Austin Hollinger has been dealing with depression and post-traumatic stress disorder for several years, ever since he was bullied at school. Now 19, he relies a lot on his friends to help him feel better day to day.
Hollinger is disabled and doesn’t drive, so his friends would often come to him. But with Alabama, where he lives, under a shelter-in-place order, most of them aren’t able to visit anymore.
“I’ve been very isolated,” he said, “which is not good for anyone.”
It’s a message many mental health experts have been sending in recent weeks, as millions of Americans face not just the spread of a new and dangerous virus, but also the measures necessary to stem that spread, which can cut people off from friends, family, therapists, and others who could ordinarily support them through difficult times.
As weeks of distancing turn into months, many people are experiencing a greater and greater sense of isolation. They’re also dealing with the uncertainty of when and how the pandemic will end, the fear of getting infected, the economic crisis that has cost millions of Americans their jobs, and the inconsistent messaging about the virus from authority figures.
“All aspects of life are affected” by the pandemic, said Arash Javanbakht, a trauma specialist and assistant professor of psychiatry at Wayne State University. “It was like one day, everything changed.”
And many are concerned that the painful changes brought about by the coronavirus pandemic will cause a spike in mental health problems that could persist long after the most immediate threat of the virus is over. That’s been the case with other major disasters, like Hurricane Katrina, said Lisa Meredith, a senior behavioral scientist at the Rand Corporation think tank who has studied disaster preparedness. “It’s not just during the event,” she said. “People will be stressed afterward.”
Among people who contract Covid-19 and need to be hospitalized, experts expect to see high levels of post-traumatic stress disorder and depression. Experts are also concerned about health care workers who are on the front lines battling the virus, sometimes without the appropriate equipment to keep them safe. A recent study of health care workers treating Covid-19 patients in China has already confirmed some of these concerns, finding considerable rates of anxiety, insomnia, and depressive symptoms. As Laura Hawryluck, an associate professor of critical care medicine at the University of Toronto, told Vox, “health care workers are people too.”
And while the current crisis is stressful for everyone, people who already have conditions like anxiety or depression may be especially at risk, psychologists say. For people with anxiety disorders, for example, “any new stressor can make it worse,” Javanbakht said.
It’s possible to mitigate some of these effects now if those affected have access to treatment, mental health experts say. But that will require an expansion of telemedicine to make sure people can get therapy safely while socially distancing. And it will require policymakers and society as a whole to take the psychological impact of the pandemic, not just its threats to physical health, seriously.
The stress and isolation of living in a pandemic are taking their toll on Americans’ mental health
It’s safe to say that billions of people around the world are in a stressful situation right now. For many, life changed nearly overnight, with little time to prepare, Javanbakht noted. Some are now trying to work from home while caring for children. Others have been laid off or furloughed and may be worried about how they will pay their bills.
Meanwhile, people are getting a lot of contradictory information about the virus and the measures needed to combat it, Javanbakht said. While President Trump may say one thing, public health officials may say another. “It’s confusing and stressing,” Javanbakht said.
Feeling powerless in the face of such a widespread threat is common and real. “When we are dealing with a difficult situation, the more control we have, the less stressed we are,” Javanbakht said. But for many people right now, “the only control we have is to sit at home.”
The fact that many people are unable to see their friends and loved ones in person only makes the situation worse. “Social distancing is really hard on people, and it’s especially taking its toll on people who are isolated at home alone,” Meredith said. “Loneliness can be a big source of stress.”
Even under more normal circumstances, prolonged loneliness can contribute to depression and anxiety, as well as to physical health problems. One 2016 study, for example, found that being lonely was associated with an increased risk of stroke and heart disease. Today, the ordinary risks of loneliness could be magnified by the stress of living during a pandemic. For people who are social distancing right now, “there is a high risk that they’re going to become more anxious, much more depressed, and it’s going to have longer-term effects,” Rima Styra, an associate professor of psychiatry at the University of Toronto, told Vox.
Overall, a lot of people around the world are experiencing a dip in mental well-being. Factors from “looming severe shortages of resources” to the “imposition of unfamiliar public health measures that infringe on personal freedoms” are likely to increase emotional distress during this time, psychiatry professors Betty Pfefferbaum and Carol S. North wrote in a paper published this week in the New England Journal of Medicine.
Still, while many people may experience greater feelings of anxiousness in the pandemic than usual, most who experience such distress will likely not develop a clinical mental health condition. “After disasters, most people are resilient and do not succumb to psychopathology,” Pfefferbaum and North wrote. “Indeed, some people find new strengths.”
But the pandemic does have the potential to trigger or worsen clinical conditions like anxiety and depression. And experts say that some groups of people are at especially high risk.
Health care workers, people who get sick, and those with existing mental health conditions could be especially at risk
One such group is Covid-19 patients themselves. Patients can experience delirium and agitation as a result of the virus, said Hawryluck, who has treated people with the disease. Being in an intensive care unit and using a ventilator, which requires medication that can increase confusion, can add to this effect. “We know that survivors from intensive care do have a lot of psychological symptoms” that match conditions from depression to PTSD, Hawryluck said. “I think it’s going to be higher in this population just based on what we’re already seeing.”
