Prior to the COVID-19 pandemic, “Fred” was fairly typical of many long term care residents. With three chronic medical conditions and mild dementia, he spent his days engaged in unit activities with his fellow residents. He enjoyed the regular visits from his wife and the consistent care he received from the warm staff.

Enter Pandemic

All of that changed with COVID-19. His wife was no longer allowed to visit, activities were either eliminated or significantly altered, and his caregivers were gowned and masked.

Over several months, Fred’s emotional well-being declined markedly. Although he was previously prone to bouts of mild depression, he became significantly and consistently depressed, with a severe anxiety and preoccupation with both the virus and his wife’s situation.

Although he seemed to understand the staff’s explanations that his wife was fine, just unable to visit him due to COVID-19 restrictions, his concerns began to escalate as some of his fellow residents succumbed to the virus. Some paranoid ideation began to creep in, and Fred occasionally expressed the concern that his wife had died from COVID-19 and that staff were keeping the news from him.

Perhaps as a result of that idea, he became increasingly combative with staff members, and more reclusive and depressed as the pandemic lingered on. He also lost nine pounds due to frequent refusals at mealtime. His clinical decline is, unfortunately, not an isolated scenario considering the impact of COVID-19 on nursing home residents.

A Perfect Storm of Emotional Stress

Post-acute facilities have always seen high levels of psychiatric disorders, with estimates of 70 percent of residents evidencing at least one behavioral health disorder. Depression is the most prevalent. The alarming rates of depression, anxiety, and other psychiatric and emotional disorders reflect the challenges that many nursing home residents are confronted by, including chronic medical illness; loss of home, friends, pets, and hobbies; and the stress of living in a new and communal setting.

It’s crucial that residents receive the psychiatric and psychological care they need, as these impairments are responsible for much of the overall distress residents experience. Additionally, these psychiatric disorders have a major impact on the effectiveness of medical care.

Depression, for example, the most common form of mental distress in post-acute care, has a negative impact on compliance with medical and rehabilitation treatments and on clinical outcomes, even when the medical care is excellent.

Despite a widespread awareness of—and efforts to expand attention to—the emotional well-being of residents, skilled nursing facilities (SNFs) are still medically oriented care settings, and the collective response to COVID-19 has focused primarily on preventing resident infections. But well-intended regulations and practices around infection control have taken a severe emotional toll on resident populations.

Isolating Factors

As their fellow residents succumb to the virus, personal protective equipment (PPE) has literally put barriers between residents and their staff caregivers. Prohibitions around family visitation have disconnected residents from the people who care for them most, in addition to limiting personal care providers, clergy, and other visitors.

Some facilities have actually had to restrict in-person care from the mental health workers who treat depression, anxieties, and other psychiatric issues, making psychiatric providers “nonessential” in the face of the greatest threat to residents’ emotional well-being in their lifetime.

Nationally, researchers have identified increases in depression and anxiety in community-based populations. While data on residents of SNFs are less clear, it’s safe to assume that a population with extremely high pre-existing levels of psychiatric stress and faced with arguably the most difficult pandemic-related changes will demonstrate commensurate increases in psychiatric disorders.

Time to Act

The Centers for Disease Control and Prevention argues that our “public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address related mental health conditions.”

Fortunately, there is already a road map that SNFs can follow to mitigate the deleterious impacts of the COVID-19 pandemic on residents. SNFs are required by the Centers for Medicare & Medicaid Services to deliver care that supports residents’ “whole emotional and mental well-being.”

That mandate places the emotional functioning of residents on an equal level with medical disorders, at least theoretically. Here are some suggestions for getting there.


Facilities are required to screen all residents for depression using the Patient Health Questionnaire-9. When residents screen positive for depression, either at admission or during their stay, facilities should take aggressive action. Make sure that there is a follow-up evaluation by a mental health professional and that treatment, if indicated, is initiated in a robust fashion.

The identification of depression, by itself, can lead to increased reimbursement to facilities, so that is an incentive for facilities to aggressively identify and treat depression.

SNFs are now required to provide “trauma informed care” to those residents who need it. Many residents have pre-existing trauma histories that were never identified or treated, others may have been traumatized by the events leading to their SNF admission, and still others may have experienced trauma connected to COVID-19 and its impacts.

Anyone who has experienced trauma deserves adequate assessment and response. A good place to start would be by administering the PC-PTSD-5 (Primary Care-Post Traumatic Stress Disorder-5), an extremely brief screening tool for trauma that, for most residents, will consist of just one question. Residents who need it should receive follow-up behavioral health care, and all residents will benefit when facilities increase their knowledge about the best ways to treat residents with trauma histories.

Antipsychotic Medications

The burdens of the pandemic, combined with the fact that some residents lost access to behavioral health clinicians, may have contributed to an increase in the use of psychotropics in general, and antipsychotics in particular.

Clinicians should be vigilant about Gradual Dosage Reductions. As behavioral health clinicians are permitted to return to in-person treatment, psychiatric and psychological clinicians should work diligently to increase the use of nonpharmacological interventions such as psychotherapy and behavior management.

At the same time, the use of all psychotropics, particularly any antipsychotics, should be carefully assessed, especially any that may have been prescribed recently due to exacerbations of unwanted behaviors.

Staff Support and Training

Nursing home staff, even prior to the pandemic, are often overwhelmed by the need to care for a rising number of residents with psychiatric impairments. The pandemic and its emotional stress on residents will only exacerbate the problem.

On top of that, staff members are struggling with what is likely the most challenging moment of their careers. Surrounded by death and dying, grappling with PPE and new practices at work, these workers return home with anxiety about their own health and the risk of transmitting the virus to their loved ones.

It’s counterintuitive to believe that providers can improve the psychological well-being of their residents without a commensurate effort to support the people who are caring for them.

Staff members need enhanced training regarding best practices for managing psychiatric impairment, but they also need to receive the support that will help them emotionally navigate the pandemic themselves.

Outside Support Groups

Facilities are encouraged to discuss staff support programs with their behavioral health teams, as well as with community-based organizations that can provide such services.

Post-acute facilities and providers have been impacted more than most by the COVID-19 pandemic. They’ve lost thousands of residents to the virus. At work, residents are struggling along with staff, and at home staff have the same concerns and uncertainty as others.

The challenge is to be sure to provide optimal care during the pandemic, and to learn from it in order to gain strength and knowledge that can be put into practice post-pandemic.

To achieve that, providers will need a robust and thorough strategy that provides every resident the chance to obtain their best level of mental health and emotional well-being, despite the challenges they face.

Richard Juman, PsyD, is TeamHealth national director of psychological services and co-chair of the TeamHealth Clinician Resiliency Work Group. A licensed clinical psychologist working in the field of behavioral health and substance use services for more than 25 years, he coordinates TeamHealth’s psychological services in hundreds of contracted facilities in multiple states. He can be reached at​