We Need a National Mental Health Response to Coronavirus
The mental health fallout of Covid-19 will be huge for health workers and all Americans
The greatest coronavirus-related risk America faces right now is from the virus itself, and the deadly disease it causes, Covid-19. There’s no drug or vaccine, the United States has a shortage of ventilators, and there’s not enough protective gear for health workers, putting those tasked with caring for the sick at the highest risk for infection.
But after a vaccine is developed, or cases are treated and isolated so that further spread can be contained, there will be lingering and persistent mental strain and trauma among those who survive.
Even people who aren’t sick will have been isolated in their homes for months at a time. Millions have lost their jobs. While the final death toll will be determined by the effectiveness of the response, the White House recently estimated it’s somewhere between 100,000 to 240,000 Americans (some projections are now lower). Most estimates are still projecting the pandemic could claim more American lives than the Vietnam War. Many of these deaths will happen in hospital rooms where loved ones are barred from entry and doctors’ faces are (rightfully) hidden behind masks and face shields.
“The extent of the consequences of Covid-19 are going to be with us for years, and I am terrified about that.”
“The extent of the consequences of Covid-19 are going to be with us for years, and I am terrified about that,” says Sandro Galea, MD, dean at the Boston University School of Public Health and an expert on mental health and disasters.
Past research on the mental health consequences of disasters — including epidemics — suggests there may be a significant increase in depression, post-traumatic stress disorder (PTSD), domestic violence, and substance use problems. After the 2003 SARS pandemic, researchers found that the experience of being in quarantine was associated with higher rates of depression and PTSD symptoms, and the symptoms were greater the longer a person was sheltered. Other researchers found that high levels of stress and depression symptoms persisted at least a year after the pandemic among people who survived the disease and health providers who cared for people with SARS.
The mental burden of Covid-19 may be especially great for health care workers — thousands of whom in the U.S. were burned out even before the coronavirus pandemic. Studies of the SARS pandemic found that health workers were at an especially high-risk for PTSD, depression, anxiety, fear, and frustration. One 2012 study of 549 hospital workers who responded to SARS found that 9% had high depressive symptoms that lasted at least three years after the outbreak.
“The doctors and nurses are seeing all of this death and bad outcomes,” says Dennis Charney, MD, the dean of the Icahn School of Medicine at Mount Sinai. “There’s going to be a very high rate of PTSD. We have to be prepared for that. Even if the pandemic ends in a couple of months, people are going to come out of this experience with horrific memories.”
Health care workers treating people with Covid-19 are already reporting a toll. In a study published in JAMA Network Open on March 23, researchers surveyed 1,257 health workers in 34 hospitals in China and found that about 50% of workers experienced depression symptoms, 45% experienced anxiety, 34% experienced insomnia, and 72% experienced distress.
The United States wasn’t prepared for the coronavirus pandemic — but it still has some time to prepare for the oncoming mental health crisis.
“The scene in OR 22 captures many achingly familiar and universal features of this pandemic — our comfortable pavement and reassuring routines ripped up overnight and replaced by precarious hand-to-hand combat with a virus, accompanied by vanishing productivity, extinction of familiar roles, personal and professional dislocation, illness, and loss of life,” wrote Craig Smith, MD, the chair of surgery at Columbia Presbyterian, in one of his daily dispatches from the hospital.
The United States wasn’t prepared for the coronavirus pandemic — but it still has some time to prepare for the oncoming mental health crisis, and policymakers have models in past responses to national trauma, including the Vietnam War and 9/11 attacks.
“There are strategies to mitigate risk,” says Ann Masten, PhD, a resilience researcher and professor of child development at the University of Minnesota. “It would be good if we think ahead about what resources and investments we wish we made before, so that we can make them now.”
Disasters are often viewed as point-events — the hurricane hits, and then it subsides. Epidemics are unique in that their endings are often impossible to predict. “In a pandemic, there may be a clearly defined beginning (first case), but no clearly defined endpoint,” wrote researchers in a 2008 paper on mental health considerations during influenza pandemics. “The impact period may be prolonged, which impedes the recovery process.”
