Anxiety in the Time of COVID-19: Q&A With Dr Jud Brewer

Coronavirus disease-19 (COVID-19) has had a major effect on mental health, with both healthcare workers and the general public experiencing heightened levels of anxiety and psychological distress.

According to a press release published by the American Psychiatric Association last week, 40% of Americans are anxious about serious illness or death as a result of COVID-19. Furthermore, 59% of Americans report that COVID-19 is having an effect on their daily lives, and 36% of respondents to the poll say that COVID-19 is taking a toll on their mental health.¹

To learn more about the mental health ramifications of COVID-19, we spoke with Jud Brewer, MD, PhD, director of research and innovation at the Mindfulness Center and associate professor in psychiatry at the School of Medicine at Brown University in Providence, Rhode Island. Dr Brewer has a background in addiction psychiatry, and he cofounded MindSciences Inc. As part of his work, he has developed app-based digital therapeutics for the treatment of anxiety.

The following conversation was edited for readability, clarity, and length.

How do you see the COVID-19 pandemic affecting mental health?

I’m seeing a lot of worry and anxiety, and some panic. People with generalized anxiety disorder or panic disorder have higher anxiety at baseline, and they’re more likely to get tripped into anxiety and then panic. With social contagion or the fear of the unknown, this is happening more easily for them. For the rest of us, our baseline is getting bumped up to their current baseline.

Our brains do not like uncertainty. Our thinking brain needs accurate information to plan. Our brains do everything they can to control their situation and make things more certain. Coronavirus is still a very uncertain situation in terms of how contagious it is, how it can be transmitted, and how deadly it is. If you look at the flu, it kills people every year, but we’re not afraid of it, because we know it.

There’s some distrust of certain government figures because they’re putting out information contrary to science. When political figures say this is going to be over in 15 days and it clearly is not, that makes people lose trust in the people who run their government.

People often experience anxiety, depression, or other mental challenges as an isolated, individual experience. What changes when these challenges become part of a common, collective experience?

These challenges can spread via social contagion, or the spread of emotion from one person to another. You have the physical spread of a virus, but you need to be within a certain distance to catch it. But with an emotional contagion, someone can essentially sneeze on your brain from anywhere in the world. Everyone is affected by the coronavirus, and they have a collective understanding that this could affect me or my family. Then we have social media on top of that, where people are panicking and that spreads.

How can mindfulness help people cope with the stresses of this pandemic?

I take an evidence-based approach. The theory underlying mindfulness is that it helps us change our relationship to our emotions. In cases of anxiety, somebody can actually form a negative habit loop where anxiety triggers worry as a mental sense of “I’m doing something about this.” The reward, which drives the behavior in the future, is that we feel that we’re in control. Our brains catch on to this relatively quickly and realize that worry is just making anxiety worse, causing us spiral out of control.

We use awareness as a way to help people identify these habit patterns, so that they can understand how their mind works. From there, they see how unrewarding worry can be and it highlights the need for something better. Mindfulness does this: it helps us see how unrewarding worry is and it can bring in the attitude of curiosity.

I’ve had people in our anxiety program who say that they have developed the habit of being curious when panicking. Clinically, we’ve completed 2 studies, and we’re going to publish 1 next week on anxious physicians. It is timely as physicians are not only burnt out now, but they were burnt out before the pandemic. We had a 57% reduction in clinically validated anxiety scores in just a couple of months with physicians using an app-based mindfulness training.²

In our randomized clinical trial of people with generalized anxiety disorder, we got a 63% reduction in anxiety scores. With medications for anxiety, the number-needed-to-treat is 5.15, and with this app, the number-needed-to-treat was 1.6. App-based mindfulness training is great because you can disseminate it to anybody with a smartphone at very low cost, with no side effects and no copay. You don’t need to see a doctor to get it; all those barriers go away.

How can mobile applications and telemedicine address patients’ needs amid the pandemic and self-isolation?

I had clinic yesterday and conducted all of my patient visits via telephone. Hopefully I will be converting to Zoom. You can guarantee that you don’t spread the virus but still be effective in treating patients by being able to see them, hear them, and see their facial expressions and body language — in other words, many of the benefits of in-person visits.

Telemedicine and digital therapeutics are the next generation; they’ve just gotten a huge boost with people realizing that it can be used at relatively low cost.

Healthcare workers are coping not only with an unprecedented pandemic but also a neglected healthcare system with little capacity for combatting COVD-19. What can medical workers on the frontlines do to cope with a high level of stress and trauma?

The most important thing for them to do is to learn how their minds work. If their minds can go from a black box to a known, then they can already take a huge step forward.

For example, 1 of my clinic patients came in on a referral for anxiety. He had panic disorder and generalized anxiety disorder; he was also 180 lb overweight. I sent him home with the Unwinding Anxiety app and the instruction was to map out some of his habit loops. By his follow-up, he had lost 14 lb, even though he had never talked about eating. Once he realized that he was stress eating to cope with his anxiety, he just stopped doing it because it didn’t make sense to his brain to do something that wasn’t helpful. He went on to lose 97 lb, I think.

Learning how our minds work is the key step in learning how to work with them. How can healthcare workers use this? We set up 10-minute training segments so people could watch a video in the morning and implement it in their busy day. Physicians can actually do this. We got a 57% reduction in anxiety and some aspects of burnout because the 2 are highly correlated.

Do you have any advice for providers on how to continue practicing psychiatry at this time?

Be creative. Find the technology platforms that work. I know a lot of insurers are quickly adapting; we now have billing codes that are for virtual care. That barrier is disappearing. It’s a matter of seeing what works and learning to iterate it. Everybody will find something that works well for them and their patients. Don’t try to force something, but play with it and use everything as an experiment.

What can people do to help stem anxiety about the pandemic on an individual or collective level?

The solution for both of those is the same. We need to find ways to ground ourselves with practices of mindfulness; we can do that through just 5 minutes of meditation or prayer in the morning or through short moments of mindfulness practice throughout the day, or taking a moment to connect with our loved ones. I’ve been putting out a video each day on YouTube — last week I put out 1 about making connection with the new infection.

Last, was there anything else you want to add?

The more we can see how rewarding it is to work together and be kind to each other, the more we can get through this less scathed. Hopefully, people will start to see that kindness is a bigger, better offer than divisiveness, and as we all come out the other end of this, we’ll be a changed world for the better.

References

1. American Psychiatric Association. New Poll: COVID-19 Impacting Mental Well-Being: Americans Feeling Anxious, Especially for Loved Ones; Older Adults Are Less Anxious. [published March 25, 2020]. https://www.psychiatry.org/newsroom/news-releases/new-poll-covid-19-impacting-mental-well-being-americans-feeling-anxious-especially-for-loved-ones-older-adults-are-less-anxious
2. Roy AH, Druker S, Hoge EA, Brewer, JA. Physician anxiety and burnout. Is mindfulness a solution? Symptom correlates and a pilot study of app-delivered mindfulness training,” JMIR mHealth uHealth (in press). https://mhealth.jmir.org/2020/4/e15608/