How Nurses Can Fight Diseases of Despair

BY JEBRA TURNER

We have an American public health epidemic of drug addiction (especially opioid), alcoholism, and suicide that cuts across racial, ethnic, and economic segments. Nurses are in the middle of it all, often as caretakers, sometimes as patients, so they need to learn as much as they can.

So, what is a disease of despair?

The term was first coined by economists who noted a shift in American society: white, middle-aged, working class adults were struggling with drug overdoses, suicide, and alcoholic liver disease. (Black Americans have always suffered greater income insecurity and had higher mortality rates compared to white Americans, though the gap is narrowing.)

According to the U.S. Centers for Disease Control and Prevention, life expectancy in the U.S. is dropping or remaining flat, after decades of increases. Babies born in 2018 (the latest year we have statistics) can expect to live to age 78.7, a number that ticked up from 2017, though it is less than the 2014 high of 78.9 years. Compare that to similarly wealthy countries where average life expectancy is now at 80.8 years—even though they spend half what we do on health care.

In addition to drug- and alcohol-related fatalities and suicide, more young people are now dying from heart disease, diabetes, and other common conditions. One possible cause is obesity, which at 42.4% percent for American adults, is at a record high. (By contrast, in 2000 the obesity rate was an already alarming 30.5%.) Obesity also makes COVID-19 more deadly.

A rising suicide rate— up 25% over the past two decades—is also a driver for early mortality. It was responsible for more than 48,000 deaths in the United States in 2018—while 1.4 million attempted suicide, according to the CDC.

“I do believe a term like ‘diseases of despair’ is helpful, even if it may not be a classical medical diagnosis,” says Diane Solomon, PhD, PMHNP-BC, CNM, a Portland, Oregonbased psychiatric nurse practitioner in private practice.

She encourages a broad definition that includes substance abuse and suicide, but also depression, anxiety, PTSD, etc. “To me, the term is really a place holder for trauma—and we all have trauma that we have to work out.” Solomon incorporates the ACEs model, based on the groundbreaking Adverse Childhood Experiences Study which showed a tie between childhood adversity and adult onset of chronic illness.

During the COVID-19 pandemic, despair is common regardless of trauma history, caution many experts. “Isolation and fear has created a mental health pandemic that will be with us long after the physical pandemic is over,” asserts Solomon. “Anxiety and depression may be much worse because patients live alone, but being locked down with many people can also be problematic.”

Recent studies show that health care professionals aren’t immune from diseases of despair. In fact, doctors die by suicide at double the rate of the general population.

“White physicians have more diseases of despair than nurses, including burnout and

suicide because of a culture of individualism,” says Solomon. “BIPOC and people with religious or spiritual beliefs are more resilient. I’m Jewish, which is not a part of standard white culture. It’s family and socially-based, communication, and collaborative-based,” which boosts resiliency.

Nurses are Poised to Lead in the Battle Against Diseases of Despair

Social scientists may be the first to identify this public health crisis of despair, but it’s the nurses who are on the frontlines in the war on unnecessary deaths.

“Our code of ethics is about the welfare of the sick, injured, and the underserved. Nurses have a strong role to act in order to change the social structure,” says Liz Stokes, JD, MA, RN, director of the American Nurses Association Center for Ethics and Human Rights. “Nurses have an obligation to care for everyone and to address social justice. disparities. I spoke to a nurse in Texas who asked: ‘Why are most of the patients in my ICU Hispanic?’”

Stokes is hopeful that awareness will spread out into the wider society and reduce bias in health care delivery. “Nursing is the largest health care workforce; we impact so many people,” she explains.

The landmark 2010 Future of Nursing report recommended that nurses should be full partners in redesigning U.S. health care. Inspired by the report, in 2014 the Robert Wood Johnson Foundation (RWJF) launched the Nurses on Boards Coalition to put 10,000 nurses on governing boards by 2020.

“We know that nurses need to be at every table to transform health care,” says Solomon, and diseases of despair present another opportunity for nurses to play a pivotal role. But leadership and activism aren’t the only ways to battle despair: nurse-based approaches, such as trauma-

During the COVID-19 pandemic, despair is common regardless of trauma history, caution many experts. “Isolation and fear has created a mental health pandemic that will be with us long after the physical pandemic is over,” asserts Solomon.

Nurses know, and the public is aware, that nurses are against racism—we are nonjudgmental and unbiased.”

The COVID-19 pandemic and Black Lives Matter protests have served to expose and amplify how racial and ethnic bias impacts on health care, Stokes says. “As nurses, we’re witnessing higher rates of death and health informed care, are inherently transformative.

“Nursing as a discipline is all about collaboration. Nurses are treating diseases of despair, even when treating a patient for an ingrown toenail,” says Solomon. Nurse practitioners focus on preventative care and health promotion, an approach that could save the U.S. economy billions of dollars and produce better health outcomes, she adds.