No disaster is ever really over when the storm breaks or the curve is flattened. After Hurricane Ike in 2008, 5% of people in Texas affected by the storm met the criteria for major depressive disorder during the following month, and later research found that “post-disaster stressors” — including job loss, marital stress, and displacement — were linked to PTSD symptoms over the following 18 months. “Getting kids back into school, paying rent, taking care of parents, those stressors actually extend [the trauma] and increase the likelihood of mental illness,” says Galea.
It’s already clear what the post-disaster stressors of the coronavirus pandemic might be. In the U.S. alone, some 75% of Americans are under stay-at-home orders, and over 10 million people have applied for unemployment benefits. High numbers of young people are out of work, which studies have shown can create a “scarring effect.” One 2020 study of young adult unemployment found that for each year without a job, the odds of having depression increased by 33% and the odds of generalized anxiety disorder increased by 19%. Nearly half of Americans feel the coronavirus crisis is currently harming their mental health, according to a recent survey.
So what can be done?
It’s helpful to keep in mind that while the potential for a significant mental health burden from the pandemic is high, studies suggest that most people who experience a traumatic event or disaster do not develop mental health disorders. Symptoms of PTSD after natural disasters have also been shown to decline among people over time, at least in some cases.
Humans’ ability to adapt in hardship has been the subject of active study since the 1970s. The 20th century brought a series of disasters that affected tens of millions of people around the world including the Great Depression and World War II. This spurred the development of the field known as human resilience research: The study of how people and families adapt during economic, natural, and political disasters. Today there’s growing consensus that resilience does not mean the absence of mental health symptoms after a traumatic event, but is instead the ability to “bounce back” or adapt to a new normal. And it’s not just something individuals have or don’t have; societies can be resilient as well.
For people to feel safe, systems need to be in place that won’t break down. The trauma of coronavirus could have been lessened if the U.S. was better prepared for the pandemic — if people could quickly get tested, health workers could have easy access to protective masks, students could easily continue classes remotely, workers felt a move to remote work didn’t mean eventual job loss. In the absence of resilient systems, people find ways to create physical and mental protections for each other. Parents keep kids distracted and entertained, for example, and people sew masks for health workers and their neighbors.
“The most powerful protective system in human life is surge capacity,” says Matsen. “Communities have surge capacity. Parents have surge capacity. If their kids are in trouble or there is a threat, they can up their game.”
But no one can surge indefinitely — you get depleted, and it gets harder to cope. “You have to keep renewing,” Matsen says. “To keep your immune system in order, you need enough sleep and exercise. None of us are able to cope quite as well if we are exhausted. Our physical and mental selves are deeply interconnected.”
“It’s not good to run everything up to the margin,” she adds. “If you are going to be able to respond to a shock you don’t want to go into it [exhausted]. Right now people are juggling multiple things — like family and work.”
Resources and reinforcements are needed, including tools for mental health care. Some of those resources, like video and texting apps that allow people to connect with mental health professionals, are being utilized. As Elemental recently reported, one such app called Talkspace has reported a 25% increase in user volume in just the last month and a 30% increase in use of coronavirus-related terms in text exchanges with providers since March 5. Crisis Text Line, a confidential text messaging service, reports that 80% of their texters are now mentioning anxiety versus 30% pre-pandemic.
But to adequately address the mental health impacts of the coronavirus, the nation needs a call-to-action to provide the resources and expertise for the treatment of Americans affected by the pandemic, with particular attention paid to health care workers. “The federal government needs to be a part of this, but state and local governments need to be a part of it too,” says Mount Sinai’s Charney. “A lot of the bills passed are appropriately for job loss and supporting medical centers, but they are also going to have to provide programs for the emotional consequences of front line workers.”
There are at least two large-scale, trauma-related initiatives currently in the United States: the National Center for PTSD and the World Trade Center Health Program.
