bit better” (FG3, Nurse Practitioner).
Focus groups raised two concerns about the person-centeredness of virtual care. First, there were concerns that virtual care impeded the therapeutic relationship. “There are challenges with that…connection is really lost” (FG5, Mental Health Therapist). As well, there can be challenges with the nuances of communication during virtual psychotherapy, in particular. “I do notice sometimes on the phone there’s a lot of pauses…like I thought they were going to say something, but then they were waiting for me. So, there’s been a lot of like disconnection” (FG4, Social Worker). Additionally, focus groups raised concerns that the lack of visual cues limited their assessment ability. “The biggest challenge is the transition and adjustment to going virtual and phone based and not having, especially with the phone…not having the same amount or type of information that I would get from in person” (FG5, Mental Health Therapist).
Impact on providers
Provider roles
Focus groups identified three ways that the pandemic affected provider roles: i) new professional responsibilities, ii) increased workload, and iii) the need to be innovative. Most focus groups described starting new patient care activities since the onset of the pandemic. First, most teams initiated check-in calls to patients. “We were doing wellness checks with people at the beginning of the pandemic…We were calling and just following up on mental health and how they were doing” (FG3, Social Worker). Some focus groups also conducted targeted wellness checks, “There was a list of vulnerable patients that were put together, whether they be older adults, or lacked support in their own community, living on their own. And we would call to check in” (FG1, Social Worker). For some focus groups, check-in calls were a strategy used when wait-lists for mental health services grew: “They’ve had to change how they’re delivering… They are doing more check-ins…. It’s more just to say: how’s your mood? How you doing, just dealing with some of the psychosocial issues” (FG4, Social Worker). These check-in calls were meaningful to patients. “Talking with the patients…I think they really value the check-in calls…because it just shows that you know they’re not being forgotten about” (FG11, Program Coordinator). New professional responsibilities also emerged because of the lack of in-person administrative support. “Not having some of that clerical support has also been a big challenge because they would [help with] my waitlists…, even just booking appointments, I’m doing that all from home without…clerical support” (FG1, Social Worker). This resonated with another focus group: “The other challenge…was just not feeling as efficient in…my work because I don’t have the same access to [administrative] resources… just the added layer of work…so there’s a lot of extra I’m finding now” (FG4, Mental Health Therapist).
All focus groups experienced an increased workload. Prior to the COVID-19 pandemic, the “no-show rate” for mental health appointments was high, so providers’ scheduled patients back-to-back. Since the pandemic, most participants indicated that “I’m getting less no-shows, because people are able to just do it from the comfort of their home” (FG3, Social Worker). Many focus groups explained that the challenge was that providers previously used the “no-show” time to complete in-direct patient care activities. “It is much more intense in that you rarely get a no-show or a cancellation with telephone…So in terms of workload…now it’s back to back. Go, go, go, because nobody’s canceling” (FG4, Social Worker).
All focus groups spoke about needing to be innovative to meet patients’ mental health needs during the pandemic. One focus group explained that they revised their triaging process for mental health services because of the high demand. “
We sort of became creative…That’s where [the Nurse Health Promoter] came in…and we came up with this sort of outline of how that would look…she does such a great job of being able to figure out what their needs are…rather than waiting to see the social worker” (FG9, Executive Director). Another focus group explained how their team adapted their triaging approach and implemented a new psychoeducational group, for patients with COVID-19 related anxiety. “
We…try to within the two weeks deal with the case…versus wait-listing them for 6 months….Now we’re doing the group as sort of like a step one …so that’s how we sort of dealt with the influx of the referrals for COVID related anxiety” (FG4, Social Worker). One team created asynchronous videos for patients that addressed various mental health topics:
I recorded all the sessions…and I just refer people to these YouTube clips. They’ll go through the clips at their leisure, and then I’ll follow up with them for a post-test a week or two later…Just recently I recorded with our pharmacist a sleeplessness group that we’re just about to roll out. (FG3, Social Worker)
Personal wellbeing
All focus groups overwhelmingly spoke about the personal toll they experienced and described feeling exhausted and isolated. One participant explained:
I think the real palpable feel of COVID fatigue. People are tired, and I think the frontlines…have been helping patients all along, they’ve changed the way they work…I think when you initially do that…there’s a burst of energy…people feel that urgency, and they problem solve, and they come up with great solutions, but… there’s no end in sight… I think we’re seeing more mental health needs with staff as well…I have referred more to our EAP recently just because people are feeling just exhausted. (FG7, Nursing Manager)
The theme of exhaustion resonated with another focus group, “When it was March and there was all this like ‘rah rah health care workers!’…you kind of felt like you had this calling…and then the work continues on and…the team is feeling like very exhausted and run down…and you’re still like in the thick of it” (FG9, Executive Director). Many focus groups expressed concerns of potential burnout: “From a high level…I could see the clinicians…having more fatigue and burnout” (FG4, Program Manager).