Overdose Crisis: an Epidemic that Proves the Power of NPs

Over the past two decades, opioid use disorder (OUD) and associated deaths have skyrocketed; it is a major factor in declining American longevity. According to the CDC, a record number of Americans— nearly 27,000—died from drug overdoses in 2019. The COVID-19 pandemic is slated to fuel the rate of deaths due to opioid, cocaine, and meth overdose in 2020.

Some experts blame the addiction epidemic on the widespread marketing of prescription opioids that started in the 1990s. But regardless of culpability, nurse practitioners have become an integral part of a pragmatic solution.

“From a primary care perspective, nurse practitioners are oftentimes on the frontlines, working in rural and underserved areas,” says Sophia L. Thomas DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners. “Nurse practitioners who get specialized training can diagnose symptoms of withdrawal, such as excessive sweating and diarrhea, and prescribe medical assisted therapies (MAT) for patients who want to stop using opioids.” Greater access could help to raise the distressingly low 20% of people with OUD who receive treatment.

“In Oregon, we have the most progressive laws in the nation—no physician oversight and wide ranging prescription authority,” says Solomon. “The law requires Social scientists may be the first to identify this public health crisis of despair, but it’s the nurses who are on the frontlines in the war on unnecessary deaths.

that nurse practitioners and physicians be paid the same per procedure code. This is the only state in the nation that requires this. Nurses like me can start our own practices and set our own way of working. It’s a very different model.”

For Americans to defeat the addiction epidemic, more nurse practitioners must be empowered to provide OUD care—especially in rural areas, where the overdose incident rate is greatest and access to addiction specialists is most limited, according to Deborah Wachtel, DNP, MPH, APRN, FAANP, who practices at the University of Vermont College of Nursing faculty clinic. She focuses on integrating medication assisted treatment for OUD disorder into primary care.

Though MAT is evidencebased care for a chronic disease, some clinics, courts, and families insist on complete abstinence. “We’re treating a disease that causes comorbidity, addiction, and chronic changes to chemicals of the brain,” says Wachtel. “If a patient had diabetes you wouldn’t tell them to ‘just pull yourself up by your bootstraps’ and not give them insulin. We say, ‘yes, you need counseling, peer coaches, and therapy—but you also need medication.’”

Nurse practitioners provide complete, comprehensive care, including diagnosing and treating all of a patient’s medical problems: high anxiety, difficulty sleeping, etc., says Wachtel, “just like any other primary care patient.”

Wachtel explains that a “hub and spoke” system is commonly employed. The hub is an intensive outpatient treatment facility where patients go every day to get their dose, which was originally methadone, now includes suboxone. When they become stable, they get treatment in a primary care setting, preferably on a monthly basis.

Having to go to an outpatient facility every day for medication makes it hard to go to work, or take care of children, and there’s a social stigma attached, she adds. “On the other hand, there are patients who really need to be out of their usual environment. Inpatient treatment, known as residential care, is best in that case—short stays of five to seven days, though longer is ideal, especially for methamphetamine users.”

Nurses Suffer from Diseases of Despair, Too

Especially during the COVID-19 pandemic, many nurses are facing excessive job and personal demands, which may lead to PTSD, burnout, or even suicide, cautions ANA’s Stokes.

“Social isolation and other psychological factors are affecting everyone right now,” says Stokes. “Nurses “Nursing as a discipline is all about collaboration. Nurses are treating diseases of despair, even when treating a patient for an ingrown toenail,” says Solomon. Nurse practitioners focus on preventative care and health promotion, an approach that could save the U.S. economy billions of dollars and produce better health outcomes, she adds.

must learn to identify signs of emotional distress, both within themselves and within others.”

Stokes explains that some nurses are experiencing a profound crisis and unable to fall back on their usual strategies for remaining resilient. “Nurses in the surge phase of Covid say one of the hardest parts is that in the past, if you had a bad day you could go to a coworker and get a hug,” she says. “You can’t have that physical support anymore. There’s social isolation at work at a time when you really need each other, during a very challenging time.”

Additionally, because nursing is a predominantly female occupation, some common gender-specific coping mechanisms may be problematic. “Nurses probably go into

the profession because they have certain trauma,” says Solomon. “Women tend to internalize trauma, and experience depression and anxiety. Nurses need to be aware of their own trauma and care for themselves in order to best care for their patients and not get burned out.”

Nurses who have been in the profession for any length of time may have experienced multiple health care crises, loading trauma upon trauma. “I can tell you from personal experience, the way life has been during Covid has been reminiscent of Katrina. I had a house call business and worked during that time. I remember I was driving through Red Cross lines to get supplies, taking it one day at a time because the guidance changed daily,” says Thomas. “Nurse practitioners “From a primary care perspective, nurse practitioners are oftentimes on the frontlines, working in rural and underserved areas,” says Sophia L. Thomas DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners.

are problem solvers. We get the job done for our patients. Sometimes we have to improvise. We put our lives, our health, and the health of our families on the line.”