PTSD became an officially diagnosable condition in 1980 following the clear mental health burden born by some American veterans of the Vietnam War. The National Center for PTSD was created in 1989 within the Department of Veterans Affairs as part of a congressional mandate to treat veterans and trauma survivors. The VA has since developed several divisions across the country. The World Trade Center Health Program, which was established by the James Zadroga 9/11 Health and Compensation Act of 2010, provides free medical treatment, benefits, and mental health services to 9/11 responders and volunteers. While both are national programs, there’s training and programming for people on state and city levels as well. Setting up a fund or similar national program for health care professionals treating people with the coronavirus could go a long way.
“The same globalization that has helped spread the disease so quickly could also help diffuse models for how to deal with the mental strain caused by it.”
Cities with especially high caseloads, like New York City, may benefit from more local initiatives. The city currently has 24-hour anxiety text and call lines and websites offering additional mental-health resources for people dealing with Covid-19 stress, but there could be more. (The top two coping tips on the city’s health department website currently include “try to remain positive” and “remind yourself of your strengths.”)
Experts are calling for mental health considerations to be a greater part of the Covid-19 response worldwide. In a March study published in The Lancet Psychiatry, researchers in China wrote that “mental health care for the patients and health professionals directly affected by the 2019-nCoV epidemic has been under-addressed.”
The researchers call for four steps that could be used by any country dealing with the pandemic. First, the creation of mental health teams (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) established by health authorities at regional and national levels that are available to deliver mental health support to health workers and people with Covid-19. Second, updates about the outbreak as well as treatment plans and progress reports should be quickly given to people with Covid-19 and their families to address uncertainty and fear. Third, people need secure ways to virtually talk to mental health professionals. And fourth, people with suspected or diagnosed cases of Covid-19, as well as health professionals, should receive regular clinical screening for depression, anxiety, and suicidality by mental health workers.
Mental health experts in the U.S. are beginning to call for similar measures, including the sharing of accurate and timely information on the outbreak to cut down on panic and uncertainty, increased access to telemedicine tools, and the development of mental health-specific response teams.
“A government taskforce on coronavirus-based trauma should be assembled to advise on best practices and monitor nationwide trends,” three prominent health leaders wrote in a recent op-ed for The Hill. “If needed, extra resources should be made available immediately in areas of concern.”
In the absence of a national mental health task force for Covid-19, practitioners and clients have been forced to improvise. Therapists are taking appointments over video and telemedicine is offering more mental health services for people who may not already have a relationship with a therapist.
Resilience researchers admit the current climate doesn’t make the usual science-backed coping strategies easy. One of the most often-cited tips is to lean on social support; multiple studies show social support through family, friends, or religious groups can help ease stress. But finding community is harder during a pandemic, where people need to stay away from each other. While in-person connections tend to be the most highly recommended, phone calls or virtual chats are considered the next best thing. Checking in on people who are especially at risk, like the elderly, people with financial stress, and those with mental illness, is important.
“Resilience is a part of who we are. It’s a part of our collective heritage, biological and psychological and also cultural. We pass down our knowledge and strategies.”
Realistic optimism is also frequently cited as an important factor in recovery from adversity. But looking on the bright side might feel too Pollyanna-ish or even inappropriate for the moment. Instead, Masten says that people should simply keep in mind that resilience during adversity is a part of the human experience. Many of the mental health frameworks and response protocols in place today were explicitly developed in response to traumas. “Resilience is a part of who we are,” she says. “It’s a part of our collective heritage, biological and psychological and also cultural. We pass down our knowledge and strategies.”
The coronavirus outbreak is worldwide, but that also means that all over the world, there are models and examples of resilience in action. The same globalization that has helped spread the disease so quickly could also help diffuse models for how to deal with the mental strain caused by it. In parts of East Asia, including Wuhan, where the outbreak began, there are tentative returns to something like normalcy, as lockdowns lift and new case counts decline to low levels (at least as reported). Just as U.S. medical officials are learning from their colleagues in South Korea, Italy, and China about how to trace, treat, and test for the illness, hopefully leaders can also learn from each other about how to respond to the mass trauma faced by billions.
“A novel virus can overwhelm our capacities temporarily,” says Masten. “We will gain from the experience of going through this — one of our great resources is our ability to learn and create new ways of dealing with adversity.”