In addition to patients, health care workers are also at risk of the most serious mental health effects of the pandemic. “We share a lot of the same fears” as anyone right now, Hawryluck said — and health care workers may even be more fearful because they have seen the full extent of what the virus can do at its worst. They also must deal with the prospect of losing patients, and the task of delivering terrible news to families — often by phone, because the family members of Covid-19 patients are typically not allowed to visit hospitals.
On top of that, they face their own risk of infection because of shortages of protective equipment. And at the end of the day, “they’re still going home and self-isolating in the way everybody else is, so they have all of that impact as well,” Hawryluck said. Some health care workers are even more isolated than others, staying in hotels or even in their cars to avoid infecting family members.
The combined impact of these stressors could lead to mental health diagnoses and, in the long term, could cause people to leave the health care field, Hawryluck said: “I think, unfortunately, a lot of people will probably not necessarily want to continue in their career.”
A third group that could face added risk is those who had mental health conditions before the pandemic began. People with addiction, for example, may not be able to meet with their support groups or get access to medication-assisted treatment during this time, Meredith said. People with conditions like anxiety, depression, schizophrenia, or PTSD may find their symptoms worsened by the stress of living during a pandemic, Javanbakht said.
That’s doubly true if someone with an existing mental health diagnosis gets Covid-19. “We all need to be conscious of how scary it is for somebody to need to be admitted to hospital who’s got underlying mental health issues,” Styra, who has treated patients with the disease, told Vox. Even after they recover from the virus, “people with underlying illnesses are going to need a lot more help from their psychiatrists and their mental health teams,” she said.
Experts say without a major policy response, the mental health effects of the pandemic could linger long after the crisis has passed
Some mental health service providers are already seeing an uptick in people reaching out during the pandemic. Crisis counselors at the California-based nonprofit Didi Hirsch Mental Health Services, for example, got 1,800 calls related to Covid-19 in March, up from just 20 in February, according to the Los Angeles Times.
And experts fear that, for some, the mental health impact of the crisis could last even after the pandemic — or, at least, its current phase — has passed. Even years after Hurricane Katrina, people in New Orleans who had been affected by the storm reported trouble going to work during hurricane season due to reactivated trauma, Meredith said. The SARS epidemic in 2003 also led to high rates of PTSD and depression among patients who had contracted the disease, Styra said. And research in Sierra Leone has found that people affected by the Ebola epidemic experienced high rates of depression, anxiety, and PTSD symptoms as well.
However, there are public health and policy measures that can help. One is more widespread access to — and insurance coverage of — telemedicine for mental health care. Many insurance providers have begun covering telemedicine during this time, and the Trump administration has announced that Medicare will expand such coverage to help reduce the need for seniors to travel to health care facilities where they could be exposed to the virus.
But coverage for telemedicine should continue long after the immediate crisis has passed, many say. “A lot of our patients have to drive 50, 60, 80 miles to get to a psychiatrist or a therapist for care,” Javanbakht said, an especially difficult task for low-income patients without reliable transportation or child care.
State and local governments are also recognizing the importance of offering remote mental health support. New York has announced an initiative to provide free phone or video chat support to people dealing with the mental health impact of the crisis, with more than 6,000 psychiatrists, psychologists, and other clinicians volunteering their time.
“We talk about the economic consequences, but we also need to talk about the social consequences,” Gov. Andrew Cuomo said when he announced the program in March. “But the stress, the anxiety, the emotions that are provoked by this crisis are truly significant, and people are struggling with the emotions as much as they are struggling with the economics.”
Also crucial for mitigating the mental health effects of this crisis — and the next — is simple preparedness, Meredith said. For hospitals, having appropriate plans in place for allocating resources and housing patients isn’t just about caring for people’s physical illnesses — it also helps to protect the mental health of everyone involved. And leaders should be trained in how to communicate with the public about the risks of the virus and other threats. For people in power, being transparent and empathetic — “showing the public that you’re in it with them” — can help reduce the stress ordinary people feel during a time like this, Meredith said.
And while they aren’t a substitute for mental health treatment, there are things people can do to feel better during this time. Keeping to routines is important when possible, Javanbakht said. One of his patients, he noted, has begun taking walks with her husband when she would ordinarily be driving to or from work. “They call it commute time,” he said.
For those who have the time and energy, learning a new skill like gardening can also have a psychological impact. “For a lot of us, our sense of productivity and purpose is decreased,” Javanbakht said. “That’s a way of staying productive.”
It’s also important to maintain social relationships as much as possible using phone calls, FaceTime, and other remote communication. For that reason, Javanbakht prefers the term “physical distancing” rather than social distancing to describe how people should behave right now. “We can be physically distanced and socially very connected,” he said.
Living under a shelter-in-place order, Hollinger has been staying in touch with his friends by text and phone when he can. “They’ve been as supportive as possible,” he said.
A songwriter, he’s also been continuing to record music, releasing a single in April and trying to finish an album. “I have so much material over the past three months,” he said.
While he and others are finding ways to be creative amid the pandemic, millions of Americans remain in a state of extreme uncertainty, unsure when, if ever, they can resume their normal lives. That can take a psychological toll.
But a positive change since the days of SARS is that the mental health impact of the crisis is getting a lot of attention, Hawryluck said — not just from experts and policymakers but also from the media, with widespread discussions and tips for coping with stress. “At least this time,” she said, “people are talking about it.”