Personal Well-Being Initiatives: Caretaking Begins with Self

Most experts agree that to battle diseases of despair in America, we must address economic and social justice as well as access to health care, food, housing, and employment.

But in the meantime, nurses can take advantage of personal well-being initiatives, some offered by nursing associations.

“During Covid, some nurses have been furloughed or made the decision not to work because they don’t feel safe. In addition, there’s racial and social unrest in the world, and a tremendous amount of turmoil,” says Stokes. “We must proactively address mental and emotional wellbeing and hospitals need to deploy resources on the unit or deploy them virtually. Don’t wait for nurses to go to an EAP.”

The American Nurses Foundation, along with other nursing organizations, is offering a mental health digital toolkit designed to help build resilience and mitigate distress. “It includes virtual support systems such as an emotional support app, and an expressive writing initiative,” Stokes explains. There are a variety of ways for “nurses to get support, 24-hours a day, 7 days a week, in an anonymous safe space during this time of racial and social unrest that continues to unfold,” she adds.

Meredith Mealer, PMHNP, PhD, RN, is the nurse-scientist heading the innovative “Narrative Expressive Writing” program. Her work is informed by the research of

For Americans to defeat the addiction epidemic, more nurse practitioners must be empowered to provide OUD care—especially in rural areas, where the overdose incident rate is greatest and access to addiction specialists is most limited, according to Deborah Wachtel, DNP, MPH, APRN, FAANP, who practices at the University of Vermont College of Nursing faculty clinic.

James Pennebaker, who found that writing about stressful and traumatic events has a number of physical and mental benefits.

“During this extraordinarily stressful time, we asked ‘how can we train nurses to be more resilient?,’” explains Mealer. “It’s been three months now and 300 nurses have taken part. We have mental health providers to read and provide feedback. We validate what they wrote but also challenge it.”

The program involves five writing prompt-based sessions of about 20 to 30 minutes each week. “We have two therapeutic intents with the writing and feedback: to reframe experience and to provide a form of exposure therapy,” she says. “I read the writing and give it thought and then provide feedback in four to five sentences. For example, to a nurse who’s overwhelmed during Covid, I might respond: ‘On the one hand you mentioned that you’re depressed, and can’t sleep, but on the other hand you did make it to work.’”

Mealer’s focus is on challenging the negative and emphasizing the positive. It’s not easy during the pandemic and Black Lives Matter protests. “The narratives I’ve read so far are so powerful. Nurses are stretched thin. They’re emotionally distressed—worried about the safety of their family and their own self during this time,” she says. “They’re really questioning if they’ll still be in this profession in the long term. I’m assuming we’ll see a lot of turnover and we’re short in the profession already.” (Want to try journaling, but don’t like to write? Journify.co is an audio journaling app that gives free access for a year to health care professionals.)

Jebra Turner is a freelance writer located in Portland, Oregon. Visit her at www.jebra.com.

Voices of Nurse Practitioners on Turmoil and Despair

Here, three nurses weigh in on minority nursing issues in their unique communities.

“I’d say there is bias in treatment—I see the difference in how patients are treated here in rural Vermont. I had a white patient who went to the emergency department and was kept on the psychiatric unit for five days with a call to me before she was released. I had a Black patient who I sent to the ED five times and they did not treat her. They called her a malingerer—that’s on her electronic record. Finally, she came into the hospital in an ambulance and by that time she had kidney failure. They sent her for five days in an inpatient treatment center and discharged her to the community without any supports in place.” —Deborah Wachtel, DNP, MPH, APRN, FAANP, an adult nurse practitioner in Vermont

“Economic distress, lack of transportation, increased mental health crisis, and just the everyday concerns for one’s health and wellbeing, nurses are poised to address the population-focused challenges I often see in my community and surrounding areas. And, especially when discussing the inequities I see in communities of color, the palpable intensity that is being drawn to the surface as it applies to the pressure that essential workers have in maintaining their home, the uncertainty parents and caregivers have in maintaining healthy and consistent access to food for their children, as well as the need for computers and stable Wi-Fi to allow access for schooling from home and virtual schooling, it has become even more apparent the divide of the ‘have’ and ‘have nots’ for all.” —Antonette Montalvo, MSN, CRNP-BC, BSN, RN, a apediatric nurse practitioner in rural South Carolina

“I believe that minority nurses do suffer from diseases of despair more greatly than their white counterparts due to economic inequality and racial discrimination. While this can take many forms, the main causation of diseases of despair include a feeling of hopelessness about personal financial success, which is evident even among health care workers today. Minority nurses who experience discrimination are more likely to experience unfair treatment, harassment, and violence, which may not only exacerbate diseases of despair but also initiate emotional distress that may threaten the stability of their mental health.” —Jonathan V. Llamas, DNP, RN-BC, PMHNP-BC, PHN, ACHE, a psychiatric nurse practitioner in Beverly Hills, California